Medical Report: 25-Year-Old Iraqi Male, Detainee, Baghdad, Iraq re: Gunshot Wound to Legs and Buttocks (Death)

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• 11. Register Nbr :. 2. Name 1 1 3. Grade ' Admission Remarks FGN
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24. Name/Relation of Emergency Addressee 25. Type Disp 26. Date of Disp
TRF-OTH 2003-11-02
27a. Address of Emergency Addressee 27b. Telephone No 28. Date This Adm: Admitting0fficer: i (
I- 2003-10-31 1)(4A-el
29. ReportingMTF b ( 7) -- 1 30. Date !nit Adm 2003-10-31 32. Units Blood Components
31. Selected Administrative Data
Marital Status: DoB: 1978-07-01
In/Out Patient: Inpatient MOS:

33. Cause Of Injury: GSW BUTTOCKS
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34. Diagnosis / OperationAnd Special Procedures: DIVERTING COLOSTOMY/ SUPRAPUBIC TUBE PERUNEAL DRAINAGE
35. Total Days This Facility
Absen),_Bick Days Other Days ConLv / Coop Care Days Supplemental Care Bed Days Total Sick Days
0 ../ 0 -3
35. Total Days This Facility
Absent Sick Days Other Days ConLv / Coop Care Days, SuppleDal Care Bed Days Total Sick Days
',
Signature of Attend Si edical Records Officer

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-._{,(-___.--,c-, s\---tuar,z •-AA)--_,-;y-Ir )(\r\ArFY¦19-XY`gAe-Z:3i--\f-h-cA-r\,°-N) --w-c--,
-k--.1s(Th&W3rY'C' \-1=3_13`-3
\&
-

dit , Ai \ -kk-o_le -- 41 41. \ -ii.r. - -.-gt 'k e 7
, t,,,(N vs,a,s,,_ :)c,,A-ie A.--t 2Z l sc ?--1-:-(\c-='-krec)rini-N-Cs) (2____Z •_.._ 0).0____K--k.. ._„....,..i3. PI-cx--\- \\\,;
s--(--(\ \A-N,,_\ r\__‘_(23-.).__ cp\-gla_--Vc,,C.__Ciratz_ArA.VC,_-g---(
40S-V-e_-., GO 4_P—U_rfV0t-p_ttc\AN-tp_•:::)_k_iiif Anfc c:7_c .___, b A/KW \ f,' \ 0 2_, kr?--4-(_).---c \lf. \je-r-l/N9 eaf OA' an R;)V N -'L-k CDL-3 --1)--(2-tr) V( \'V-.1ccl- i‘`‘)() C) VIVpy-__k) t 00.--:,
‘iNc -cp,Iii, wit. \ k e._ • 4 4 'C\e--¦ '" 1111 ' . -{`c\C-4(\t C)--13-\'N. \-i..\9,,4E9 .4'0 \\'' Pri`-t\t\ CA.Y\lb .(Ncei lc° r1-61.3 SNCQ5\1\KI) *t.) rnoll-)N-ou MAP6 Pt
*pra,.),_\---e ,c) cc-\-. (__,..'-' '''.c:A.Q. cD.S -Cc).0.
6.,:e_., 0¦A, (Z \,3_ c"-: cs-,-,A -\.¦,CQ_%.-
-6.,6,\N.C.);z\ .i: \'‘? -Cc)-.CA -a LeS,cr --L-)QArg,STANDARD EOM 509 INV. 5119991 BACK
USAPA VI .00

MEDCOM - 22628

DOD-036204
MEDICAL RECORD AUTHORIZED FOR LOCAL REPRODUCTION CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION

(Sign each enhy) Ps,
4h f).,••••Ve•• C_
e A rtin,
t
csr-N, 4../_
.4 i30

s Ell %1`. E. u ,•••%.
4,,
c •
c5-12)
¦_ p4.
(-42.c
t: .2.V'•••
f S-00 -

HOSPITAL OR MEDICAL FACILITY..
DEPART./SERVICE..
SPONSOR'S NAME RECORDS MAINTAINED AT
RELATIONSHIP TO SPONSOR
PATIENTS IDENTIFICATION:
(For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex: Date ofBirth: Rank/Grade.) _ REGISTER NO WARD NO.!.

CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record

STANDARD FORM 600
(REV. 6-97)

Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1
USAPA V2 00
MEDCOM - 22629

AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
C-$2)%f \JC 6 t•cx..._,—..... tilL.NrS, ksi-V--) • -D.-\ ca
, 1 'C-fori_V•.`3-- - 6?) 19-6,,
,....

n 7_'
C e q_&c-e- -----1___q_1..__Cr2--,_0_LcA'e
C__v-v \--t‘.:_P1----1- st-S k..,:o,_ C,---yc3-2_.i-.Q.„„...;,,s,_vN-Nic_\_,,,--\,c_.,_
-K---ki--5(_C3.}(-3_:=3)(6Q----A_CI.NA "_Q_VJV...,(3,_i\\(). .-RA____4...64) C--cs-' cV c,(_c,_3.--cc-a-_-1%-C_Ouq\c-Nr\_\4-\.0.--4)_C.___o3S4A 007-\3‘_-..'_
X.nei, - - - )_V GO. r -e_1.n
. _
a \)'\_\ID-Coo,\1:4 cs:)7-6-_t\CL_'

W,____c_c:)_\_±A_______ ou3-Qa'_
-VII .¦ ()\' c-Kir\C--Q--_v.& A lga #
I --.. L\IN ,S--7--VACCA Cs.A4,,e,ozci
R---QS\ C___._ -----.\(

AD V.1 C__,It--V5-`0, Ci
\‘=_\N. \&}4-Ve. V\c'e____: c-___sr1t-lielL)'Ra .) l'AC:)?X
__-_}...- -0•iv-'1a -c-(X(_V, Wi0\--c3 .4-(14("N ACA_Kb,-‘ , P--_
1._,\INre_...\i-N \----3, % . % \--b k\ 4.41,

_
"¦111/ Alb._

¦•¦ _
Aiiiiim¦
¦sism

¦BRNmx _
¦IIIIIIIIIIIII IIIIIIIIIIMIll

HOSPITAL OR MEDICAL FACILITY STATUS
DEPARTJSERVICE
• "DS MAINTAINED AT

SPONSOR'S NAME SSN/ID NO. RELATIONSHIP TO SPONSOR
— . -......._ .__.._ _._ _

:_or ype or wn en entnes, give: Name - last, first, middle; ID No or SSN; Sex; Date

REGISTER NO.
WARD NO.
of Birth; Rank/Grade.)

CHRONOLOGICAL RECORD OF MEDICAL CARE
Medical Record

STANDARD FORM 600 (REV. 6-97)Prescribed by GSA/ICMR FIRMR (41 CFR) 201-9.202-1 USAPA V2 00
MEDCOM - 22630

DOD-036206
510-112
MEDICAL RECORD NURSING NOTES NSN 7540-034-412
DATE (Sign all notes) OBSERVATIONS
Include medication and treatment when indicated

MAJ, MC.

PATIENT'S IDENTIFICATIONIFor
Continue on reverse side
typed or written entnes give: Name--last, first, middle: grade; rank; rate:
hospital or medical facility)
WARD NO.
NURSING NOTES MedV

Record ' MEDCOM - 22631
STANDARD FORM 510 (REV. 7-91)
Prescribed by GSA/1CMR. F1RMR 141 CFR) 201-9.202-1

0'3 a

DOD-036207
MEDICAL RECORD

1. AGE
HEIGHT:
WEIGHT:

C,cym. I T-+
PREOPERATINY/POSTOPERATIVE NURSIWDOCUMENT
FOR Use this form. See AR 40407: the Proponent agency Is e Office of the Surgeon General.
2. KNOWN ALLERGIC SENSITIVITI e.g.. lodin, Tape, Medication) PCN 0 L 0 IODINE 0 TAPE 0 FOOD
0 NKDA REACTION:

3. PREVIOUS SU RY [ I NO [ I YES (type):
4. PROPOSED SURGICAL PROCEDURE:
ex a,ot,

5. ADDITIONAL INFORMATION: (Previous surgical and medical history) Skin Condition
ppd X_vrs Body Piercing

Tobacco ETON Implants
Glasses/Contact (Y) (N) Dentures
6. PATIENT PROBLEMS AND NEEDS
A. PSYCHOSOCIAL ----"potential for anxiety related*
to: Surgical Procedure& Operating Room Environment 2) Separation Anxiety
(Child)
3) Surgical Outcomes

B. AERATION
Potential for respiratory
dy,sfunction.due to:
1) Positioning
Effects of Anesthesia
3) Medical/Smoking_I-ktm

C. INTEGUMENT
"—Potential Impairment of Skin Inygrity due to: 1) Intraoperaliye Immobility ESU Padflacement 3) Positional Aids
4) Posthesia Pooling of Prep Solutions

Diabetes (Y) (N) ROM ASA/Motrin W 72hrs (Y) (N)
Respiratory Disease (Asthma COPD) (Y) (N) Anticoagulants (Y) (N) 'Hypertension (Y) (N) Herbal Medicines (Y) (N) MEDS:
7. PATIENf com.s AND EXPECTED OUTCOMES
Pt. verbalizes any specific anxiety.
Pt. Exhibits relaxed body posture.

.Adwi%/Jr-o,04(3k,
will be able to breath without
difficulty during immediate intraoperative
phase.

Pt. will exhibit signs of Impairment of
skin integrity (e.g., reddened areas).

9. PATIENT'S IDENTIFICATION: ( For typed or written entries give: Name-last, first, middle; grade, data; hospital or medical facility)
\--) c;')
• I a+ (35 )c),[-S--
Previous editions are obsolete. MEDCOM - 22632

DA FORM 5179, JUN 91
i8. OR NURSING INTERVENTIONS . Allow pt. to verbalize freely.
. Explain Or environment and answer
uestions regarding surgery.
. Offer comfort measures. (e.g. warm
anket. touch).
. Explain all nursing procedures before

t ey are done.
. Remain with pt. VVhenever possible.

O. Maintain family interface. Parents to stay with pt.
. Offer to elevate head of litter or offer
illow.
. Observe pt. While awaiting surgery for
igns of distress.

O. Assist anesthesia during intubatior
and extubation.

. Utilize pressure preventing devices
o OR table and accessories.
Check for proper positioning and

pport to maintain good body alignment.
. Pad pressure points.
. Place ESU ground pad on non

mpromised skin surface area.
. Keep prep fluids form pooling.

VERIFICATIONS AT HOLDING AREA:
V
.1 ID/Allergy Band ! Dentures Removed

V
! H & P ! Contacts Removed
V

! Jewelry Removed ! Body Pierce Removed
! NPO Since

-!—U14CG/0.412---
! Consent/Blood Transfusion
SignedNVitnessed/Dated
1 Surgical Site/Consent verified by

Pt./Anesthesia/Surgeon
I Contact precautions (
! Family/Friend: V

USAPA VI.0

-

6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES B. OR NURSING INTERVENTIONS
•

D. CIRCULATION Potential for inadequate tissue perfusion due to: V1) Intraoperative Mobility
2) Positioning 3) Existing Disease
• 4) Safety Devices 5) Hypothermia
E. NEUROMUSCULAR CONTROL
.
E.I. Potential Impairment of Mobility due to: V1) Pain
2) Intra operative Hazzards 3) prosthesis 4) Positioning
• Transfer pt. To/form OR table
E.2.VPotential Discomfort Due to: 1) Length of Surgery
V2) Positioning 3) Arthritis
F. Special Senses
F.I. -----Diminished visual perception
due to being: pre-medicated 2)._W 0 GLASSES
F.2.VPotential for Decreased
Communication due to: 1) Diminished Hearing 2) Language Barrier
F.3. Potential Injury due to
Dentures:
V1) Upper 4) Caps
2) Lower 5) Crowns

