Medical Report: 24-Year-Old Iraqi Male, Baghdad, Iraq re: Shrapnel Wounds and Amputation

Medical records of an Iraqi male, Enemy Prisoner of War (EPW) admitted to hospital with shrapnel wounds to his right thigh and knee with associated minor injuries to chest & abdomen. The medical records do not give any indication as to how the detainee received his injuries or what detention facility he came from. The medical report does not give any personal information on the detainee.

Doc_type: 
Medical
Doc_date: 
Sunday, August 17, 2003
Doc_rel_date: 
Monday, October 3, 2005
Doc_text: 

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MEDCOM -17441
DOD-031030
MEDICATION) 99-.
THERAPEUTIC DOCUMENTATION CARE PLAN,
For use of this form, see AR 40-407; Mo. 0 Yr. 7233
CLINICAL RECORD the Rroponent .f9ency is the Office of The Surgeon General.
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PATIENT IDENTIFICATION:
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EDITION OF 1 DEC 77 MAY .
DA FORM 4677, 1 OCT 78
MEDCOM - 17442
DOD-031031
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN
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MEDCOM - 17443
DOD-031032

MEDICAL RECORD-SUPPLEMENTAL MEDICAL DATA
For use of this form, see AR 4016: the woolens ;ppm is the Office of The Surgeon General.
OTSG APPROVED Ward
REPORT TITLE
Post-Anesthesia Care Unit (PACU) Flow Sheet
Date: at. _ Anesthesia Type (Circle) pinal Epidural Drains Time In: on Nerve Block Hemovac Allergies: I • R Intake: Crystalloic Colloid --NG Pre-op V/S: sh /60 EBL /)0.r.: OR Output: UOP JP
Procedures: Meds/Tim-s:
Foley
Pre Oo Meds History
Time
Sa02 Fi02 Methods 240
220
40
20
RR
T
Time
Pain (0-10)
LOS

PREPARED BY Miteirwe
PATIENTS IDENTIFICATI
first, middle grade; date; hospital or medal facEtyl
Pacu Intake
Time Solution Amount Site By
X-rays:
Criteria
Activity
(2)
Moves 4 Extremities

(1)
Moves 2 Extremities

(0)
Moves 0 Extremities

Airway
(2) Cough. Deep breath
Labs: Post-Anesthesia Recovery score ADM 30' DIC
(1)Dyspnea. united breading
(0) Apnea
Blood Pressure
(2)
SHP 4- 20 of Pre-op

(1)
SBP =1-20-50 of Pre-op

(0)
SBP =I-50 of Pre-op

Q
Consciousness
(2)
Fully Awake, audible
crYinfl

(1)
Arousable to verbal or pain

Color
(2)
Basefine odor & appearance

(1)
pale, mottled, jaundiced

(0)
Cyanotic

Circulation (Peds 5 Years)

(2)
radial Pulse Palpable

(1)
Axillary palpable. not radial

(0)
Carotid only reliable pulse

TOTALS: Must be 9 or
greater to D/C, otherwise
needs anesthesia approval for )
Ci/C.

10-1„..D
Paden teaching done; Wound Ca e. Pain Management
T. C, & DB,. Incentive Spirometer, Comfort Measures Safety: SR up X 2. Falls Precautions. Privacy Maintained
it.onttnue on
DEPARTMENTISERVICEICUNIC DATE
Airway
Nasal
Oral

ETT
Trach
Other

Infused
Codes
AIRWAY A =Ambu BB = Blow-by M — Mask FT = Face Tern RA = RoomAir NC = Nasal Cannula
V/S
X = A-line BP = Cuff BP = Pulse
TEMP S =Skin 0= Oral A = Axillary T = Tympanic R = Rectal
LOS C = Cervical T = Thoracic L = Lumbar S = Sacral
reverser
Name —last. . HISTORYIPHYSICAL / 01-6 42( ) . FLOW CHART
. OTHER EXAMINATION OR EVALUATION 1:7] OTHER apiary
. DIAGNOSTIC STUDIES
. TREATMENT

DA FORM 4700, MAY 78 WAMC OP 173-E, (Revised) 1 Apr 01 (MCXC-DN) Previous edition is obsolete USAPTC V2.00
MEDCOM - 17444
DOD-031033

MEDICATIONS
NURSING NOTES
Allergies:
Time Pain Medication & Route Pain I/E By 1 -10 fkinne 1 -10
NEUROVASCULAR
Time Site Range Sensory P Cap T Color Of Refill . Motion Adm 15' 30' 45' 60' 90'
Movement/Sensation: + = present,- = absent Temp:C = Cool, W = Warm Pulses: P= Palpable, D= Doppler. A = Absent Color: C = Cyanotic, Capillary Refill: B = Brisk, S= Sluggish P= Pale, Pk =Pink
C-SECTIONS
Adm 15' 30' 45 60' 90' DIC
Fund. Height
Lochia
Peripad#
Fund. Cond. _
DRESSINGS
Time Location Type Drainage
Adm —
30'
60'
D/C

PACU OUTPUT
Time Source Color/Appearance Amount

CARDIAC RHYTHM
Time Rhythm Symptomatic? Rhythm Strip Run?

