Medical Report: 27-Year-Old Iraqi Male re: Gunshot Wound to Right Hand

NSN 7540-00-634-4123510-112
NURSING NOTES
MEDICAL RECORD Sign all notes
HOUR OBSERVATIONS

DATE
A.M. P.M. include medication and treatment when indicated
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PATIENT'S IDENTIFICATION iFor typed or written entries give: Name—last, hest..grade: rank• rate: REGISTER No.
tiospital or medical facility;

NURSING NOTES
Fv.!scrIU.;..1 jr CS.\, ;CMR. FiPt.irA I -1
MEDCOM - 15641
DOD-029030
•
NSN 7540-00-634-4124
VITAL SIGNS RECORD
HOSPITAL DAY 1-
DAY MONTH-YEAR fiEM DAY '
POST-I
0:144 ........ •' • • • • • • 'I• • •

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(Centigrade Equivalents, for Reference only)
TEMP. F
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105°
PULSE
( 0 )
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104° .I. .I. ......... •.

180
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150 101° ....... . . .
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RESPIRATION RECORD NU • -g WM BLOOD PRESSURE
•AlliSilinia,
2 . MAIIII
c
os, HEIGHT: WEIGHT --I¦
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.
. i
a II I
a
tn
WARD NO.
REGISTER NO
entries give: Name—last, first, middle; ID No.
PATIENT'S IDENTIFICATION (For typed or written
hospital or medical facility)
(SSN or other);
r1
VITAL SIGNS RECORDS
Medical Record
STANDARD FORM 51-1 (REV. 7-95)
Prescribed by GSA/ICMR. FIRMR (41 CFR) 201-9.202-
MEDCOM - 15642
DOD-029031
111/111

Ward/Section: e..-­/cI, REQUE CHEMLSTRY RESULT FORM
Suliect to the Priv= Act of 1974)
LAST, FIRST, ',.3111.,
102. „*. cg
TEST RESULT REF. RANGE EST RESULT REF. RANGE

138-146 mmoliL
Na

33-4.9 nunoUL
K 98-109 mmoIlL
Cl

7.31-7.45
PH PCO2 35-45 mmHg (a
ramliic (vex 80-105 mmHg (az
P02

N/A (von)
23.27 mod& (a:
TCO2

24-29 mmol/L (vx 22-26 mmol/L (al
HCO3

23-2S mmol/L (vx
95-9894
s02

BEecf (-2) — (+3)
mmol/L AnGap 10-20 mmol/L
Ca

1,12-1.32 nano
8-26 mg/dl
BUN

70-105 mg/dl
GLU

0.7-1.5 mg/dl
Creat

38-51% PCV
Hct

12-17 g/d1
HO

het
TEST RESULT REF.RANG /
Troponin-1
Diog of
Abuse
REMARKS:
REPORTED BY:
GE
ALB 3.5-5,5 rid] GLU 73-118 mg/dl

PICCOLO 3 PICCOLO 3
01/08/03301/08/033

17:52 17:50
REFERENCE Rai MALE REFERENCE RANGE:3

MALE
PATIENT #: PATIENT #:

(

1)

GENERAL CHEMISTRY 12 METLYTE 83
DISC LOT #:3DISC LOT #:3

3142AA4 3152AA4
OPER #:41111, ..1211i2n. OPER #411,3

DR #: 000

SERIAL #:

ALB 3.3
ALP 67
ALT 13
AMY 69
AST 37
TB1L 0.7
BUN 16
CA++ 8.6
CHOL 99*
CRE 1.0
GLU 78
IP 9,9.

SERIAL #:

3.3-5.5 0/DL GLU 74 73-118
26-843BUN 14 7-22

U/L
10-473CRE 1.2 0.6-1.2

U/L
14-973CK 549* 39-380

U/L
11-383NA+ 133 128-145

U/L
0.2-1.6 MG/DL K+ 4.2 3.3-4.7
7-22 MG/DL CL-103 98-108
8.0-10.3 MG/DL tCO2 22 18-33
100-200 MG/DL

MG/DL
MG/DL
MG/DL

U/L
MMOVL
MMOVL
MMOVL
MMOVL

0.6-1.2 MG/DL CHEM QC: OK

INST QC: OK3
73-118 MG/DL HEM 24, LIP 1+, ICT 0
6.4-8.1 G/DL

CHEM QC: OK
HEM 24, LIP 0 , ICT 0

INST OC: OK3

DATE: LAB ID NO.:
MEDCOM - 15643
DOD-029032

ti

•
Ward/Section: REQUEST LABORATORY RESULT FORM Subject to the Privacy Act of 1974 LAST, FIRST,Mi. /,, AA T ,‘:I).z. _ /PSE
.3 11. E. .
lo (4_
,
(Hematology) CB a is 'sc. Serology
TEST • i'... --., .GE TEST RESULT REF. RANGE TEST RESULT REF. RANGE
WBC 4.8-10.8 x 10' Color N/A RPR Negative RBC ' 4.7-6.1 x 10' App N/A Mono Negative
. .., HO 14-18 eat (M) Giu Negative Kterobiology12-16 01 (F) . Hct -42-52% (M) Bili Negative Source 37.47% (F) MCV 80-94 fl (M) Ket Negative Gram 81-99 fl (F)
Stain Pit 130;500 x 10 3 SG VA Oec Bld Negative verified Lymph Va 20.5-51.1% Bld Negative H. pylori Negative
afe!ilatiokit Y):1kinnual Differential : pH N/A Micro Parasites Segs Mono Prot Negative Malaria
-
Bands Eos Urob 0.21.0 0 & P
Lymph Base Nit Negative Other
Atyp 1mm Leuk Negative .Microscopic Una "
Negative
RBC HCG
Morph ,

Spun 42-52% (M) CSF . Blood.Baak Hematocrit 3747% (F)
Sed Rate r Cell MUST SUBMIT SF 518 WITH Count EVERY UNIT REQUESTED
Other Directigen Negative ABO/Rh
Coagulation Studies. -Blood Bank Unit Crossinatcli :
: (MUSTSUBMIT S

, F 518.WITit EVERY UNIT OF BLOOD : -. . .. ktOuistED) i. ' '
TEST RESULT REF. RANGE UNIT TYPE CROSSM4TCH
PT 9.8-13.6 secs
APTT 21-34 secs
D dimer 20 ug/m1
FDP 10 ug/m1 '
REMARKS:
DOW
REPORTED BY: LAB M NO.:.
MEDCOM - 15644

DOD-029033

•

Ammo
-
SEW/ 01-08-03 WB 18:19 Patient
Limits WBC 9.4 x10'3/tiL 4.5 10.5 I.'S 4.16 x10'6/aL 4.00 6.00 ligh 12.6 siAlL 11.0 18.0 Hct 40.9 . X 35.0 60.0 IN 98.1 fL 80.0 99.9 NCH 30.3 P9 27.0 31.0 IIMC 30.9 L g/dL • 33.0 Plt 330. x10°3/aL 150. 450. urz 31.8 I 20.5 51.1 LI 3.0 x10A3/uL 1.2 3.4
MEDCOM - 15645
DOD-029034

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.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER LIST TIME ORDER
7.... 015— HOUR NOTED AND
U11115 C:10 P \,...
(---:-- .

NURSING UNIT ROOM NO. BED NO.
t
IP
PATIENT IDENTIFICATION
2_ z, A--c,k_ 6 (..) I/ YrHOURS ( .1 Ami ) /2' /0 0
DATE OF ORDER TIME OF ORDER
it\J 0 0
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t°A—e\-' el
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-41 A 1 c i ..--IIM
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NURSING UNIT ROOM NO. BED NO.
to t (A:j -I
PATIENT IDENTIFICATION DATE OF ORDS TIME OF ORDER 6.114(1
HOURS i/ (CC) At Cio
br, 10 ( ctI-2
NURSING UNIT ROOM NO. BED NO.
V1113 11/ PATIENT IDENTIFICATION DATE OF ORDER
TIME OF ORDER HOURS
NURSING UNIT ROOM NO. BED NO.
r
FORM
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.
4256
1 APR 79
MEDCOM - 15646
DOD-029035