3) Bridges
G. OTHER PATIENT PROBLEMS NEEDS
OR Continuation of Above problems/needs.
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 physical discomfort.
1. pt. will be made aware of surroundings
ior to anesthesia induction.
pt. will be transferred safely to OR table.
pt. will be able to underStand inStructions.
Minimize danger of injury during intraop

period.
A.vorv‘b,,,,kcA,
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.
C-heck that safety straps are
correctly applied.
O Offer pillow for under knees.

O Place and take down legs from stirrups with slow bilateral motion. ..--treheck that rings and all body piercing has been removed.
CI Have sufficient people available for
tr:ansfer.
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.
I Introduce self. keep pt informed as to here he. she is and what is happening. Inform pt. in which direction to move nd assist if necessary. Speak clearly and sic., . Address pt. fromVside.
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.
((-Vk OG DATE
11. POSTOPERATIVE EVALUATION : SKIN INTEGRITY: Bovie Pad Site: Clean and Dry 0 Red N/A DRESSING DRY & INTACT: LEVEL OF CONSCIOUSNESS: 0 A&O 0 Drowsy D Sleep lntubated (N)
0EATHING EASY:

LEVtl_ OF ACTIVITY: ' 0 MOVES ALL EXTREMITIES 0 Moves Upper Extremities /1
-N•JC--"N)L.1-)i1JZ

0 Transferred to Litter VVith roller due to sPinal (Y) (N) NAktAlloOdrCa,
12. PREOPERATI ARED BY 13. PREOPERAT ED
(Signature and Title) CVT1A-1J BY (Signature and Ti

-tA-N
DATE: 31 ockVOcA TIME: -20-to

TIME: DATE: REVERS OF FORM 5179, JUN 91
USAPA VI.0
MEDCOM - 22633

INTRAOP 1\TIVE DOCUMENTMEDICAL RECORD
For use of this form, see AR 40-407, '
incy is the office of The Surgeon General.

1. PATIENT TRANSPORTED TO OPLV,......V..MV•,. 2.1 PATIENT II_ . !FitV CEDURE VIA 'A_V\--(A/V BY A-1A.9 grtA411(3l. VERIFIED BYVCI7 \
3. DATEV TIME PATIENT _ARRIVED IN SUITE 4.. PATIENT IN ROOM ".. 1 OUk- 0-5 ./ TIME:Vl•t BERVot
5. PREOPERATIVE EMOTIONAL STATUS

• CALMV• ANXIOUSV• EXCITEDV• CRYINGVp ANGRYVWITH RAWNV
T OTHER (Specify)
CRMMENTS:_

.--iivtue.s.,t---k\)c.)-1 cl\---?,--t-NP asvo
.

vt- mt-uwita kt,-Eu¦A\V. ----- ,-,( 6 S"?
6. NURSING PERSONNEL
4

ASSIGNED
IT qi:0-.,-----—RELIEF S?
ZO5D- e Ocl.
SCRUB
.SCRUB
((6--I-

. - . : cam-Q,.
ASSIGNED ILV (2,r,--ICi0 ) RELIEF
CIRCULATOR

...__. _..... . —_CIRCULATOR
......,
CAT INT!,
kPtDvb

7.V --
POSITION AND POSITION • - . • cify_ .._._.... -,•_...,,,,. -
•-,
X SUPINEVIII LITHOTOMYV• PRONE. , . KRASKE',V-LATERAL:VLEFT SIDE UP III RIGHT SIDE UP

. -v ,
COMMENTS:a* Adtvalc tztiliki. AAA- im\mukt mumzuko et
\,1 8. SKIAPREPARATION