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Discharge Criteria:
Date:i7u1A1 PARS: JD
BP: 1%159 T: 9 ? FIRAY2t. RR: (II Sa02:

Pain Level at DIC (0-10): Intake: 1 5 -0 Output: Additional Data: Transferred To: Report Given To: Transferred Via: WIC rney Ambulance Transferred By C6) 1. -Cleared IAW Recovery Roo
1,)(6)-z
Charge Nurse Signature:
. REPORTING MIT Mir LOCATION ADMISSION AND CODING INFORMATION
(State or
8
2 3 4 Country For use of this form, see AR 40-400; the proponent agency is OTSG Code.)
A -1)
4. PAY GRADE 6. SEX
NAME (Last, First, Middle Initial)
. REGISTER NUMBER
16 17 18
9 10 11 12 13 14 15

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. RACE 9. ETHNIC RELIGION
7. AGE AT ADMISSION6. DATE OF BIRTH (YYYYMMOD)
30 BACK-
31
19 20 21 22 23 24 25 26 27 28 29
GROUND
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12. SOCIAL SECURITY NUMBER
ETS 11. FMP
10. LENGTh OF SERVICE
37
35 I fi 45

32 33 H34
BRANCH I CORPSHOUR OF
13. MARITAL STATUS (,.\)CL)--
ORGANIZATION (Active Duty Only)
ADMISSION 46
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16. ZIP CODE OF RESIDENCE15. BENEFICIARY CATEGORY
14. FLYING STATUS
53 54 55 56 57 §8 59 60 61

47 48 49 50 1 51
I K (3
PREY. ADMISSION

19. TRAUMA
17. UNIT LOCATION (Stare or 18. MOS
Country Code) YEAR

68 69 70 71
64 65 6

62 63 NO
t-
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD
ADMISSION fj/l)

(Include ZIP Code)
72 ADDRESS OF EMERGENCY ADDRESSEE
T--Cw k V
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
4AME AND LOCATIO 0
(

X.2.) -z. c)All
23. DATE OF DISPOSITION (V YMMDD)
F TRANSFERRED TO
21. TYPE OF DISPOSITION
81 82 I 83 84 85 86

75 76 77 78 79 80
73 74
0
5-
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26. DATE THIS ADMISSION (YYMMDDI
25. MTF TRANSFERRED FROM
24. CLINIC SVC - ADMITTING
91 92 93 94 95 96 97 98 99 100 101 102
87 88 1_89 I. 90 1
I 3o g –7

29. DATE INITIAL ADMISSION (V I'MMOD)28. MTF OF INITIAL ADMISSION

27. LOCATION OF OCCURRENCE
— — — 1 (Battle Casualty Only) 112 113 114 115 116

105 106 107 1081 109 1 1 0 111 103 104
FOR LOCAL USE
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DOD-031035
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,TIENT TREATMENT RECORD COVEi. ,;MEET
For use of this form s see AR 40-400; the proponent agency is OTSG
1. REGISTER NUMBER 2.
NAME (Last. First I) GRADE ADMISSION REMARKS
(VU;) -9 • 3.
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4. SEX 5. AGE 6. RACE 7. M).
RELIGION LENGTH OF SVC 9. ETS
10 PREVIOUS ADMISSION
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ORGANIZATION
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15. FLYING 16. RATING/ 17. DEPT/ 18. BRANCH/CORPS 19. UIC/ZIP
STATUS DSG 20. TYPE CASE
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21.
SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION
22. HOURS OF 23.
CLINIC SERVICE
ADMISSION
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24. NAME/RELATIONSHI P OF EMERGENCY ADDRESSEE
25. TYPE DISPOSITION 26.
DATEOF DISPOSITION
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ADDRESS OF EMERGENCYADDRESSEE (Include ZIP Code)
27b. TELEPHONE NO.
28. DATE ORt HIS
ADMITTING OFFICER
ADMISSION
29. (AA) K---- IAA) 14-(VI
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY
30. DATE OF IN L 32. UNITS OFADMISSION
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31. SELECTED ADMINISTRATIVE DATA
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CAUSE OF INJURY
34. DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES
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35. Total 11 . ' I. acill
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ABSENT SICK DAYS b. OTHER DAYS e. CONV. LV/COOP d. SUPPLEMENTAL BED DAYS 1.
CARE DAYS e. TOTAL SICK DAYS
CARE DAY
I
36. Total Days All Facilites
a. ABSENT SICK DAYS b. OTHER DAYS c.
1
CONY. LV/COOP SUPPLEMENTAL
e. BED DAYS I.
CARE DAYS TOTAL SICK DAYS
CARE DAYS
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SIGNATURE OF
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EDMON OF USAPPC V1.10
MEDCO
DOD-031036

