Medical Report: 32-Year-Old Iraqi Male, Baghdad, Iraq re: Blast Injuries; Fractured Legs

AST NAME FIRST NAME MIDDLE INITIAL ID NUMBER DATE NOTES .. K.4 Arm* al.a a. A • Agromisce •-_Aal ye. Aa AI AA I 0$! on at\OISNeek-f(i). Pr; 'moo.wa lorl di Oft ni A N P( ano/rutdo (a. b12., (=Orb .. ! • qt_ou) t .uLifNto 1)JUI aN\--.KG¦ 06) DLt al o ss vb U 40 * 0 At".1_0 1.t__.0 4 A IL A CA • ._1_44 slop ¦. a .'..:1,1 , 0 AAA___b j --_. . _./ 0 #t*_..1 I . ./11 ° i 1a(2„ TUC \. -toprs cW,t-t3s)k-cfrE L_VsjA OV,ivrtsDn(tc\ MEDCOM - 20241 DOD-033815 MEDICAL RECORD I. PROGRESS NOTES DATE NOTES ., . aZ ,`9 5 .)/l77 4 ) 1- -? -(3.-r --ex-e" ,-') . e .War Z-) k , 6al-L1,-;¦-•Liz' • ----r,1 a2., ../. .c._. _,.. CAt' . dhtir , i --r",7", )--21"' „ -• ../-4-s",/-Y;;--1/.---/72c1, ' ,f--) -, ----, / • .„....,_ I- , ),Z7 ;256 1)/), JO •)‹ 1D .1 . 14" ' ---1..., "---1.-c RELATIONSHIP TO SPONSOR SPONSOR'S NAME . SPONSOR'S ID NUMBER LAST FIRST ISM of Otbed DEPART./SERVICE HOSPITAL DR MEDICAL FACILITY" RECORDS MAINTAINED Al I PATIENT'S WENTIFICAT/ON: /far typed or written mines, give: Name • landist, fnifdlc• REGISTER NO. WARD NO. 1C Na of SSM• Sex; Dee of Bit* RatilArede) PROGRESS NOTES Medical Record low EL)(G),(i STANDARD FORM 509 IREY. MORI PracnIsd by GSAACIIR FPMU ‘41CM)101.11.2D31131110) USAPA VI.00 MEDCOM - 20242 DOD-033816 ¦¦••••¦•¦10 IUTH ICED FOR LOCAL REPRODUCTION MEDICAL RECORD PROGRESS NOTES sti 63-pf A-re, p' c/0 rc). -6; r rtro k - F;Sco.r-A 4 AR, PAI. riu,x4ri , p rei-e tAiore - e RELATIONSHIP TO SPONSOR SPONSOR'S NAME SPONSOR'S ID NUMBER LAST FIRST MI ISSIi waiter) DEPARTISERVICE HOSPITAL OR MEDICAL FACRITY • RECORDS MAINTAINED AT PATIENTS IDENTIFICATION: (For lYPIti or mine?. egUir4 ply Pent • kat an didk • ID No co r Sat Seg. Dna el Bitic fisalanal I REGISTER NO.. WARD ND. PROGRESS NOTES Merkel Record STANDARD FORM 509 MEV. WINO Pr.:wiled by GRAMMA FM 14ICFle 101.11203INI/0 US ?A vita MEDCOM - 20243 DOD-033817 LAST NAME. MAST NAME. MIDDLE INITIAL.ID NUMBER II DATE NOTES CALLith ajtaia) O WBA-T-s CLitti OLE. I tiaffd Mkkri. --)wmAovad t/t/fad c 2f---p-(do (3 Wi_A) W Es01.61YL4 MAY i)Le-,eiataz A,o-ktivteV( c cl AATAit fiA & PAl (_10- STANDARD FORM 509 RV. 5i1099, BACK USAPA MOD MEDCOM - 20244 DOD-033818 AUTHOR/ZED FOR LOCAL REPRODUCTION MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry/ HOSPITAL OR MEDICAL FACILITY STATUS .. DEPART./SERVICE 'RECORDS MAINTAINED AT SPONSOR'S NAME SSW) NO. RELATIONSHIP TO SPONSOR PATIENT'S IDENTIFICATION: Woe typed or written envies, give: Name - lest, fiDote of Birth; Rank/Graded middle;iddle; Ill No Or SSN; Sex; IREGISTEp NO. WARD NO. CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record STANDARD FORM BOD (REV. 6-97)Prescribed by OSARCAIFI FIRMR (41 CFR) 201-9.202-1 MEDCOM - 20245 DOD-033819 NSN 7540-01-075-3786 EMERGENCY CAREMEDICAL RECORD AND TREATMENT (Patient) RECORDS MAI AINED AT PATIENT'S HOME ADDRESS OR DUTY STATION ARRIVAL STREET ADDRESS DATE'Day Mon , Nu) TIME V, oci CITY STATE ZIP CODE TRANSPO TATION TO FACILITY SEX DUTY/LOCAL PHONE MILITARY STATUS THIRD PARTY INSURANCE , AREA CODE NUMBER ITEM YES NO N/A ITEM YES NO ry PRP ADDITIONAL INSURANCE AGE HOME PHONE FLYING STATUS .-. ,..1 DD 2568 IN CHART AREA CODE NUMBER MEDICAL HISTORY OBTAINED FROM NAME OF INSURANCE COMPANY 3 1-- CURRENT MEDICATIONS INJURY OR OCCUPATIONAL ILLNESS EMERGENCY ROOM VISIT ITEM WHEN (Date) DATE LAST VISIT 24 HOUR RETURN YES NO tb ffi'\c \ n YES n NO IS THIS AN INJURY? WHERE TETANUS ALLERGIES INJURY/SAFETY FORMS . DATE LAST SHOT COMPLETED INTMAL HOW SEND YES . NO i) tirl\ 6 CHIEF COMPLMNTr CATEGORY OF TR TMENT TIME 0 EMERGENT BP PULSE ICJ URGENT RESP TEMP . NON URGENT ti PT/PTT CXR PA & LAT/PORTABLE C-SPINE ID URINE C8S UA MSCC/CATH ACUTE ABDOMEN cc LS SPINE 0 SINUS HEAD CT co ORDERS PULSE OX TIME .n RESPONSE DISPOSITION DISPOSITION QUARTERS /OFF DUTY PATIENT/DISCHARGE INSTRUCTIONS