HAIR REMOVALVCI YESV• NO
-PREP SOLUTION (sperif.:3..A.c&Se.n.,....1.; ' DONE BY: NI ORV • NURSING UNIT SITE:Kt l¦ tt,-1-0,361,„ 5 01/4meA BY WHO
METHOD:V• DEPILATORYV0. RAZOR. . •• . SITE: ' - ' "Kkk.,
BY WHOM: CLIP
__ .
COMMENTS:M.G.' .4.A.,-.¦ (1,t., c-„; (,.._..../V i•-•,Z1-?....e.'iy-. 'C7Ol¦riiiiNTS: 4A-kr r.?CtiA.AACA isN :-Ar-g-AA •--NA.AN-C;‘,

9. LOCATION OF EXTERNAL DEVICES V i l)
- -:-,": i::

.¦
-4¦111"_:
._.

-P.'_ \_,_;It- ..
-_--""'"Towirmiii¦--. 1-4-APP—
......

LEGEND round Pal.- Safety StraV= = = Tourniquet---. 0,-"-2...k,
0 2-

hki-li ato IT c = Correct I = Incorrect Itivirvi6
C-il

te-r¦ Ortle First Closing Final Closing

10. COUNTS
Other•• Count .. 1-.;6 Ciiiint

Sponge 0 Yes No C CIRC
(-•

Needle Sharp IE:1 Yes No C
..,....:........ . Instrument Ki Yes lo C.-C-- -• --' ',..i.ki.t,;1_;.,".;,. ' Other Ej Yes No ......---.......--------
...------,--------- ----------
11. PATIENT IDENTIFICATION (For typed or wrgten entries .:glve: 12. • ELECTROSURGERY DEVICEIS) (ESU)V* YESV• NO
Name -Last, first, middle; Grade; Date; Hospital or Medical Facility;)
CAM- • 30

„...6 111 (o,Ylik JAH.

. ,. -14. ESU NO: e. A II.60,46,:
-it . GROUND PAD: BRAND a_filVallifirrIVE101.7 . . LOT NO: ON-WO_EX
..___ ! 41,7004-1 I
11111111P \A_J . ErEBU NO:
1) -

•• --..,7GROUND PAD: BRAND
'31 OtA-Cf"
-.,,
.*:. •,
LOT Nb:' -
111 BIPOLAR NO:

DA FnRIVI R1 7Q_•1 nrs-r o-/.
rre rw In "," ... A •¦ ••¦ •nam ....... . ..¦...-- — -- , _

• C L,
-

C S OBSOLETE. USAPA V1.00
MEDCOM - 22634

13. PROSTHESIS, IMPLANTSVLi YE:V. IF YES NAME: ID NUMBEF 'JRER
. : , ;:--

--„,,,,,„;,, tIV.4. ' .% . ,,::..„V--;-iN.413.4:*_,
,,, _1.4114Vk,,,,': ,tNEDICATIONS/ORDERS:5, '''' -,,, .. ,,..,,,p,.,V,,. ' ,
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) V YESVNO
:1MEDICATIONS/SOLUTION DOSAGE . TIME ' METHOD

‘ PREPARED BY GIVEN BY
-" -, --

. ._-'
_.... .

s: .
't
CS,
WOUND IRRIGATIONV.- YES • NO, TYPE(S):V ,,

_

0- c)t 70 1,ba-C2 . _S ..._,.?
THER ORDERS TIME CARRIED OUT BY
.A-A...-T1
---. --

-
.

HYSICI
-6. (0,

. _ ,-.-, ---. ,.,_ .,
15.
X-RA , IF YES, SITE
YES • NO Ej

16.
-:::-LABORATORY SPECIMENS

.,V,_ . ,„=„

SPECIMEN (S) NAMEV .- ---.- - ----........----NAME

.