MEDICAL RECORD - ABBREVIATED MEDICAL RECORD
PERTINENT HISTOR Y. CHIEF COMPLAINT. AND CONDITION ON ADMISSION ( Rah r duty of Rd Mindinn
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PHYSICAL EXAMINATION (i x
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SIGMA IDENTIFICATION NO. ORGANIZATION
Sail(/16
IDENTIFICATION (For typed or written •
PATIAM"'S tr..' 'vs ante last. first. RIM OSTER NO. WARD NO.
Pl
( -t middle: Arad•: data; hospiral or medical lac lily)
ABBREVIATED MEDICAL RECORD Standard Form sae GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMR (41 CFR) 201-45.505 OCTOBER 1975 539-106
MEDCOM - 17448
DOD-031037

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MEDICAL RECORD
CHRONOLOGICAL RECORD OF MEDICAL CARE
OATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
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HOSPITAL OR MEDICAL FACILITY STATUS
DEPART.ISERVICE
RECORDS MAINTAINED AT
SPONSOR'S NAME SSNIID NO.
RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name . last, first, middle; ID Na or SSN, -Sex; Date of Oink flank/etadal REGISTER NO.
WARD NO.
CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record
MI6
STANDARD FORM 600 iREV. 6 -971( 6)(6)1 Prescribed by GSMCMR FIRMR 141 CFR) 201-9.202.1 USAPA112.00
MEDCOM - 17449

DOD-031038

AUTHORIZED FOR LOCAL REPRODUCTION
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(k)(6)-Low PATIENTS IDENTIFICATION: fFor typed or written entries, give: Name - lest, first, middle; ID No or SSN.. Sex; (REGISTER NO. I WARD NO.
Date of fierth; Rank/Graded
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record
DPW STANDARD FORM 600 (REV. 6-97) Prescribed by GSA/ICMR6)(6) FIRMR (41 CFR) 201-9.202-1
MEDCOM - 17450
DOD-031039
DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
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MEDCOM - 17451
DOD-031040
NSN 7540-01-075-3786
LOG NUMBER T
EMERGENCY CARE
( 6) (z)- Z
MEDICAL RECORD AND TREATMENT
RECORDS MAINTAINED AT
(Patient)
PATIENT'S HOME ADDRESS OR DUTY STATION . ARRIVALS-
STREET ADDRESS DATE (0ey, Month, Year) TIME

I
CITY STATE ZIP CODE TRANSP TION TO FACILITY
../. d" _.
SEX DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE ipe\ AREA CODE NUMBER ITEM YES NO N/A ITEM YES NO PRP ADDITIONAL INSURANCE
HOME PHONE FLYING STATUS DD 2568 IN CHART , AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY AGE
CURRENT MEDICATIONS • INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT
WHEN (Date) DATE LAST VISIT 24 HOUR RETURN
ITEM YES NO
n YES n NO IS THIS AN INJURY? WHERE TETANUS ALLERGIES IIWY/SAFETY FORMS . DATE LAST SHOT COMPLETED INTITIAL SERIES
4;
HOW • YES • NO 4--0 f\'
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CATEGC4RY OF TREATMENT Mk it.nr..v") VITAL SIGNS
TIME TIME •-)13• e) i

11. EMERGENT
BP
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INITIALS RESP
f: TEMP
• NON URGENT WT
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ACUTE ABDOMEN LS SPINE
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ANKLE R/L p-1 I-rtr t'Z'
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URINE C&S
UA N?SCC/CATH
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BLOOD C&S X
ORDERS
ULSE OX MONITOR ECG 61)ME ORDERS BY COMPLETED BY 1 TIME PATIENT'S RESPONSE
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DISPOSITION DISPOSITION QUARTERS /OFF DUTY PATIENT/DISCHARGE INSTRUCTIONS
ri HOME n FULL DUTY n 24 HRS. n 48 HRS. n 78 HRS.
MODIFIED DUTY UNTIL RETURN TO DUTY

CONDITION UPON RELEASE ADMIT TO UNIT/SERVICE 100. TO WHEN
REFERRED
• IMPROVED • UNCHANGED
TIME OF RELEASE I have received and understand these instructions.

