Medical Report: 25-Year-Old Iraqi Male, Detainee, Abu Ghraib Prison, Baghdad, Iraq re: Gunshot Wound to Arm and Leg

AUTHORIZED FOR LOCAL REPRODUCTION
PROGRESS NOTES
EDICAL RECORD
RELATIONSHIP TO SPONSOR
HOSPITAL OR MEDICAL FACILITY
DEPART.ISERV ICE
(For typed or written entries, give: Name - last, first, middle;
PROGRESS NOTES
ID No or SSN; Sex; Date of Birth; Rank/Grade)

PATIENT'S IDENTIFICATION:
Medical Record
(REV. 5/19991'.
STANDARD FORM 509
Prescribed by GSAIICMR FPMR (41CFRI 101-11.203W 01
USAPA V .00
t
MEDCOM - 22041
DOD-035617

I

STANDARD FORM
MEDCOM - 22042 509 (REV. 5/1999) SACK
usApA v, nn
DOD-035618
IELATIONSHIP TO SPONSOR
RECORDS MAINTAINED AT
DEPART.ISERV ICE
(For typed or written entries, give: Name - last, first, middle;

PROGRESS NOTES
3ATIENT'S IDENTIFICATION: ID No or SSN; Sex; Date of Birth; Rank/Grade/
Medical Record
511999) ­
STANDARD FORM 509 (REV.
Prescribed by GSA/ICMR FPMR t41CFR) 101-11.20303)00)
USAPA V1.00
An 09) (w-cf
MEDCOM - 22043
DOD-035619

STANDARD
FORM 509
(REV. 5/7999) BACK
USAPA V1.00
MEDCOM - 22044
DOD-035620
ID NUMBER
MIDDLE INITIAL
FIRST NAME

NOTES
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4

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11.0411110L
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• gre.lb.
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db.s.S.
11116.
STANDARD FORM 509 (REV. 5/1999) BACK
USAPA V1.00
MEDCOM - 22045
DOD-035621

NOTES

. RECORD
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RECORDS MAINTAINED AT
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DEPART.ISERVICE
(For typed or written entries, give: Name - last, first, middle;
PROGRESS NOTES
ID No or SSN; Sex; Date of Birth; Rank/Grade) Medical Record
PATIENT'S IDENTIFICATION:
(REV. 511999)
STANDARD FORM 509
101-11 .203Ib)(101,
141 CRR)
USAPA V1.00
Prescribed by GSAIICMR FPMR
MEDCOM - 22046
DOD-035622

PROGRESS,

ELATIONSHIP TO SPONSOR
RECORDS MAINTAINED AT

EPART./SERVICE
fFor typed or written entries, give: Name - last, first, middle;

1/2TIENT'S IDENTIFICATION:
ID No or SSN; Sex; Date of Birth; Rank/Gradel
PROGRESS NOTES
Medical Record
STANDARD FORM 509 IREV. 5/1999) Prescribed by GSA/ICMR FPMR I41CFR) 101-11.2030)100)
USAPA V1.00
MEDCOM - 22048
DOD-035624

PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT
MEDICAL RECORD
FOR Use this form. See AR 40-407: the Proponent agency Is The Office of the Surgeon General.
2. KNOWN ALLERGIC SENSITIVITIES (e.g.. lodin, Tape, Medication)
WEIGHT:
1. AGE Z S ,NKDA . PCN . LATEX . IODINE . TAPE . FOOD
REACTION:
HEIGHT:
3. PREVIOUS SURGERY pd NO [ J YES (type):

4.
PROPOSED SURGICAL PROCEDURE:

5.
ADDITIONAL INFORMATION: (Previous J urgical and medical history) Skin Condition

Tobacco ppd X_____vrs Body Piercing ETOH Implants Glasses/Contact (Y)(4)) Dentures
6. PATIENT PROBLEMS AND NEEDS
A. PSYCHOSOCIAL
...----potential for anxiety related to: .....-
..----
1) Surgical Procedure& Operating Room Environment 2) Separation Anxiety
(Child
---"" 3) Surgical Outcomes
.

B. AERATION
,../----Potential for respiratory
dysfu ion due to:

..- Positioning ---12) Effects of Anesthesia 3) Medical/Smoking History
C. INTEGUMENT
---- Potential Impairment of Skin Integrity due to:
"----1) Intraoperative Immobility ----2) ESU Pad Placement ...-----3) Positional Aids 4) Prosthesis -----5) Pooling of Prep Solutions
9. PATIENT'S IDENTIFICATION: ( For typed or written entries give: Name-last, first, middle; grade, data; hospital or medical facility)
2C00 ,kc Zg rtis_ C."231-
DA FORM 5179, JUN 91 Previous editions are obsolete.
Diabetes (Y)0 ROM
ASA/Motrin W 72hrs (Y Respiratory Disease (Asthma COPD) (Y) Anticoagulants (Y)
Hypertension (Y) Herbal Medicines Y
7. PATIENT GOALS AND EXPECT6 OUTCOMES
Pt. verbalizes any specific anxiety.
Pt. Exhibits relaxed body posture.
,..0-1---

Dt. will be able to breath without difficulty during immediate intraoperative phase.
D.Pt. will exhibit signs of impairment of
skin integrity (e.g., reddened areas).

•.:r
8. OR NU SING INTERVENTIONS
. Allow pt. to verbalize freely. . Explain Or environment and answer estions regarding surgery.
. Offer comfort measures. (e.g. warm
anket. touch).
. Explain all nursing procedures before
t y are done. . Remain with pt. Whenever possible.
0. Maintain family interface. Parents to stay with pt.
, . Offer to elevate head of litter or offer
ft:6.
. Observe pt. While awaiting surgery for
gns of distress.
. Assist anesthesia during intukiatior
and extubation.
. Utilize pressure preventing devices OR table and accessories. . Check for proper positioning and
upport to maintain good body alignment.
. Pad pressure points.
. Place ESU ground pad on non

ompromised skin surface area.