YES NOV"&" - --:
FROZEN SECTION (FS) NAME

NAME
YESVNO NI

CULTURE (C) NAME
NAME
YESV• NO IK -_-__ ____.
NAME NAME

NAME
-

NAME --
NAMEV -4 . 18. DRESSING/IMMOBILIZATION (Specify)
-_-_-_ ---tt- x g

17. TUBES, DRAINS/PACKINGVYESVNO •
_ ....__

TYPE/SIZE X:;%1 1. 2. e.
7' •

i i tA %A/1"K) 1 b F F 1 C 10 viApvt/(' Priv IA, -%, ,
SITE 1. Su.tirslyrtSc, 2. 3.
R.Q.Ck¦AVV) (0 kb (.1.6-YIN RAA V...i.LLA--...............A-

19. ADDITIONAL INFARMATI
&
SlItorplY. tf --i-,---

. ;;;..1:,.-..1 /:,'
i\-Vea-tki : All-._

-
. •
_ .._...,, . _
.:

1% Snc) [14-1-h-tta
20. OPERATION(S) PERFORMEDV —
t .
E 4 Ac sAdq cky,---ic.-_C“).i4eiT,. c...,2.4A,a..t.,4--1 is,

cit L-k. c c ir CAIN \ (gsl.eLA-N6-\4_, 1. Ceit t -.-T)eAr;v4 evv.4.:-.A. k q ec...„A-,—,,..., , 911-2 jc, c"ro....9.-13/06.4..A.A
•
c":.
t CA.( ,.----,....r...L.,-.1/4-

21. PATIENT TRANSFERRED TO TIME s-ez METHOD
I C--til -I- \--, a '' 1--.70A--1-mq-t:k4Aziv

fill1111111.KJRE 1
CCIA-ki
•

REVER I • FORM 5179-1, OCT 87 •• • V
USAPA V1.00
I INTRAOr —'E DOCUMENT

MEDICAL RECORD (
For use of this form, ee AR 40-407; s -
enc •ffice of T :7--

1. PATIE2tTRAMZ). TO OPL .G ....ADM 2. PATIENT ,,,.,• URE VIAV, BY ' VERIFIED BY
Yi r-,X )

3. DA--TEV TIME PATIENT ARRIVED IN SUITE 4., PATIENT IN R• • ! 0 2 /VD Li Q3 TIME: ,2 0 V:3 NUMBER /
5. PREOPERATIVE EMOTIONAL STATUS

IN CALMV• ANXIOUS • EXCITEDV• CRYINGV• ANGRY WITHDRAWNV&POTHER (Specify)
COMMENTS: C-/.. ti&A.,r
,(4-,..C.)
_. ., -. .. _
6. NURSING PERSONNEL
_

ASSIGNED 40_1 Z._....---RELIEF
SCRUB ...SCRUB

111.
.7b((ikt
/

ASSIGNED RELIEF
CIRCULATOR ____CIFICULATOR
IN i-:.

.

7. POSITIOVAND POSITIONA I -..., -
SUPINEV, • LITHOTOMY • PRONEV__ • KRASKE.-LATERAL: . LEFT SIDE UPV• RIGHT SIDE UP -7--
/4"--eL.: (.2. 0 eN.P-A.-.74-0--d-

COMMENTS:V-.0?.
-. ' ' -' ,...CD'.:f-'V.t.,-JS LI-) C./ eLit-IX....4) ON..., q.A...••••...-4b-3 CrLie-, 2.,4 ---R-;--0›..Z-4-1-'1e, 6---,'..4, t.P0,-.,,,,,,
8. SKIN PREPARAT10NV

.-1 ,r i i_-t. 7 --c, (w.f.,
HAIR REMOVALVYES 910 ' -PREP SOLUTION (Specify) 4
-te,-) AP3e.
DONE BY:V• OR • NURSING UNIT SITE:VOL-Ax.).... i B WHO
METHOD:V• DEPILATORY II RAZOR SITE:Vkt....., -LS BY WHO -*r•'-'4" S /00,3 , A ,,,

.., ,.
CLIP .. ___________L.
. .,..