• DETERIORATED
PATIENT'S SIGNATURE
PATIENT'S IDENTIFICATION (For typed or written entries, give: Name — last,
first. middle: lb no (SSN or other); hospital or
medical facility)

EMERGENCY CARE AND TREATMENT (Patient)
Medical Record
STANDARD FORM 558 IREV. 9.961 Prescribed by 05A/ICMR FPMR 141 CFR) 101-11.203(b)(10) USAPA V1.00

MEDCOM - 17452
DOD-031041

NSN 7540-01-075.3786
TIME SEEN BY PROVIDER
EMERGENCY CARE AND TREATMENT
MEDICAL RECORD
(Doctor)
TEST RESULTS
WBC
Check it read by
ABG/PULSE OX RADIOLOGY
radiologist
H/H SUP 02 PH P02 RESULTS
PIT PCO2 SAT OTHER
DIP -71(f EKG INTERPRETATION
/X(z-co_,
APTIT BHCG ETOH GLU MICRO
PROVIDER HISTORY/PHYSICAL
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CONSULT WITH TIME ACTION RESI ENT/MEDICAL STUDENT SIGNATURE AND STAMP
PROV IDER SIGNATURE AND STAMP
DIAGNOSIS
-2-
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(For typed or wrhten entries, give: Name — last, first, middle;
ID no. ISSN or other); hospital or medical facility)

PATIENT'S IDENTIFICATION
EMERGENCY CARE AND TREATMENT (Doctor)
Medical Record
STANDARD FORM 558 IREV. 9-96)
Prescribed by GSA/ICMR FPMR 141 CFR) 101-11.2031b)(1M USAPA V1.00
100,X110
MEDCOM - 17453
DOD-031042
NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST-DAY
MONTH-YEAR /41.46 DAY (-1 I k 1 11
1



3•9-..,D0.3 HOUR 10 • -• -

' • ' I
....
. . . .
. . . .
" "
....



PULSE TEMP. F . . : : : . . :
....
--1
C. W0 C.,J (A)CO 4.) CO Co 4.) 0)41. 41. rn cn cri a) cr, --4-4-4CO CO (C.00K
ba) i-. . 1.1 bIQ bo i.,..) (0 :11. b b) :0
0 000000 0 0 0 0 0 ,..)
(Centigrade Equivalents, for Reference only)
. . . . . .
" "
(0) ( 6 )

105°
• •. • • ••
...•.
. . . .
. . . . : :
. . . .
....
.
-•• --••
. . . . . . .
. . .
.. . .
,'
. . .
. . .
.
. . .
180 104°
. . . . . .
. . ..
. . . . . . . . . . . .

170 103°
. . . . . . . . . . . . . . . . . . . . •• -• •-•-•-•• •-•• • • •• ••

" •
. . . . . . . . . . . . . . . . . . . . . . . .
160 102°

" •-•• " •• •
. . . . . . -. . -•• -• •• •• . • •• . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . 101°
150
. . . . . . . . . . . . . . • •• -• •• -. •. . .
" • " • • " •
.... ....
.. ....

140 100°
-• •• •--• "
. . . . . . . . . . . . . . . . . . . .
130 99° l• • ••
98.6° : : : : : : : : .•: : : : : : : : : : : : : •. : : : : •.

120 98° •
II • • •

. .
....
•• •-•• •--•
. . . . . . . .
. .
110 9.7° , . •• . . .
. .
. .
. .
11• ••
. . .
. . . . . . . . . .
100 96° . . . . . . . . . . . : •. . . . . . .
•' -' •" " " • " " ••
. . . . . . . . . . . . . . . .
-•••



• • -• •-. .
90
80
. . . . . . . . . . . . . . . .
. . . .
. . . .
-
70
.. ..
. . . . . . . .
' ...
. . ..
•• " ••
. . . . . .
. .
. . . .
. .
. . . .
60
50
....
. . . . . . .
--. • . . . • •• . . . . . .. . . . . .
....
....
•• -•• ••
. . . . . . . .
. . . . . . . .
"
• • "
. . . . . . . . . . . . . .
40 t2.9 • " RESPIRATION RECORD 46%
Record special data only when so ordered
BLOOD PRESSURE
MI%
HEIGHT: I WEIGHT —ill.
PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle: ID No. (SSN or other); hospital or medical facility) REGISTER NO WARD NO.
VITAL SIGNS RECORDS Medical Record
STANDARD FORM 511 (REV. 7-95) Prescribed by GSA/ICMR, FIRMR (41 CFR{ 201-9.202-1