. Keep prep fluids form pooling.

VERIFICATIONS AT HOLDING AR
! ID/Allergy Banci . ! Dentures Re
! H&PV Contacts oved
! NPO Since . ! Jewel removed
!—l4Het/L10115 I Bo. Pierce Removed

I Consent/Blood Transfusion Signed/VVitnessed/Dated ! Surgical Site/Consent verified by
Pt /Anesthesia/Surgeon ! Contact precautions )(5) ! Family/Friend:
USAPA VI.O
MEDCOM -22049
DOD-035625
6. PATIENT PROBLEMS AND NEEDS
7. PATIENT GOALS AND EXPECTED OUTCOMES
8. OR NURSING INTERVENTIONS
D._SLReULATION
Potential for inadequate tissue perfusion due to:
1) Intraoperative Mobility Positioning

3) Existing Disease
••• 4) Safety Devices
Hypothermia

E. NEUROMUSCULAR
CONTROL

E.I. Potential Impairment of
Mobility due to:
1) Pain

Infra operative Hazzards 3) prosthesis
-- 4) Positioning
Transfer pt. To/form OR table

E.2.
Potential Discomfort Due to: 1) Length of Surgery
2) Positioning
3) Arthritis

F. Special Senses
F.I. --Diminished visual perception due to being:
_1) pre-medicated
2) W 0 GLASSES
F.2. Potential for Decreased
Communication due to: 1) Diminished Hearing
2) Language Barrier
F.3. Potential Injury due to Dentures:
1) Upper 4) Caps
2) Lower 5) Crowns
3) Bridges
G. OTHER PATIENT PROBLEMS NEEDS OR Continuation of Above problems/needs.
___—‘2)!151. will exhibit signs of adequate tissue perfusion (e.g. color, warmth. pedal pulse.
pt. will be transferred to OR table without
ifficultly.
pt. will be not experience unnecessary
hysical discomfort.

pt. will be made aware of surroundings
rior to anesthesia induction.
pt. will be transferred safely to OR table. c pt. will be able to understand instructions. c Minimize danger of injury during inlraop period.
OTHER PATIENT GOALS AND EXPECTED
OUTCOMES. Or continuation of above goals and outcomes.
O Check foe support stocking or ace warps. if none, check with doctors. eak that safety straps are correctly applied.
O Offer pillow for under knees.
O Plac.6 and take down legs from
stirr_pawith slow bilateral motion.

u
Check that rings and all body
piercing has been removed.

Have sufficient people available for
ran sfer.
i
Insure proper body alignment. Allow patient to lie in position of mfort while waiting for surgery. Offer support (i.e..pillows. Bath
towel. etc) for positioning.

Introduce self. keep pt informed as to here he. she is and what is happening. Inform pt. in which direction to move Ind assist if necessary.
Speak clearly and slowly. Address pt. from1.4 AI 111-/. side.
Validate pt.'s understanding of verbal communication.
0 Verify removal of dentures.
OTHER NURSING INTERVENTIONS OR continuation of above interventions.
10 OR NURSING INTERVENTION COMPLETE D/ADDITIONAL INTRAOPERATIVE INTERVENTIONS NOTED.
CAk 42,0 0 (k13.3
DATE
11. POSTOPERATIVE EVALUATION : SKIN INTEGRITY: Boyie Pad Site: MiClean and Dry . Red . N/A ',MESSING DRY & INTACT:
LEVEL OF CONSCIOUSNESS: . A&O kDrowsy . Sleepy . Intubated C.Ly (N)
.1MOVES ALL EXTREMITIES tAr LEVEL OF ACTIVITY: Moves Upper Extremities BY)ATHING EASY:

%/M.
. Transferred to Lit ith roller due to spinal N)
12. PREOPERATIV
PAR 13. PREOPERATIVE E
EPARED
(Signature and Title)
BY (Signature and Title) NA-Ki
DATE: (9 ca--)
TIME: 111-(c DATE: 26134G­
6 TIME:
REVERS OF FORM 5179, JUN 91
MEDCOM - 22050
USAPA VI.0
DOD-035626

1. PATIENT TRANSPORTED TO OPERA I . 2. PATIENT IDENTA .0 REVIEW PROCEDURE
VIA k;\--W/ BY A7Aterpr7 -f. -.,....,N tk VERIFIED BY 55"c--- (b)(6)- 2--
3. DATE TIME PATIENyRRIVED IN SUITE 4. PATIENT ROOM
2-to Ojc 1Ci TIME INLy NUMBER
5. PREOPERATIVE EMOTIONAL STATUS

. li'• CALM . ANXIOUS . EXCITED : II CRYING . ANGRY • WITHDRAWN • OTHER (Specify)
COMMENTS: y (.:v.c..v.ouvv\ \jo•-:; tavA
6. NURSING PERSONNEL
.........,
ASSIGNED c_.-+F---RELIEF
SCRUB SCRUB

ASSIGNED \ ( ( RELIEF
CIRCULATOR ... ... ---CIRCULATOR

7. POSITION AND POSITIONAL AIDS (Specify) _..,,
SUPINE • LITHOTOMY • PRONE • KRASKE' -LATERAL:
• LEFT SIDE UP III RIGHT SIDE UP
co",,si k
botl, tk,Qtlevvv¦IjAAk .,; -0\-Zi01, COMMENTS:
8. SKIN PREPARATION HAIR REMOVAL • YES rg NO • PREP LUTION (Specify)
'RI:Lk, SC4"Jan gialNOLRok.j.,N.d...4c-DONE BY: • OR • NURSING UNIT SITE L. a.„..,.„.,, tfictwv.,421BY WHOM:) _ 'r-11- r
-
METHOD: 11• DEPILATORY • RAZOR . SITE:. . BY WHOM:
• CLIP _.____ COMMENTS: _______----COMMENTS:e\A_Nzi ' ,
e) • ' ON( SVA-A..), ..S. -t-s_etleta
9. LOCATION OF EXTERNAL DEVICES
....., .......