-2
IA Order Date Clerk Nurse Veil? f byInitialing L0-2, THERAPEUTIC,.DOCUMENTATICN CARE PLAN (TION-AIEDICA770N) SINGLE ACTIONS Dete to be Done Mo.Yr 2003 Time toDone Time One Initialsbe kioc0J11111
ornd
247 • 10 OW cf,--T dQrn luk, (03er

Order/
PRN
INITIAL PROPER COLUMN FOLLOWING COMPLETION
Date .-ACTION. FREQUENCY,'
meipMg:COMPLETED
t
•
MEDCOM - 15647
DOD-029036
Verify by THERAPEUTIC DOCUMENTATION CARE PLAN 1i-dialing (NON MEDICATION) Mo.Yr
Order Clerk Date to Time to
SINGLE ACTIONS Time Done Initials
Dote Nurse be Done be Done
/
Orde I Clerk/ I PRN.INITIAL PROPER COLUMN FOLLOWING COMPLETION
Espir ..n .
ACTION, FREOUEAICY TIMEMATE COMPLETED
DI) -
7.-11111 T -7I(.9„Q( csb"_ fa tori
/ (rtj;
rixeLfs or^.
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....,, L....f-
ANIL

1. ,
MEDCOM - 15648
DOD-029037
INPATIENT TREATMENT RECORD COVER SHEET
For use of this form. one AR 40.400; the proponent agency is OTSG 1
( c,tI-LA
.-
2. NAME Mut, Aril, MU
3.IGRADE ADMISSION REMARKS
.--- 0I
4.
8.I.(IET; 0-A-
SEXi -IGEI,IRACE 7.IRELIGION
LENGTH OF SVC 9I
VETS 10.IPREVIOUS AssISS8
\J\ I ''g' 1
u.04_ uyo IL__ w Pr p A
la FMPI112.ISONI\,,,, ( Le_ ,_ (.4, 13.IORGANIZATION 14. WARD
I qI 1--I
15. FLYING 16. 17_4111i
8 11). BRANCH/CORPS Is. UIC/ZIP
STATUS DSO 20. TYPE CASE
)
‘t-j iJ A-L i u I 4
is...'
21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION
22.I
HOUPS OF 23.ICLINIC SERVICE
ADMISSION
ICf2'De..4
I01 (2 (.7-ri 1010 A (N-A-
24. NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
25. TYPE OISPOSITION
26. DATE OF DISPOSITION
V'. 0 14
27a. 30-4-4k., 0'3
50
ADDRESS OF EMERGENCY ADDRESSEE OrnIude ZIP CAI) 27b. TELEPHONE NO. 28. DATE Of THIS ADMITTING °PACER
ADMISS1ON
CO LI
(..-./A. /3 V-----
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY Li ALI' & (Dt

29. 0 r. OWN
30.IDATE OF INTIAL 32. UNITS OF WHOLE 9L000/ADMISSION
COMPONENT TRANSFUSED
( 2- ) -7
31.
Chock if Continuml an Rams
33.
CAUSE OF INJURY

34.
oucNosEstoPEataions AND SPECIAL PROCEDURES

...
9P0(70. 57
62..oti%)
e £ g7 fe q v/6,5
CS U)
. 44 ‘4. ,./ I .i‘•a....
_5 7 , 3c2
5 gA c %. -2
35. Total Days This Facility
a. ABSENT SICK DAYSIlb.IOTHER GAYSI
c.ICONE. LV/COOP d.ISUPPLEMENTAL CARE DAYS I.IBED DAYS I.ITOTAL SICK. DAYSCARE OATS
I /Th 0
0I

UI 0
36. Total Days All Facilites b 01 ) _ (2....
+. ABSENT SICK OATS OTHER OATS
c . CONY. LV/COOP I SUPPLEMENTAL
e BED DAYS f. TOTAL SICX GAYSCARE DAYS CARE DAYS
C3)
r)
0...‹.)
SIGN aAa'
MEDCOM -15649 iECOROSOFF