MEDCOM - 17454
DOD-031043

Ward/Sectto • REQUESTING PHYSICIAN:
CHEEMISTRY.RESULT FORM li'L ,, -..--4 : A -.:.. (Subject to the Privacy Act of 1974) -—
LAST, FIRST, MI. \ _ TIME SSN/PE_IIP0 SSN:„ .
'--.....„
• .; .: 4 '
t
4 .
w. 4091P)P , kOji ": 4.01510. #4 1Wrai
: ,...?...i.--:-.::4i.::..Y.i'
TEST. RESULT REF. RANGE TEST 1 RE SULT .REF ; _TEST _RESLZT: : REF. RANGE
t , z s i -,.: z .. c :Ca': i :' i'.0 ' ', 4'

Na 138-1461:mm1A GLU 73-118 mg/dl
.
: ; : -
.
K 7-22 mg/dl
3.5-4'"un°111; -- - - -PICCOLO - - - - - - -BUN Cl " 98-109 mmol/t; 17/08/03 03 : 03 CA. • 8.0411.1 in;dt
pH -7.31-7,45 , REFERENCE Ili MALE --C 0.6-1.2 raWdl • — PATI ENT # • (b)Cf") - ./
PCO2 35145 mmHg ty ,. .,,,.,_ 2,.., , 128-145 mmol/1
NAT
41-51 mmHg (vet ME r LY 1 t_ ti -P02 8°4°512'41B (31 DISC LOT # ' 3152AA4 K 2 i 3.3-4.7 mmo1/1
N/A (ven1
• ,
TCO2 23-27 mmol/L (to OPER # : DR # : °° : CL 9i-it4 mr-
-polA
24-29 mmol/L (v¦ -,
SER IAL •
1-1CO3 22-26 morl/L (al 1 ICO2 18-33 mmol/I, '¦ :1 2
23-28 mmol/L. 6,, s02 95-98% , "-' 1 (,LU 114 73-118 MG/DL iCOl..0•:14*.iir aiiejl tay...,4 1
mG/Di_ ....: ..!..:-..
, ;,...E;..;::-:4:!:' ...,...: v •• , .
- • BUN 33* 7-22
BEecf (-2) --I+1). , -, 1 TEST ' RESULT -, •.`REFRANGE'
nunon • s -CRE 1.9* 0.6-1.2 Mb/ DL : AnGap 10-20 iitmol/I., CK 833* 39-380 U/L ALB — — 3:3-5.5 -Wdl
..... Ca 1.12-1.32 nuno) NA + 132 128-145 11.10•f/L ALP__ _ 26-84 u/1
._ ._ .K+ 3.2* 3.3-4.7 MMOi/L
BUN • 1047 u/1
_.... _ 96* __. , tCO2 23 18-33 MMOVL Amy .
8-26ngh! CL-98-108 MMOR_ ALT
GLU 70-105 mg/d1 14-97 u/1
Creat 0.7-1.5 mg/dl INST OC: OK CHEM OC: OK ...AST ti -38 uti HEM 1+ , LIP 0 , ICT 0 .
Hct 38-51% PCV TBIL 0.2-1.6 mg/d1
Ilgb 12717.g/di GOT _ _ 5-65 ull

-. • ,i
1Vlisc , .g11415 TP 6A-8.1 Wdl ,...,..,,,,, , , ,,., .-.,,,,, ...,:::. :,'. . 11:'. , kt, • TEST RESULT i REF. RANG) {pjccola)•401406 yte. 1 `..', •s! ; t''-•,. 1
„ ,... 4.
Troponin-1 TEST RESULT — REF: RANGE
. _
Drug of N. 128-145 rnmol/I -
..i.._.,2 :.1 ,.
Abuse
÷ 3.3-4.7 mmol/1

. - ' , 98-108 inmoLl
CI: _ . . ,.
' — tCO2 18-33 mmol[!.
REMARKS: '

air DATE: .
REPORTED BY: — , LAB ID NO.:: - - - - -- '
, •
, 1 .
(b) (0 -1

MEDCOM - 17455

DOD-031044
F.
•• _ • ::ss ?
• ( 6
MEDCOM — 17456
DOD-031045

518-124
NSN 7540-00-634-4159
MEDICAL RECORD
BLOOD OR BLOOD COMPONENT TRANSFUSION
SECTION I - REQUISITION
COMPONENT REQUESTED (Check one) TYPE OF REQUEST (Check ONLY if Red Blood Cell
REQUESTING PHYSICIAN Pont)
Products are requested.)
elC;11) BLOOD CELLS
(61(6) -2-
.
FRESH FROZEN PLASMA cr`T'PE AND SCREEN