. .
A
.....

V.-sg9
LEGEND X Ground Pad (AA - Safety Strap = = = Tourniquet,--:::::-
C = Correct I = Incorrect r..c jaickl. t
First Closing Final Closing . -'

10. COUNTS
Other• • Count .. I ,.. : COUnt SCRUB
6 4)— Z / CIRCULATOR Sponge Li Yes lo J
'''''•-• Needle Sharp [ Yes No „.-_ -.. -
Instrument Ej Yes No .. _ . ..i.N.-i;0:7i,. "
_
Other . Yes lo
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) • YESXN0
Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;)
ESU NO: / 1 VV . C31_12-1t0 V E NQS QS
1 Mil b19 •
L GROUND PAD: IgRANDBRAND Vi.- Wmoi_-, rov leiveg• : . .. .LOT NO .707(i 7196S.
1 •.
•,-=._--

El.....6:111 NO:
_
Z6004--0.-.. --GROUND--GROUND PAD: • BRAND

-..,
LOT NO:
WON • BIPOLAR NO:

-1, REPLACES DA FORM 5179-1 (TEST), DEC 82, WHICH IS OBSOLETE.. S. USAPA V1.00
) 4 #
MEDCOM -22051
DOD-035627
........._

ci I 6-4- 5 Lx-y-Sir:q.;L: x--
(­
_,Root›,-A OK 2-al 1 0.-
11R ' \)•-iSk (-..-
....—
"14. ,,,' ,5 .,,,,,'MEDICATIONS/ORDERSP7 ' '-',1. W '44' ,. , Vigt ii,30tt IRRIGATION/MEDICATIONS GIVEN IN OPERATING. ROOM (NOT BY. ANESTHESIA) YES • NO
[It
;MEDICATIONS/SOLUTION DOSAGE - . TIME -'
'. .--------— "
WOUND IRRIGATION YES • NO TYPE(S):
0-61 % b¦b,- CO-. ,
'OTHER ORDERS
16 .--Ic .-Vo No\o-cxcik,9_,,r utc,4_ ¦......Ac-e.431/¦,...-c1._
....,.___ . .

,
fT'HYSICIAN'S SIGNATURE
F=
15. X-RAY IN OPERATING ROOM IF YES, SITE
F ,

YES JR-NO • ­
0.14 e1..,
16. -'. ­
' -!-LABORATORY SPECIMENS , ,,,,
SPECIMEN (S) NAME -- — ----.-----;,---------
YES • NO IN ----.'
FROZEN SECTION (FS) NAME
YES III NO X
CULTURE (C) NAME
YES • NO k -__ _._

NAME NAME
NAME NAME
• ------
17. TUBES, DRAINS/PACKING YES E3 NO •
_ .__..

TYPE/SIZE 1. 2.
16 A74C
SITE 1. 2. 3.

eic.,-fAace.A/

19. ADDITIONAL INFORMATION
. . :
.___.

20. OP ATIOri(S) PERFORM ;D
--,...... "1-¦¦.
\ 1-..1.-)

X.V¦VV WA-A -I-V-NvI¦ ‘t - - cs
;
21. PIENT TRANSFERPtED TO TIME :45eR0 CAIV"" C VA-(AA) 1tr.tec1
.

22. REGISTERED NURSE SIGNATURE --— _ ;.4
( RI--‘/4-4,)

REVE
MEDCOM - 22052
METHOD PREPARED BY GIVEN BY
TIME CARRIED OUT BY
: I: : I 0
(k) ) -Z-, . ., -
5,
NAME NAME NAME NAME
18. DRESSING/IMMOBILIZATION (Specify) )ewNri trIA-A1 VA-•-.
Y-01-ekk .3
ei-bD

.
METHQP
lilt ri-e,v
USAPA V1.00
DOD-035628

11. PATIENT TRANSPORTED TO OPERA M . 2. PATIENT IDEN I iii .0 ORD REVIEWED tr/PIrC.EDURE VIA ht J`vgkkositt BYA ii\g.1-- krtf-14 VERIFIED BY I Cr
kJ) ) —9-;•
3. DATE TIME PATIENT ARRIVED IN SUITE 4. PATIENT IN ROOM
TIME: ; 1155 NUMBER 5

OZ OCX 03 /--
5. PREOPERATIVE EMOTIONAL STATUS CR CALM . ANXIOUS • EXCITED : U CRYING II ANGRY U WITHDRAWN • OTHER (Specify)
COMMENTS:
__.,:_..,....._

10Cb N ,

woo 7 ri1K)

6. NURSING PERSONNEL 1111.1.11111L___ __
ASSIGNED . :T. 7777-7-------RELIEF SCRUB SCRUB
•
ASSIGNED RELIEF CIRCULATOR _ ..._ _ __CIRCULATOR IN . 1 , •
7. POSITION AND POSITIONAL AIDS (Specify) ..,..,. Zi. SUPINE 1 LITHOTOMY c IN PRONE / KRASKE, :. ., LATERAL: U LEFT SIDE UP • RIGHT SIDE UP
C TARA--b0 0-9¦%Ywv.StIN ; ., -0.Ahn'x'e,-i6'..;Lek.,
COMMENTS: 8. SKIN PREPARATION
HAIR REMOVAL I YES N NO PREP SOLUTION (Specify) R/
DONE BY: II OR • UNITNURSING SITE: BY WHOM:
METHOD: I DEPILATORY U RAZOR - SITE: . . BY WHOM:
• CLIP ___ • .
COMMENTS: .. __.________ .COMMENTS:

9. LOCATION OF EXTERNAL DEVICES
_
.
I

w_7PEP
LEGEND X Ground Pad - Safety Strap = = = Tourniquet... -‘..-.-.....--C = Correct I = Incorrect
First Cloatng Final Closing

10. COUNTS Other" Count ... .CotInt .SCRUB
CIRCULATOR Sponge . Yes Vo Needle Sharp II Yes No . ... Instrument . Yes Vo ___ ._ :. ?.;.,";,.': .
....-._. ..__._. _Other . Yes No
11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELECTROSURGERY DEVICE(S) (ESU) • YES iSirNO Name - Last, first, middle; Grade; Date; Hospi al or Medical Facility;)
.. ESU NO:
.