kAll^
. .... __1----Zi : 7, t - ••
-7-r-rn . --.C.-"9:-/I
DOD-029038

MEDICAL RECORD
-.ABBREVIATED MEDICAL RECORD
PERTINENT HISTORY. CHIEF COMPLAINT. AND CONDITION ON ADMISSION (Bahr dery of adeurtioe p
'106-81,0 +b bk\t--(.1-v t /1,17,14,y 11
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PHYSICAL EXAMINATION
Sce,k
ALJ--J AA,(-
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Lflekt
CAA--(___
PROGRESS (Enter dale of disdarpt and final diagnosia) a--
P,..0"vjsb le,y4/1 (7,f eif,t 1.411(14it
dtoc-1"-z--x,
Pc :I
6\11—
DATE
IDENTIFICATION NO.
ORGANIZAT ION
or typ or written entries /ice Name last. 5,sr,
REGISTER NO.
middle; grade: date: hospital or medical taerlity) WARD NO.
ABBREVIATED MEDICAL RECORD Standard Form 589
GENERAL SERVICES ADMINISTRATION AND INTERAGENCY COMMITTEE ON MEDICAL RECORDS FIRMA (41 CFR) 201-45.505OCTOBER 1975 539-106
MEDCOM - 15650
Or
DOD-029039

MEDICAL RECORD
PROGRESS NOTES
6.?INrci-a-(2A-Ti VE S I

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PATIENT'S IDENTIFICATION
.
Wtinue on revers ;de
'For typed or written entries give.. Name - last, first, middle;
grade; rank; rate; hospital oredical facility! REGISTER NO.

7
WARD NO.
F.--u_
ei") r¦sz_e_
PROGRESS NOTES Medical Record
STANDARD FORM 509 {REV. 7.91)
Prescribed by GSA/ICMR. fiRMR {41 CFRI USAPPC V1.00
MEDCOM - 15651
DOD-029040

•
NUJ 71140-00431-4176
AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD I CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE.
1.SYMPTOMS, DIAGNOSIS, TREATMENT TREATING ORGANIZATION (Sign each entry)
3,010th 03
t 6_Sc)-) /
01'6-Ls 1,1 /auersI
a 6d044{1 .
„spicti 0e _Ae
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HOSPITAL OR MEDICAL FACILITY
STATUS DEPART./SERVICE
(RECORDS MAINTAINED AT
SPOI•
SSN/ID NO.
RELATIONSHIP TO SPONSOR PATIENT'S IDENTIFICATION:
(For typed or wfitten entniss, give: Nome - last first, middle; ID No or SSN; Sex; 'REGISTER NO.
Dere of Birth; Rank/Graded (WARD NO.
2_
CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record CPUJ k) STANDARD FORM SOO (REV. 6-97)
Prescribed by GSAJICMR
MEDC04- 15652
FIRMR (41 OFR) 201-9.202.1
)'(q)
DOD-029041

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD
CHRONOLOGICAL REC
RD Or MEDICAL CARE
• y.
•.•.••
EATING ORGANIZATION
(Si n each entry)
LOS temok
.13 S66 cialbte
I 1
J =2

HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE
RECORDS MAINTAINED AT
SPONSOR'S NAME RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION:
(For typed or written entries, give: Name - last, ffrst, middle; ID No or SSN; Sex;
Date of Birth; Rank/Grade.) WARD NO.

REGISTER 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 - 15653
DOD-029042

AUTHORIZED FOR LOCAL REPRODUCTION
MEDICAL RECORD
CHRONOLOGICAL RECOR
, 6 Or MEDICAL CARE
DATE
SYMPTOMS, DIAGNOSIS, TREATMENT, TRE TING ORGANIZATION
(Sign each entry)
* CALUNK-,
-,7;infi.0
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/VC 011-0 . A.1 4cet..dfravyui a/r464--(1_ oath nui.kj nudte:„tfak d
HOSPITAL OR MEDICAL FACILITY STATUS DEPART./SERVICE. I RECORDS MAINTAINED AT
SPONSORS NAME SSN/ID NO.
RELATIONSHIP TO SPONSOR
PATIENT'S IDENTIFICATION:
(For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex;
REGISTER NO.
Date of Birth; Rank/Grade.) WARD NO.
I
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
01111111. '\-D(
MEDCOM - 15654
DOD-029043