DIA OSIS OR OPERATIVE PROCEDURE
.
PLATELETS (Pool of units) II CROSSMATCH (- )"(

.
CRYOPRECIPITATE (Pool of units)

DATERE.q.JESTED L
I have collected a blood specimen on the below
/ y „.....,) ) q 9_7
. Rh IMMUNE GLOBULIN
named patient, verified the name and ID No. of the DATE AND HOUR REQUIRE patient and verified the specimen tube label to be
. OTHER (Specify) correct.
CP'‘
VOLUME REQUESTED Of applicable) KNOWN ANTIBODY FORMATION/TRANSFUSION SIGNATURE OF VERIFIER
REACTION (Specify)ML 11111111111111107)00..) - 4
REMARKS: IF PATIENT IS FEMALE, IS THERE HISTORY OF: ATE VERIFIED
RhIG TREATMENT? DATE GIVEN:
1 7
TIME VERIFIEDHEMOLYTIC DISEASE OF NEWBORN'?
a I 11c
SECTION 11- PRE-TRANSFUSION TESTING
UNIT NO.
TRANSFUSION NO. TEST INTERPRETATION PREVIOUS RECORD CHECK: ANTIBODY SCREEN CROSSMATCH
. RECORD . NO RECORD PATIENT NO.
SIGNATURE OF PERSON PERFORMING TEST
DONOR RECIPIENT
. CROSSMATCH NOT REQUIRED FOR THE COMPONENT REQUESTED
DATE ASO ABO REMARKS:
Rh Rh
SECTION III - RECORD OF TRANSFUSION
PRE-TRANSFUSION DATA
POST-TRANSFUSION DATA INSPECTED AND ISSUED BY (Signature) AMOUNT GIVEN TIME/DATE COMPLETED/INTERRUPTED ML REACTION
TEMPERATURE PULSE BLOOD PRESSURE AT (Hour) I ON (Date) . NONE . SUSPECTED IDENTIFICATION
If reaction is suspected—IMMEDIATELY:
I have examined the Blood Component container label and this form and I find all 1. DisContinue transfusion, treat shock if present, keep intravenous line open.
information identifying the container with the intended recipient matches item by item. 2. Notify Physician and Transfusion Service.
The recipient is the same person named on this Blood Component Transfusion Form and 3. Follow Transfusion Reaction Procedures.
on the patient identification tag.

4. Do NOT discard unit. Return Blood Bag, Filter Set, and I.V. solutions to the Blood Bank. 1st VERIFIER (Signature) DESCRIPTION OF REACTION
. URTICARIA . CHILL . FEVER . PAIN
. OTHER (Specify) 2nd VERIFIER (Signature)
OTHER DIFFICULTIES (Equipment, clots, etc.)
PRE-TRANSFUSION . NO . YES (Specify) TEMP. I PULSE I BP SIGNATURE OF PERSON NOTING ABOVE DATE OF TRANSFUSION TIME STARTED
PATIENT IDENTIFICATION—USE EMBOSSER (For typed or written entries give: Name—Last, first, middle; grade; rank; SEX Ip¦
;:j...7.....)
rate; hospital or medical facility)
BLOOD OR BLOOD COMPONENT TRANSFUSION
(0(6)-ii
Medical Record
STANDARD FORM 518 (REV. 9-92)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9202-1

MEDCOM - 17457
Medical Record Copy
DOD-031046

.
-• -
CVNICAL RECORD • DOCTOR'S ORDERS
Far !,?se or this form, AR 40-66, the propimitnt agenty is OTSG
THE DOCTOR SHALL RECORD DATE, Tun AND MN EACH SET OF ORDEFIS. if PROBLEM ORIENTED SAEDIC.Xi.. ITECORI5 SYSTEM IS USED WRITE PROBLENI NUMBER IN COLUMN INDICATED BY ARROW EIE-Mv3i_
PATIENT IDENTIF ttATION :DATE DS' OPI6ER tiii411' -bF Ont.tri : 7.771'.4:'W':
1 : (WE2.1k-'1:*•: -
:3 c): t'Qvi*. : 7 ..L.V4, ' •-•
id Awcazz4 2-5
."(Y, 7 K461-4" --
,'eejg
. .g1;",•!21L2A"'"(" 4A-S.A. /0• -- ) /-' "Q"e -. - ..---- ---
.
CO (6) '.
; sue--

t---
, .
-.
L
NURSIND UNIT (ROOM NO BEP. Na
4 64.1.dC411.17 6? ‘
' ---• -/-
1 1111 . ' "..-5-c., _ z- - ,...,..o. ,5 (27,.;,-,,,,./2„.i.:4/ ..2-Y
PATIENT 1 DE NT uF tr,'ATtOn • DATE OF DMA: TIME OF OROER
—....... _ ........ i4oURs