• GROUND PAD: BRAND
gill' ( 4'.(f ) , : ...
: _._ •
LOT NO: ::.'1=1,',ES -1) NO:
_ _,..
.._ 7.'GR(JUND PAD: BRAND

mu. ("gz) -1--
,,, LOT NO: 2g0u4-133 • BIPOLAR NO:
REPLACES DA FORM 5179-1 (TEST), DEC 132..W1-11CH IS OBSOLETE. USAPA Vi .00
MEDCOM - 22053
DOD-035629

13. PROSTHESIS, IMPLANTS 11 IL ,L) it T tJ NHIVIt: ILJ INJUIVII:5t1-. I Ullth
. .. --- „---
'''1,.-‘, MEDICATIONS/ORDERS
14• 1-;;--,' • ,i -=,4-NiW ;! IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • NO ;MEDICATIONS/SOLUTION DOSAGE-'... TIME METHOD PREPARED BY GIVEN BY _ ....s. • .: .-_ —
is
;: 9 WOUND IRRIGATION A YES • NO, TYPE(S):-i 0.9 6/ 13g j a
. .
;OTHER ORDERS TIME CARRIED OUT BY i :
' eAAISVd ___—_--
'PHYSICIAN'S SIGNATURE .__
it.,,,?2,,,,,,,K,9,1,1;,,,,,CA2K,,,,,,xv1,,,,,,,, ,,t •I, -
15.
X-RAY IN OPERATING ROOM IF YES, SITE
YES / NO g-_

16.
' ' '':!LABORATORY SPECIMENS

SPECIMEN (S) NAME NAME
... .. ..

-r
FROZEN SECTION (FS) NAME NAME
YES Il NO ri

YES • NO PPA'
'
CULTURE (C) NAME NAME
YES • NO k] ._ __ •_

NAME NAME NAME
NAME NAME _ . -..-,:-18. DRESSING/IMMOBILIZATION (Specify)
Ke.vbACIThilAk.-

17. TUBES, DRAINS/PACKING YES . NO I:0
— --

TYPE/SIZE 1. 2. .
r_st-AAA
itl3t3
SITE 1. 2. 3.
19. ADDITIONAL INFORMATION
SOGY-IY\ ¦ 's--;'''V,
(4 7:7?-rR..7.5.7
tA,Ste'aal

.
. ---Nc Snel I A OilaCt
20. OPERATION(S) PERFORMED . --
C--
i

21. PATIENT TRANJERRED TO TIME. _ METHOD
75= LtA3 C 9A-CAA) -D/tZei -1-"-Ve-Jv
22. RS S GNA URE \.0

Na) -

REVERSE OF DM FOR 179 OCT 87 USAPA VI .00
MEDCOM - 22054
DOD-035630
11011 LH*

L19
VITAL SIGNS REcORD
RD

• -- - - - --HOSPITAL DAY
.-

DAY ' TH-YEAR DAY VatlailMIMIEriEl.0. er • 0 EWE31 cr_. HOUR 1 • BEI -0 • •• • ffg; • • 1111111TI • • PAPIESII ' •
law-
nimmi.
r

am
TEMP. FPULSE

-vo0
—I WW W W
AArn 0100(4S3C4)1 W00000K O 6i-. L., bi..) Co 14 io 't+ bin :13
0 0 0 0 0 0 0 0 0 0 0 0 0
i ir

WA: WM

(0) (6)
105°

MEAN

milk .
.
H :• :.
:

:: :•• : :
. . . .
180 104° . . . . . . . .
. . . .
. . . . . . . •• • • ••
. . . . . . . • . .
. . . . .
•

(Centigrade Equivalents, for Reference only)
170 103°
. . . .
.

• '
. .
' • ' • "
. .
"
. .. . . . .

.
.
. .

. . . . . . . . . . . . ' . •. . " . . " . . " . . " . . ' .• . ' .• . ' . ' •. .• . . . . . . . . . . . . . . . . ' •• • • 160 102° . . . . . . . . . . .
. . . . . . . 150 101°
I
. . . . . .
. .

. . . . . .
140 100° Ill•
:: :•• rairingla
•

•
OMR •A MEE
Mill
99 °
98.6°

120 98°
EMI Ill4
11im
•

BINIIII:. -:111,I ::
SIZINERW11111111.11EIMENIKIMERMINUNIrr
: :. imoi
161

MEI i• :1111
: :

: : 1111111E1 .

