Medical Report: 26-Year-Old Iraqi Male, Detainee, Abu Ghraib Prison, Baghdad, Iraq re: Fractured Nose

Error message

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Medical report on a 26 year-old male Iraqi detainee at Abu Ghraib prison who broke his nose while playing soccer. There is no suspected foul play or abuse in the medical report or claimed by the detainee.

Doc_type: 
Physical (non-death)
Doc_date: 
Friday, October 3, 2003
Doc_rel_date: 
Friday, October 14, 2005
Doc_text: 

; • . ;d; ; Sex MALE () FEMALE 01) 3 4 5 E
ASA Physical State 1
Age DAYS MOS WT: 4X—el/LB HT: IN. PROPOSED PROCEDURE: ALLERGIES: Alii) SURGICAL SERVICE:
I
p VIA-,A
NPO SINCE: .
HABITS: TOBACCO: ETOH: DRUGS:,
CURRENT MEDICATIONS: ( ) = ordered as premed
( )
( )
()

PREMEDICATIONS:
None Yes (0 Firs) ICC
. mg IV IM PO
. mg IV OA PO

mg IV OA PO
LABORATORY STUDIES:
HEI/HCT: IA WA: .A OTHER: PREOPERATIVE
PAST MEDICAL HISTORY/SYSTEMS REVIEW Cardiovascular: Hypertension Angina MI
CVA
Other
Pulmonary Syste
Asthma
Bronchitis/URI
COPD
Other

Renal System:
AcutelChronic

Gastrointestinal:
Hepatitis
Hiatal Hernia
PUD/GERD

Endocrine System:
Diabetes
Steriods
Thyroid

Neurological:
Seizures
Neuropathy
Other

Gynecological :
Pregnancy

Y
Other Significant Hx:
N Y
N Y
N Y
Familial HX
ASSESSMENT PAST SURGICAUANESTHETIC
PHYSICAL EXAMINATION
BP HR R T Pain Scale 0.10 HEENT - Teeth
Trachea TMJ/Neck 3 r=iKS Orophamyx Nares
CHEST: C-4 /4-
CARDIAC:
EXTREMITIES:
IV Access: Ulnar Filling:
BACK:
OTHER:
NPO Since
{ } General: Mask Intubation
( ff,R4ional (Specify):
{ } MAC
ANESTHETIC PLAN:
NSEUNG STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to and
INFO
Megal guardian. Questions answered.
to understand and agrees. Cionlgr Date: 7-X,
Signed ESIA EVALUATION AND NOTE (NON ASU)
PO
ENT ANESTHETIC COMPUCATIONS ( } OTHER

Hrs
Date:
Signed:
Patient Identification: (Ward)

/ 0.00 Hrs
Time:
SEDATION KEY:
1.
MINIMAL (Anxiolysis) Patient

responds normally to verbal commands

2.
MODERATE (conscious sedation)

Patient responds purposefully to verbal commands alone or accompanied by right tactile stimulation. Airway assistance is not
necessary-
3. DEEP SEDATION/ANALGESIA. Patient responds purposefully
following repeated or painful stimulation_ Airway assistance may be necessary.
4. ANESTHESIA. Patient does not respond to painful stimulation
MEDCOM - 20641 Previous edition is obsolete
WAMC Form 2300 (Revised) 15 Mar 01 MCXC-DOS
DOD-034215
MEDICAL RECORD - DOCTOR'S ORDEN
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. AOnly 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.AThey 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 ANESTHESIAANESTHESIA ORDERS (circled Items)
0 VS q 5 min X 15 min, then q 15 min until discharge.A-- - • - -
0 Supplemental oxygen. A. 0,A-I- 9 3'1.,
Morphine / Motaer-4144e 7-5-mg IV now and 2 -5" mg q 3-5 min prn pain for a
max dose of Ai 0 mg.
4 ZofranAmg IV pro N/V q 15 min, may repeat x A.
5 MetoclopramideAmg IV prn N/V x 1.
6 Droperidol Amg IV prn N/V x 1.
0 Phenergan 1 I...Cmg IV prn N/V x 1.
8 Benadryl 25-5Gmg IVP ql hr prn, itching while in PACU.
9 IVF: A COA cc/hr.
10 Discharge from recovery status when PACU discharge criteria met.
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PATIENT IDENTIFICATION Complete the following information on page 1 on y. Note any
changes on subsequent pages.
.10 09) (io ) —1 Diagnosis:
..
Height:A Weight:A Diet:
Allergies:
Nursing Unit Room No. Bed No. Page•No.
PACU, 28th CSH 1 of 1
MEDCOM FORM 688-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE A MC V1.00