G S7-9 --7­
:-/0-.A.--",-,--v,-Q -YZ-1-cooa--s-ca--1/4.
a/zizo---€A--.
-1--" I CA-r C.7",-ite-•-et..../T'''6,"
.
4._ 4/..).L.,...1,1:______ef.:?„..,..-_.-ors,---e---____ ___._.
liURS-ING UNIT !ROOK NO. aEry ND. t
41,
PATIENT q)ENTli., teATtoN DATE C OR R TIME -DER
1) -3 0 HOURS ..:
Chl„..., ‘.._Tet-tA......j•--
lrIriardr Yle---1-4-t-.3t,kp___ 1
NURSiNc.: UNIT ROOM N.O. BED No.
I .­
€ 17? Xi0 Z
PATIENT +DENTt.s1CATioN DATE OF ORDER TIME OF ORDER
/ -2
. .____ .,.. Hoi.¦ HS
¦
ill-4-)
Ci,)(0 "1-
( 6) -7--
NURSING UNIT 1 ROOM No. Eno NO
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
A 1 A°AM 4256
MEDCOM - 17458
DOD-031047

THERAPEUTIC DOCUMENTATIONCARE PLAN (NONMEDICATION) '
-
CLINICAL RECORD Far use of this form, see AR 40-407;
M O • Yr. 2003
11 -.. • • • I - /I ••,. a .1 -*2 I -.1 .J1 11-il I
1 -. , ' '::

VERIFY BY INITIALING :1-;3::=V 4:: ' :: ; ,, a- = -7 r -. INITLIL PROPER COLUMN FOLLOWING EACH COMPLE770N
NR DATE COMPLETED
ORDER CLERK/ RECURRING ACTIONS,
al
DATE NURSE FREQUENCY. TIME

IVIII111120
ORAL- 1 III
IMMINIZIE111111•111111M11111111 IIIIIIIMIIIIIIIIIIIIIIII
,,...,...-,,,,,,,,..,..-.,.....,,4,,,,,,,,„....:.,....,_ :,,,, i
. .. r,......
. .
,, ._...
. ,,,_,_.,,..44,-,
¦...mm MIL— -- rm.! MIIINIRWRIQ 1 .'4ViVem,..t.-.,,Vr—amehmIdIMINi
A

EINEMIESIEMMIR II
MIZI • Fri . • IIII
, r-----wijm ,,„,, .
siiimmoo
IN
=El fa ¦ 1111

31 II 111 III
MI
II 11
Il
II II
1111
111
II III
II
II
. ¦II
ALLERGIES: - YES - NO PRIMARY DIAGNOSIS: • ADDITIONAL PAGES IN USE:
MI YES p NO

.
PAGE NO'
N " 4 S kr • nz I 4 1
•:
ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES

D 8 9 10 11 12 13 14 15 ( 17)(0 - 't
E 16 17 18 19 20 21 22 23 N 24 01 02 03 04 05 06 07 DA FORM 4677, 1 OCT 78 EDITION OF 1 DEC 77 MAY BE USED. USAPA vl.00
MEDCOM - 17459
DOD-031048

. Verit y, by
THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing

(N011-MEDICA770N)
Mo) yr 2003
Order Clerk
Date to Time to
SINGLE ACTIONS
Date Nurse
Time Done InttlaIs
be Done be Done
At.1-70 511111/ A ' 4 C) . ,/,1 rr,( —1-C (,C .14a rilLet9, o.Aa?)
03)00- 2. _.,
Ab46-= c.on.-14 -tor\ ..s-4-6 Lie.--ofivq03 t3a LA) o2.3a IIIIII
ikzr 00( ....,._ p 1 z; r \ or4ko 4-4.
ate-(11-1(403
(,.?c1.,)-a 84.14.A._ „pkileinii—
nnA0 030 ( L)-7 Ckan wo-uv lot C1,4,14 -4 KAU_ q triofr OW COO (so) U )-z
dA(1/6 OIRSSil
.
.
,
.