I In

1 : :Ea
:: ::

:: I
I
110 97°
. • •••
I •
960

I 11
•'
: :
1M
I

:

100
:

•
:

IIIII
I-. I ::
:' • • i
90 95° so
NI111111
•
80
¦
. . .
. .
-
70 IL.2111
C . '

. . . : : . : : : : ' . •• . . .
60
•
:
. .
. . . . . . . . . " • " • ' •
. . . .
lf111111,1 .
" ' •
' •
50
.
•
. .
. .
•
. .
.....
......
. ..
"
. . . ......
. . . . . .
. . . . . .
40
• 1 . . . AIN
11111111 • • MIN
IGIMIMISUr. EEC712?Ii
PIRATION RECORD

•ffIll
GAIIIIIM MA f t b
BLOOD PRESSURE MOM
rio
11L:il
111111=17231111111EN
MIN

EIMM :WA'
uMffell.l
i il1•111 EMPIMIIMI
I II

HEIGHT: WEIGHT —0.

ir
examisztarittsfommit.wiv-mmucep
li-to
. ,
ENT'S IDENTIFICATION (For typed or written entries give' Name—last, first, middle; ID No. • REGISTER NO . WARD NO. (SSN or other); hospital or medical facility)
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 511. (REV. 7-95)
Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1

MEDCOM - 22055
DOD-035631

MEDICAL RECORD VITAL SIGNS RECORD
HOSPITAL DAY POST DAY MONTH-YEAR NoV DAY V
0 lb HOUR
. . .
PULSE TEMP. F . . . ...... .....
(0) (•)
. . ..........

105° .
.....
.. .
180 104° . . 170 103°
. . . ..... ........ , ......

,
co co co c...) o.) co co co co c.‘
at ()I a) a) --.1-,, —, co co q O6k-.16k) bo L.JCD .F
0 0 0 0 0
°
°°° •
(Centigrade Equivalents, for Reference only
•
•
160 102° ........

.. .. ..
•
150 101° _40 100°
...... ......
130 99°
..... ... .. . . . . . ....
98.6° '
20
98°
•
......
•
110 97°
I.00 96°
p
00 95°

............

80 70 60
......
, ......
.... ...
ter,
. .,;.. . ..
40 RESPIRATION RECORD ,,, 2 -c' 2 a`r. 1 BLOOD PRESSURE HEIGHT: WEIGHT --0. P: Z947 ,
Ij
. "i" n 7,,j `-',
T-d cc _ A !-;Frs:r'S IDENTIFIC:ATION For typed (SSN or written entries give: Name—last, first, middle; ID No. or other); hospital or medical facility) REGISTER NO WARD NO.
STANDARD FORM 511 (REV. 7-95) BACK

MEDCOM - 22056
DOD-035632

LABORkTOR.:: RESULT FOR2k4
(Sub ¦I ect to the Pr ivac ,' Act of 19741
a
1 DATE TIME -SSN7PSECTDO ss N:
CWI IV )
O
thrin•stlysis.•
•
. . . . • ;
iNGE
RESULT REF: RANGE TEST 1 RESULT W. R.4 iYGE
A 111.2
WA
RPR Negative
WA

H Mono -I Negative
Negative

H
Negative
Ket Negative
Gram Stain
PI SC I 'N/A
°co Bld Negative
Bld H. pylori Negative
Micro Parasites Prot Negative
Malaria
BE
Urob 0.2-1.0
I 0 & P
Ly

Nit Negative
Other
At
Lcuk Negative
roscoPic Urisi a
la r'
RAPIDPOINT COAG ANALYZER V4.54
SERIAL #005485 10/26/03 14:35

Patient ID:111110)(0-1
Test Name :PT

MUST • BM I' S 8 WITH
Test Result:= 13.8 sec.

EVERY a QUESTED
Ratio = 1.1

igen Nep-tive
Calculated INR = 1.22 ABO/Rh I
Sample Type:citrated wh. blood

- -•
Test Date :10/26/03 • .Blood:Batik. Unit CrOss Match" - • `•
MUST SuBmitSF 518 WITH EVERY UN

Test Time :14:34 . . NT-1--OE' BLpOD
. :REQUESTED)
Card Lot

:080201

UNIT
TYPE
Operator aral 644 CROSSAL4TCH
RAPIDPOINT COAG ANALYZER V4.54
SERIAL #005485 10/26/03 14:38

P.ifi ,:!nt ID:

((0)(04

Nameall,

la t Result:= 30.9 sec.
Type:citrated wh. blood
it-t Date :10/26/03

LA,B ID NO.:
lu.t Time

:1 :35
I

Lo ey,

d or
MEDCOM -22057
DOD-035633

.,,,„...,,,,s,tion: cii, _rI REQUESTN -
' I CITEMISTRY RESULT FORM
I (Sub'ect to the Privacy Act of 1974)
LAST, FIRST, MI.

D kr' TiNfE: SSNRSEUDO SSN:
(.(8
. . . .
..-'
o " ­
1;' .•(P "..47 .0) ',Qh.-kRaii_ti, -!''''.:(PitCd",6)..1.,4*Iio..1i f?ati.1:1'.-:.:• .. ..,
TEST RESULT REF. RANGE TEST • : SLTLT SF. RESULT
TEST REF. RANGE RANGE
i Na 133-146 canon -GLU I 73-118 mg/d1
K 3.549 mrool/L: 1 7-2
lailli 04(0 f BUN 1 -?:mg/c11 98-109 Inman -PICCOLO
- - -CA" 8.0-10:3 mgicil
26/10/03

7.31-7.45 15:21
PH CRE 0.6-1.2 rag/di
REFERENCE'
MALE
PCO2 35-15 mmHg (,et
NA" . • ;28-145 molo1/141 -51 trunfig (vr-a) fl
RAT I ENT . P02 80-105 mulligOTO GENERAL CHEMISTRY 12 .K.-:,.3-4.7 ramal/1
14/A(veul
TCO' .5-27=101/1.4,* DISC LOT # 6 /;-1 3204AA4 a.: .
-