COMMENTS: _______--. . C-01WENTS:Vs." r 8,-,.."
9. LOCATION OF EXTERNAL DEVICES
..,.... ,

1.- r.1 • . ,..... -111' _ ...
_.....m.......415.1

. -
.
1.111111139-
.....
) 6 0 -p ps-t

LEGENDVX Ground Pad I---evty StrapV= = = Tourniquet.---,-;.,::::---
-
= CorrectVI = Incorrect

,-. .(-fi' —2„..
ii,,, I, ii..... orstt losin, Ficntamltoosing
unCi g

10. COUNTSV ... -C SCRUBV CIRCULATOR
SpongeVIfg es --' Needle SharpVP.1=1131 o

NUMMI

InstrumentVKIM 0 ,/
Ekii--

OtherV11' Yes • o....---------__-------"-
11. PATIENT IDENTIFICATION (For typed or wntten entnes give: 12. ELECTROSURGERY DEVICE1S) (ESU)VYESV• NO
Name -Last, first, middle; Grade; Date; Hospital or Medical Facility;)
—_
...01-20

SUNO:V L 1-ortt t-0, ‘, . GROUND PAD: BRANDVlr-ips-,1,-)
: ___ LOT NO:V6 S -1 ‘°
. :1EIZESU NO:
.

-'.----drfciuND PAD: BRAND
114)`' k

LOT NO: / BIPOLAR NO:
.

PLACES DA FORM 5179-1 (TESTI, DFC.82, WI-IICH IS OBSOLETE. USAPA V1.00
MEDCOM -22636

13. PROSTHESIS, IMPLANTS III YES IF YES NAME: ID NUMBER; ' JRER
„...._..._
r_.

__.
-:,, , .., r .
i14 V ,__, ;.,$; ::-.' -:.4'''!,91,-!figeire':w ,:-V,,„ ,..::', 'MEDICATIONS/ORDERS V, ;,
:;V_
IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA) YES • NO OAEDICATIONS/SOLUTION DOSAGE . TIME METHOD PREPARED BY
GIVEN BY ......-V: -, ; ,..„ _ _ , . ..
r

WOUND IRRIGATIONVYES • NO, TYPE(S):
,__
6. 7 v/c, 44

I,V
mOTHER ORDERS TIME CARRIED OUT BY
CPHYSICIAN'S SIG
—1.—

15. X-RAY IN OPE IF YES, SFE ,,
: -Tii: ,
YES • -.,:-
16. . ".! LABORATORY -SPECIMENS
_

SPECIMEN (S) NAMEV -- ------- .---V„.,,
. :

YES • NO L -
FROZEN SECTION (FS) NAME NAME
YES • NO •
CULTURE (C) NAME NAME
YES • NO • —
NAME NAME

NAME
.
leeC

NAME _
NAMEV 18. DRESSINGCAM44ZATION (Specify)
--' ---/_o,f
-_-

,--S? / 0_
17.VTUBES, DRAINS/PACKINGVYESV-_ NO • TYPE/SIZE 1.:7,7X" i 2. -. ' , / 0 /3 9Y 9
C c._/.93. iThc7(
SITE • .
.vk ;PiL--

61.(...A_ A...I-PA_
19. ADDITIONAL INFORMATIONV -
.

./73 K f
/ Ci-k- /

&C-IA (^4 Q...c./ 7 7 `7,77.:',11:,: ,.. _ .
..,•; -. f-'Pl:,;;10'.

,_ R? (./ri, "I /
.... __ ___........ ... . _
A7 (1()I—

-
514_,1 C . ,

---, (AL6e7_-... . _
,

,
A.,V( 6t,,,,k,ixo.., ,-„,/ wi,L.,..( s- ,76,y(ckt)--6,

20. OPERAVN(S) PERFORMED
/
• C ,,S.-/ -"-/ ' ''' C_C

/ ' Ca Q,144-t-i4 .
_I 4. p_i(--_-,::.---,,
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