Order/ clerk/ •
PRN INITIAL PROPER COLUMN FOLLOWING COUPLE:HON
DD ir Nurse ACTION. FREQUENCY ......

. TIME/DATE COMPLETE

1
- - - - -
USAPA V1.00
MEDCOM - 17460
DOD-031049
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of this form, see AR 40-407;
0)
MO. C'r .
the or000neet aaency is the Office of The Surgeon General.
VERIFY BY INHALING ''• :;; 3iA ,17-7,..-11',.. INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED
ORDER CLERIC/ RECURRING MEDICATIONS,
DATE NURSE DOSE, FREQUENCY

C
11 i tAdf 1" ry-1 nLOCIna 410
Loc(0)-..7-:. p ',b)(0-2.
I Ii'
04 .
.. -
ALLERGIES: El YES NI NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE: Ei YES MN NO
PAGE NO.
PATIENT IDENTIFICATION: DISPENSING TIMES

' USE PENCIL. CIRCLE MED TIMES MilD 7 8 9 10 11 12 13 14
-
EPW
E 15 16 '17 18 19 20 21 22
C °)(-(43) -‘f
N 23 24 01 02 03 04 05 06
DA FORM 4678, 1 FEB 79 EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED. USAPA V1.00
MEDCOM - 17461
DOD-031050

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN ,
Initialing (MEDICAMONS) Mo_) Yr.
Order Date Clerk/ Nurse SINGLE ORDER, PRE-OPERATIVES Date to be Given Time to be Given Time Given Initials

.
#11

Order/
clerk/ PRN INITIAL PROPER COLUMN FOLLOWING ADMIVISTRAIION Dara TIME/DATE DISPENSED
MEDICATION, DOSE, FREQUENCY
VT446. 11111 li4
cg 1,e15 M.; 01
(30) (ta)- I —
V i el,
S—V le 1 prn ak (6)(0_2
P 6sin
1,5bms-kfie,-‘5I
Loso.:-.,_ .
0 ....
ro VI Pr-ri FOver-• . •
1


1
USAPA V1.00
MEDCOM -17462
DOD-031051
1 . REPORTING MTF 2. .. _OCATION

ADMISSION A..10 CODING INFORMATION
1 2 3 4 5 6 7 8 /Stare or
Country

For use of this form, see AR 40-400; the proponent agency is OTSG
( Code.)
A k L D -Y-
3. REGISTER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX
9 10 11 12 13 14 15 16, 17 I, 18 1
cpki 4:51.• cb)c6)-it
mo 7-471
6. DATE OF BIRTH IVY V YMMDDI 7. AGE AT ADMISSION 8. RACE 9. ETHNIC RELIGION
_3_
19 20 21 22 23 24 25 26 27 28 29 30 BACK-
GROUND

tAA) IL
2 .Z z 2. .z-z, z e & X ,q
10. LENGTH OF SERVICE ETS 11. FMP 12. SOCIAL SECURITY NUMBER
32 33 34 35 36 37 38 39 40 41 42 143 144 45
ORGANIZATION (Active Duty Only) ' 13. MARITAL STATUS HOUR OF BRANCH / CORPS ( )(6) -"I
ADMISSION

46
,
Dia
14. FLYING STATUS 15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE
47 48 49 50 51 52 53 55 56 57 58 59 60 61
`--Z-z-

17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREY. ADMISSION
Country Code)

62 63 64 65 66 67 68 69 70 71 YEAR 1. ,,I
Ni NO

..._
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
ADMISSION
(./tA))C-•
72
ADDRESS OF EMERGENCY ADDRESSEE (Include 21P Code)
LA Alle^
N T FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

CVX 2') -2- tA „Ai r-
1. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION (V Y M M D D)
73 1 74 /. 75 76 77 78 I 79 80 81 82 83 84 85 86
I
.46W \t--) 0 3 0 8 ( 7

24. CLINIC SVC -ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION IY YMMDD)
87 88 189 961 91 92 93 94 95 96 97 98 99 100 101 102
._E L_ A 1 L 0 3 0 0 I -7
27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION IYYMMD DI - -(Battle Casualty Only)
.
103 104 105 106 107 108 109 110 111 112 113 114 115 116
_ -.-
.._.

FOR LOCAL USE

AWMUMm..-

6.ra 6.I i IS MTN
MA.... UP ---'7'.-"•••¦
0616 sq P
q / 6

e-qq,q
ADMITTING OFOrdER-ISIgnarilfe,-a-slequired)
'
EA BZ A¦ AA On
MEDCOM - 17463
DOD-031052

Doc_nid: 
3930
Doc_type_num: 
72