98-108 rnmoVI
24-29 znmoLL (vat: opER ft :
i DR #: 000 v
HCO3 22-26 mmol/L (art) #. tCO2 18-33 mmoUl
23 -28 mmoUL (vcri )E31 / hiL if. s02 95-98%
•- (,pi .c -Olii)71:,i.'eefr.e,1 pr!..,-,-...,:::-...
,,,..:•::..,,,:::..,7...,:.::.,...,„. ,,,:..:.,:..,:r...f..-....,,...,-.-....,..
..
ALB 4.7 3.3-5.5 G/DL

BEecf (-2) - (+3)
TEST RESIAT REF. RAJVGE
ntrnoWL ALP 48 26-84 U/L Ana p 10-20 mmol/L ALT 32 10-47 U/L ALB
3.3-5.5 g/d1 Ca 1.12-132mmo1/1 AMY 44 14-97 U/L ALP . 26434 al
AST 31 11 38 U/L .
BUN 8-26 mg/dI . ALT 10:47 oil
TBIL 0.9 0.2-1.6 MG/DL GLU 70-105 mg,/d1 BUN 15 7-22 1131 DI-. AMY 14-97 ill CA++ 9.2 8.0-10.3 MG/DL Creat 0.7-1.5 mWdl CHOL 137 100-200 MG/DL AST
11-38 u/i Hct -38-5 wo PCV • CRE 0.8 0.6-1.2 MG/DL , TBIL
0.27 1.6 mg/c11
0._U 134* 73-118 MG/DL
Hgb 12-17 gill GGT 5-65 ull
TP 8.2* 6.4-8.1 G/DL

. .N .-6.4-8:1 g/d1
...;',.c.ti.elhiq .-TP
'
TEST RESULT REF. RANGE INST GC: OK CHEM GC: OK •

ccolo)..,EIectroljte:,... ' HEM 0 , LIP 0 , ICT 0 ,:.:, r:• !.
•:..:::.-;:`..,:--. ,.1-:'..!...:-::::-•'-::.".i:.:-.,.. --• ,
Tropcnin-I
TEST ULT REF 4NGE
Drug of NA' i ili 128-145 mrtiol/1 Abuse
3 ,
3.34.7 mmolri
CL I 0 9S-10S mmoLii
tC0 18 -33 omio'il !
1 I
I
REMARKS:
REPORTED BY: 'DATE: LAB ID NO.:
I I 1
MEDCOM - 22058

DOD-035634

..Age
74—BAYS MOS YRS PROCED

PROPOSED PROCEDURE Sex
SURGICAL
MALE () FEIVIAL th
SERVICE:NPO SINCE:
HABITS. WT: Physical Stated) 2 3 4 TOBACCO: IZ/L8 HT:

ALLERGIES:
ETON: wv N.
PAST MEDICAL PFIEOPERA E /C
DRUGS: HISTORY/SY
Cardiovascular: TEMS
REVIEW
HypertensionCURRENT MEDICATIONS:
0 4` Angina PASTASSESSMENT ordered as Premed MI . AURGIC
ALJANESTHETIC
•E'l/I-r I
CVA cv
Other
()
Pulmonary System:
Asthma
Bronchitis/UR;
()
COPD
Other
PREMERenal System: ir

DICATIONS:
BP lin
None Yes (CO Acute/Chronic RF
Hrs) /CC Gastrointestinal : Y

Pai Scale 0-10
.
mg IV IM PO Hepatitis HEENT - Teeth

.
mg IV IM PO Hiatal Hernia .R Trachea

. mg IV 111+1 PO PUD/GERD Firo,11 TMJ/Neck Endocrine System: 3 F 60
670rophamyx
LABORATORY STUDIES:
Diabetes Nares
CHEST:
11B/HCT: Steriods 67
U/A: Thyroid
OTHER: Neurological:

Seizures
Neuropathy
Other
Gynecological :
P

regnancy
Other Significant Hx:

Familial HX
ANESTHETI PLAN: { LOCAL { ) MA
NPO Since Air Le/
Regional
(Sp cify):
FORMED
;cussed CONSENT/COUNSELING { I
STATE
With the patient legal guardian. General: Mask Intubation
patient/legal
guardian anesthesia includin
reed: seems to unde
death
have been explained to and *61 —1/4i g
;7-ANESTHE3IA EVALUATION Date:
10 G
AND
APPARENT ANESTHETIC CO NOTE
(NON ASU) Time: MPLICATIONS { }OTHER
Hrs
SEDATION KEY:
Date: 1. MINIMAL
Time: (Anxiolysis) Patient
re-sponds
Hrs
comm nonnahy to verbal
t Identification: (Ward) ands
2. MODERATE
(conscious sedation)
C/U Patient responds
--5/1&)? verbal purposefully to
commands alone oraccompanied by light
37
stimulation. tactile
nAirway assistance
ecessary.
is not
3. DEEP
SEDATION/ANALGESIA.
Patient responds purposefully
sty
lowingfollowing repeated
or painfulAirway
be necessary. assistance may vas 2300 (Revised) 15 Mar 4•
ANESTHESIA.
oi Ancic,:pos respond to Patient does not painful stimulation.
7.1,7,,-,T71,7VF.'77,4W-74
ANESTh
.
MEDCOM 22959
Previous editirwi