MEDCOM -20642
DOD-034216

MEDICAL RECORD - DOCTOR'S ORDER.
For use of this form, see MEDCOM Circular 40-5
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.A
DIRECTIONS:AThe provider will DATE, TIME, and SIGN each order or set of orders recorded. A
They may be signed off, as completed, in the far right column.
ORDER NOTED COMPLETED ORDER DATE. TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS
NUMBER TIME & INITIALS TIME & INITIALS
g POST ANESTHESIA ORDERS (circled Items) VS q 5 min X 15 min, then q 15 min until discharge. A-- •
Supplemental oxygen.Afl 1Ai

Morphine / Meperidine3-3 mg IV now and 3-3 mg q 3-5 min prn pain for a max dose of /o mg. 4 ZofranAmg IV prn N/V q 15 min, may repeat xA. 5 MetoclopramideAmg IV prn N/V x I. 6 DroperidolAmAIV prn N/V x 1. 67 PhenerganAmg IV prn N/V x 1.
a
8 Benadryl 25-50mg IVP ql hr prn, itching while in PACU.
IVF: /1/5A@_/cc/hr.
10 Discharge from recovery status when PACU discharge criteria met.
PAA
/9/1101) 5*--1-c_ZI c -#,20. jecideril/
PATIENT IDENTIFICATION Complete the following information on page 1 only. ANote any changes on subsequent pages. Diagnosis: Height:A Weight: Diet:
Allergies:
Nursing UnitAC.L.P-1-.) -7,-Room No. Bed No. Page No.

PACUall. I of 1
_
MC V1.00
MEDCOM FORM 688-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETE
MEDCOM - 20643
DOD-034217
MEDICAL RECORD - DOCTOR'S ORDE:.
•A
For use of this form, see MEDCOM Circular 40-5
DIRECTIONS:AThe provider will DATE, TIME, and SIGN each order or set of orders recorded. AOnly 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.AThey 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)
1. VS q 5 min X 15 min, then q 15 min until discharge. -- — - .A.
2 Supplemental oxygen.
3 Morphine / MeperidineA:).____ mg IV now and 2— mg q 3-5 rnin . prn pain for a
max dose of ifij mg.
4 ZofranA(---- mg IV prn N/V q 15 min, may repeat x A.
5 MetoclopramideAmg IV prn N/V x 1.
6 Droperidol .0 4-in2 IV prn N/V x 1.
7 PhenerganAmg IV pm N/V x 1.
8 Benadryl 25-50mg IVP ql hr pm, itching while in PACU.
9 IVF:A(—. 4_.©1/.2,rcahr.
10 Discharge from recovery status when PACU discharge criteria met.

MIIIIIIIib e-&--z,

(do w-L
PATIENT IDENTIFICATIO Complete the following information on page 1 on y. ANote any
changes on subsequent pages.
0, ) 0:)) ­y Diagnosis:
e.
Height:A Weight:A Diet:
Allergies:
Nursing UnitA(..10.1a,) -2- Room No. Bed No. Page No.
PACUMIIII 1 of 1
MEDCOM FORM 688-R (TEST) (MCHO) MAR 99 PREVIOUS EDITIONS ARE OBSOLETEA MC V1.00

MEDCOM - 20644
DOD-034218

is OTSG RECORD
CLINICAL RECORD - DOCTOR'S ORDERS MEDICAL For use of this form, see AR 40-66, the proponent agency
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MEDCOM - 20645
DOD-034219
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DTR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
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IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
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MEDCOM - 20646

DOD-034220

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 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.
LIST- TIME
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NOTED AND

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DOD-034221
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 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.
LIST TIME
TIME OF ORDER
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MEDCOM - 20648
DOD-034222
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG

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MEDCOM - 20649
DOD-034223
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
DERS. IF PROBLEM ORIENTED MEDICAL RECORD AD SIGN EACH SET O R THE DOCTOR SHALL RECORD DATE. TIME N
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MEDCOM - 20650
DOD-034224
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ORIENTED MEDICAL RECORD
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MEDCOM - 20651
DOD-034225
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
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CLINICAL RECORD - DOCTOR'S ORDERS RECORD For use of this form, see AR 40-66, the proponent agency is OTSG
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MEDCOM - 20653
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CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40 -66, the proponent agency is OTSG
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MEDCOM - 20654
DOD-034228
CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 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.
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THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION )
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THERAPEUTIC DOCUMENTATION CARE PLAN ( NON -MEDICATION)
CLINICAL RECORD For use of this form, see AR 40.407;
Mo. Yr. 2003
the proponent agency Is the Office of The Surgeon General.
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Doc_nid: 
3946
Doc_type_num: 
77