411111111„
YMPTON , DIA N.
TREATMENT T ATIN.
ANIZA.lgn each entry,
Akuid than.cd
E 4,91,4e/ 041 h /r1. ter, /7 44-7/ / te`;//C5
—t edy LL r
61
7c "GIZA- -1 1/1 1 S'144-4-74 6,47) s-27e,g, 2") 4444-K7 6/e...„../t 7-2
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FPI. LEX. Printed on Recycled Pap*,
STANDARD FORM 600 (REV. 8417) SACK
MEDCOM - 15655
DOD-029044
CLINICAL RECORD NURSING NOTES
(Sign all notes)
OBSERVATIONS Include medkotion and treatment when indicated
Lie Ste-8
1(I-
t-o(c_k_
PATIENT'S IDENTIFIC_ATION (For typed or written entries give: Namr—last, first. I
middle; grads; dale; hospital or medical facilid)
N 'I, NG NOTES
Standard Form 510
General Services Administration and
Interagency Committee on Medical Records
FPMR 101-11.1306-8--October 1975
510-109

MEDCOM - 15656
DOD-029045

SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION
(Sign e 17 entry
IA..I.1:1)c 4#
Al l AL,.04p,
• /11 lizt..•
Ah•
STANDARD FORM 600 (REV. 6-97) BACK
MEDCOM - 15657
USAPA V2.00
DOD-029046

,-.,-, ...,.0, N ,f-1-1-, 1 VrN
....,l,Flt-rccrmvut.A, i ILJINI
MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE
DATE II
SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry)
¦ ' 1 0 lir'IL-C
/1AFIS-ALLAJZ; .IA/LA-a 4 S CA---c_A -S2_ i re_..... ( di? ist.L._efit.„..t
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HOSPITAL OR MEDICAL FACILITY
STATUSI I DEPARTJSERVICE
RECORDS MAINTAINED AT I I SPONSORS NAME SSN/ID NO.I
I RELATIONSHIP TO SPONSOR I I
PATIENTS IDENTIFICATION:I(For typed or written entries, give: Name - last, first, middle; ID No or SSN; Sex; Date
I
REGISTER NO.
WARD NO.
of Birth; Rank/Grade.)
CHRONOLOGICAL RECORD OF MEDI
Medical Record -"t STANDARD FORM 600 (REV.
Prescribed by GSNICMR
FIRMR (41 CFR) 201-9.20
Via
MEDCOM - 15658
DOD-029047
41.100.^.
NURSING NOTES
(Sign all notes)
IHOUR
DATE
I
A. M OBSERVATIONSI
=rim'
Include medication and treatment when indicated
CoI- s/61,,to
4 -I-"Aagrlrfarr
of •
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MEDCOM - 15660
DOD-029049

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MEDCOM - 15665
DOD-029054

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MEDCOM - 15679
DOD-029068

NSN 7540-00-634-4776
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MEDICAL RECORD
AUTHORIZED FOR LOCAL REPRODUCTION
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CHRONOLOGICAL RECORD OF MEDICAL C
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CHRONOLOGICAL RECORD OF MEDICAL CARE
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Medical Record
STANDARD FORM 600
Prescribed by GSA/ICMR (REV. 6-97) FIRMR (41 CFR) 201-9.202-1
MEDCOM - 15680
DOD-029069

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MEDCOM - 15681
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MEDCOM - 15682
DOD-029071
MSN 7540 -00.634
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MEDICAL RECORD
AUTHORIZED FOR LOCAL REPRODUCTION
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STANDARD FORM 600
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MEDCOM - 15683
DOD-029072

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MEDCOM - 15686
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MEDCOM - 15687
DOD-029076

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DOD-029077
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TREATMENT, TREATING ORGANIZATION
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MEDCOM - 15689
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MEDCOM - 15690
DOD-029079
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1540-01-o75-3711
MEDICAL RECORD EMERGENCY CARE
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(Patient)
RECORDS MAINTAINS
PATIE T.
STREET ADDRESS HOME ADORES
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Medical Record STANDARD FORM 558
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MEDCOM - 15691
DOD-029080
MEDICAL RECORD
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MEDCOM - 15692
DOD-029081

MEDICAL RECORD
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NATURE AND TITLE
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PITAL OR MEDICAL FACILITY
RECORDS MAINTAINED AT 1TION TO SPONSOR
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MEDCOM -15693
DOD-029082
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Ibuprofen 800 mg TID PRN pain/fever

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MEDCOM - 15695
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