DOD-035635

MEDICAL RECORD - ANESTHESIA
For use of this form, see AR 40-66; the proponent agency is the OTSG
TOTALS TOTAL EBL DRUG Writs
u) yr
/5.0
7 giz Ar11170757 .3°?0
ec tc -0
0 08i,, III ( _, ...3-' TOTAL URINE
_
0 22 2. 4/8 r 4, 21_
o?C9C)
u) 0- . z (
i-`ctics a
(
uj Cr) CO
W E -. FLUIDS - SUMMARY
0 1-3,- 6"-- /.7 .----4,5*----42.5---C
0 0nz VOLAT ,6/4„de 5- del
CRYSTZLRD*0 AGENT % e.t.
(,) 11. p2
r= F.'.u. AIR L/Min
uj Z let.' • CO(L'.0ID-
I 0,,a N20 L/Min
-0
02 3 L/Min
CO BLOOD-
Z SINGLE DOSE DRUGS-MARK ON GRID.-
4 WITH NUMBERS & ENTER IN REMARKS
REMARKS14i,El Warmed 4
LINE site .¦
s5 Code drugs with numbers,
. Warmed - --- FINI/01111
events with letters
. Warmed 411110/
OVA 1 EST BLOOD LOSS . Warmed
LOSSES ,
URINE -cp.lwo cero c 0 7„
PHYS STATUS TIME 4 0 t. /510 r" 30 “ /6R1, /7------1 2©4 5 t OA( i
,,i/Oplill-r,27
SYMBOLS: I
BODY WEIGHT: 220 ,
XleCi4Cre_ i
.
KG BP by cuff , . .
200 .
LB " .(//r-C.t 6
V
HEMATOCRIT: , .
180
A 3 c-octrolar" #6--is';') 4/1101 Heart rate . ¦
160 I I mu. . ' . 474(7,4
INITIAL DATA: •
Resp rate 140

BP-AgligAdeat't /C-
173 120 , ', • 2,4/

.
Pr
BR 1 ECOMPIW-A•A' iffilINI 11006 ,...-./
HR-7 100 : . I ¦ I I I X I -,Qd Yej,
97Z, (transducer!)
7
.1. 1101111WAISKIN r MaillIPM
80
EQUIP CHECK APIE112/11WIEN214!1411131di , due tai(
T
01a-Y N TOURNIQUET 60 ,

KAM , „ 7:j-9fcrdevgef/'
PATIENT RECHECK T —4" MiiirriMA
40 , „ WI
11111Nr
OK for I I
PROCEDURE? ANES- X-X 1111
20 „ MriAill ' ' ' 11111117411 .
PROC-e_0 WO'
TIME
' ....s
.
VT - ml MCA c, P f - breaths/min /° 0
2
Lu Peak ma pres / PEEP -t _
,;g‹.

"ODE S(pon), fssist), C(on) 0 I/ CV 5 RECOVERY AT 8P/Auto Cuff CO2 (torr) 5-3 / 32. PACU ICU Specify) U) INO V F 2 IFrac or %) ROI
Rth
Di OTHER
,_
EE ART line S 2 (%) .0 _,Le__19 ' & AW
CONDITION: ri21/411/e____
CO th- PC/ES ECG Ma551 , mu
to RESP-1 Sp02-,,,,,
w v Gas analyzer TEMP-site
C.) 13,25-' 7 HR-,e(S----
0 N-M Block (T14)
rug' E HESIA I PROCEDURE
Q TIM S
C7)
CC Start Room End,
i-Z 20 ?7,2_ /4/5'-
0 Warming blkt
Ready Begin End
2 Cony wanner
Mark with letters & symbols, EVENTS_,

explain under REMARKS Position

Ok
( 62-(3)

03 to
tiA0
ANES ETIC 1.ECHNI a U 7Describe block technique under Remarks
PREDURES nd CPT Codes
e r eft' A Aletaq / ? a aej-ie„-4/ t:71/ 10
w AI AY MANAGEMEN : / tubationzotrte, blade, teth9ique, comments
PATIENT ID NTIFICATION: Typed or w tten entries: Name, Grade/Rate, Medical facility
---i------i e e SURGEO
PROCEDURE
LOCATION:
LX12) - 7,
j,i) (C)Lf Doz,, I i:;3
-1.--ANE Rilt----... PAGE / OF . _....__.._.. _—...--..............-,.
DA FORM 7389, FEB 1998
MEDCOM - 22060
DOD-035636
MEDICAL RECORD - ANESTHESIA
•
For use of this form, see AR 40-66; the proponent agency is the OTSG
cn co DRUG (Units0 (.2 _i ‘44.0...0 TOTALS TOTAL EBL 0 2 z LAI / i /
E, 13 8 ,(7.:3, crze4 -( d ..-1 / I / 3
0 2 2 2 4.i.....-i ( ---/ 0 .2. ft"-4--`•
' 4/
Z I-g j
TOTAL URINE
cL 'S 2 1_ (..vi / o,c.%).
i ea it,
rn 0- . z
(
I-CCLU Cfl
•
m Z ( fa
17 0 D ZOVOLAT % del
' --
' FLUIDS SUMMARY
-
D U AGENT
U z_u H % e.t.
r_. rz oc CRYSTALLOID.
AIR L/Min 30
Li l. •
i O ut N20 L/Min

1---0
COLLOID-
0 02 L/Min A..) 4" .---4/
LI1
z "5
SINGLE DOSE DRUGS-MARK ON GRID
./ WITH NUMBERS & ENTER IN REMARKS BLOOD-

LINE site
rn A /17,2_ 0 Warmed -Ant-3' o 0
o REMARKS
1:1 Warmed
5
Code drugs with numbers,
...1
El Warmed
u. events with Miners
. Warmed /V y°0 , Ph./ V
EST BLOOD LOSS
LOSES S
'
URINE -PHYS STATUS tkr2J1414 --
TIME I*. n_ 5-c/ V /3
x 1 X I
i (1)-4 5 E ' ' , S, ,:m A OIC
SYMBOLS:BODY WEIGHT:
220 ' 11 1 , /244.1...1t..... ini1-4-1 11 I r , ,
KG ,
BP by cuff , .
. II II 11
h32 LB 200
V
.
ifiAlgi
HEMATOCRIT: . . ' e )ti
A ,"„' Mcot '

180 ;
. .' 11
11 11
' .. V;i34...rwl2,.......

Heart rate .. ,, ..
160 II II 1 II /1 I 11 11
INITIAL DATA: • -1 1
_10_,V ' e

I II (4,....)-4-t
Resp rate 140 II II
BP-14u -v-V7i--7--II ' I .
• .2..
p4.f.44
I I I ' A '
131. / IS 120 " '
4 # 4
HR-BR ,
i ) -L. (transduced) 100 ----;--7
-k
ct4.4-ok
_L
EQUIP CHECK ao /S /,¦ A.
T
OK?-#9 N
TOURNIQUET 60
PATIENT RECHECK ,

T —4/
40
OK for
PROCEDURE?-# TT
ANES- x-x ,
PROC-Cy0
TIME ii Yy 20 ,
VT -ml
1-

...,
f - breaths/min
Z
W Peak int ores / PEEP

MODE - Srpon), A(ssist), Clon) 1 3-BP/Auto Cuff ET CO2 (torn) RECOVERY AT l / X r r
–
tu BP/oth F102 (Frac or %) ‘rc,.._PtCU Specify) EC. - ART line Sp02 (%)
0 7. X)
c7 l'e 5 7 OTHER
rn Steth- PC/ES ECG R

(r) 3 1-CONE/MON:1%. /0 I.
•ur Gas analyzer TEMP-site
V AV Pt / i,
U RESP-/Z 402-
N-M Block (T/4)
.4 BP. HR. /13
CA
CC ANESTHESIA / PROCEDURE
0

TIMES
1-
f/J Start Room End
0 Warming blkt z

Z Cony warmer .1 I No IUB / a A4
Mark with letters & symbols, EVENTS_, t.) Ready Begin End exple n under REMARKS
Position '-
&C. ill/ I 1.0 s' A1,1
PROCEDURES ac5PT Codes:

ANESTHETIC TECHNIQUES:
Describe block technique under Remarks
PATIENT IDENTIFICATION: PI VC-
Typed or written entries: Name, Grade/Rate,
AIRWAY MANAGEMENT:
lmubation route, blade, technique, comments
Medical facility
iji 1 6 !'....-----------"--
OMNI
SURGEONS:
PROCEDURE LOCATION:
072 I
(10)I kf) - Z
-' DATE: ANESTHETISTS:
• '
iminimir 24 0‘4-03 PAGE 1 OF /
DA FORM 7'1R4 PPR 1 oar:
MEDCOM - 22061 COPY 2 - ANESTHESIA PROVIDER USAPA V1.00
DOD-035637
-MEDICAL RECORD - DOCTOR'S ORDEi,
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. Only one order is allowed per line. Nursing will list the time the new order(s) are noted and initial in the column provided. Orders completed during the shift in which they were written do not require recopying. They may be signed off, as completed, in the far right column.
ORDER ORDER NOTED COMPLETED NUMBER
DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS TIME & INITIALS TIME & INITIALS
POST ANESTHESIA ORDERS (circled Items)
VS q 5 min X 15 min, then q 15 min until discharge. - .
.:, ....--= Supplemental oxygen. Morphine / Itrepepi4ine 3 mg IV now and -.S 5---(0 q-minpm pain for a.mg
max dose of 10 mg.
4 Zofran nig IV pm N/V q 15 min, may repeat x .
5 Metoclopramide mg IV pm NA/ x 1.
I Droperidol mg IV prn N/V x 1.
;\cc Phenergan mg IV pm N/V x 1.
Benadryl 25-50mg IVP ql hr pm, itching while in PACU.
9 IVF: Q cc/hr.
-. Discharge from recovery status when PACU discharge criteria met.
, . Mme /_5"-- 5- t— vlie 114/

_
PATIENT IDENTIFICATION Complete the following information on page 1 only. Note any
changes on subsequent pages.
Diagnosis:
Ink (L) (0—q- Height: Weight: • Diet: :
Allergies:
I Nursing Unit Room No. Bed No. Page No.
PACU, 28th CSH 1 of 1
MEDCOM FORM 688-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS AftE OBSOLETE MC V1 .00

MEDCOM -22062
DOD-035638
CLINICAL RECORD - DOCTOR'S ORDERS For use of thi;:, form, see 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF
ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN

INDICATED BY ARROW BELOW.
PATIENT IDENTIFICATION DATE OF ORDER ' TIME OF ORDER LIST TIM
ORDER
NOTED AND

HOURS SIGN
11
NURSING UNIT ROOM NO. BED NO. Qt =
€_."---' C 1 , te-C;4-( r.

"7.---.11,x_so 2_-c-, -r..) 6_,-,.°-:
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER

3, C ei-c-oLiut---f--if .1-&-D___,
HOURS

illffsillonim
TAN'• -fQ. 0_, go c - (,-
...._ ,
I ri t r—e___0-4ed,--c.s2_
NURSING UNf--Y OM NO. 0 NO.
,,,ggillir
PATIENT IDENTIFICATION DATE OF ORDER
HOURS Illk,
2 iia 0 ¦
e•
f-/. Neo ivr
Fr
P S r s . oc Ml •
......./21

NURSING UNIT ROOM NO. BED NO.
¦111011111°P.' INF
dr) 211111
11116,1M, tide° tal21111111111111W 111.
PATIE1770E TIFICATION DATE OF ORDER IME 0

rk.1/ HOURS .'
0 ( ... ... • • tiri•X3 .1 ..... I.1"
....,
_.? Ilibql _ P • ' ' _ '
,,.\.%. `c
lq A• dr
•
. .1 ' ... /Gar, Zn-PPP

--„'
=
AIMIIIMM. ZeIL.( all iv _,Ir iled
NUR SING UNIT ROOM NO. BED N, //

EIIIIIMIWIIIIJL

DWU4 2q, bf
REPLACES EOITION OF 1 JUL 77, WHICH MAY BE USED.
DA I APR 79FORM 4256
MEDCOM - 22063
\o)
DOD-035639