HOME n FULL DUTY n 24 HRS. n 48 FIRS. n 78 HRS. MODIFIED DUTY UNTIL RETURN TO DUTY CONDITION UPON RELEASE ADMIT TO UNIT/SERVICE "TO REFERRED ION. WHEN IMPROVED . UNCHANGED . DETERIORATE TIME OF RELEASE I have received and understand these instructions. PATIENTS SIGNATURE PATIENTS IDENTIFICATION (For typed or Rattan entries, give: Name — lest,first , middle; ID no. (SSN or other); hospital or medical facility) EMERGENCY CARE AND TREATMENT (Patient) Medical Record STANDARD FORM 558 (REV. 9-96), Prescribed by GSMCMR FPMR (41 CFR)101-11.203(bX10) USAPA V1.00 MEDCOM - 20246 DOD-033820 NSN 7540-01-075-3766 MEDICAL RECORD EMERGENCY CARE AND TREATMENT (Doctor) TIME SEEN BY PROVIDER U U WBC H/H PLT C.) 2 co TEST RESULTS ABG/PULSE OX SUP 02 PH P02 PCO2 SAT OTHER RADIOLOGY RESULTS Check if read by radiologist . PT APTT BHCG ETOH GLU DIP MICRO EKG INTERPRETATION PROVIDER HISTORY/PHYSICAL ki/icr-vt Amon.61(m. h( 011.1.1 mq_2_ 411111111111¦ CONSULT WITH TIME i ACTION RESIDENT/MEDICAL STUDENT SIGNATURE AND STAMP PROVIDER SIGNATURE AND STAMP DIAGNOSIS Ill O 0 PATIENTS IDENTIFICATION For (Wed or written entries, give: Name—last, &M. middle; 11:1 no. (SSN or other); hospital or medical facitny) EMERGENCY CARE AND TREATMENT (Doctor) Medical Record STANDARD FORM 558 (REV. 9-96) Prescribed by GSAACMR FPMR (41 CFR) 101-11.203(b)(10) 11111111 (40-1 USAPA V1.00 MEDCOM - 20247 DOD-033821 510-112 0 MEDICAL RECORD DATE A.M. P.M. NURSING NOTES k.,611 an 1 ItilCJ) OBSERVATIONSInclude medicaton and treatment when indicated,... FRIMIrMENNIMINEVI¦ AVIIMANIK M I . i 1. A. t • Erb .,S PU( \\ . 3.t, i NSN 7540-00-634-4123 .......I' la.• L. f- - c . (' r . (_ v (()--- . . Int-infiri i,. nn renimr•rs r•;.-1...1 PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle; grade; rank; rate; REGISTER NO. hospital or medical fad ity) WARD NO. NURSING NOTES Medical Record STANDARD FORM 510 (REV. 7-91) Prescribed by GSA/ICMR, FIRMR (41 CFR) 201-9.202-1 MEDCOM - 20248 DOD-033822 MEDICAL RECORD PREOPERATIVE/POSTOPERATIVE NURSING DOCUMENT For use of this form. see AR 40-66: the proponent agency is The Office of the Surgeon General. 1. AGE: 2. KNOWN ALLERGIC SENSITIVITIES (e.g., Iodine, Tape, Medication): HEIGHT: 3. PREVIOUS SURGERY ] NO YES (type): WEIGHT: 4. PROPOSED SURGICAL PROCEDURE: Leit I-62r/ 5. ADDITIONAL INFORMATION: Last PO: Medical FIN: Implants: Medications: Jewelry removed: yes/no Family waiting: yes/no 6. PATIENT PROBLEMS AND NEEDS 7. PATIENT GOALS AND EXPECTED OUTCOMES 8. OR NURSING INTERVENTIONS A. PSYCHOSOCIAL Allow pt. to verbalize Pt. verbalizes any specific anxiety. ---;otential for anxiety ree4plain OR environment Pt. exhibits relaxed body posture. nd answer questions related to traumatic injury; egarding surgery. language barrier; Offer comfort measures, surgical environment e.g., warm blanket, touch) Explain all nursing rocedures before they are one. Remain with pt. whenever ossible. o Maintain family interface. B. AERATION Offer to elevate head of ,-----Potential for itter or offer pillow. respiratory dysfunction due to Observe pt. while awaiting sedation; positioning; injury urgery for signs of distress Assist anesthesia during tubation and extubation C. INTEGUMENT PT. will not exhibit signs of impair-Utilize pressure preventing ment of skin integrity (e.g., reddened evices on OR table andareas. impairment ccessories. of skin integuity due to bovie Check for proper pad; position; fluid shift ositioning and support to aintain good body alignment. Pad pressure points. Place ESU ground pad on n compromised skin surface rea. Keep prep fluids from ooling. 9. PATIENTS IDENTIFICATION (For typed or written entries give: Name- last, first, middle; grade; date; hospital or medical facility) 1111111111(96s)1 DA FORM 5179, JUN 91 Previoius editions are obsolete. USAPA V1.01 MEDCOM - 20249 DOD-033823 6. PATIENT PROBLEMS AND NEEDS D. CIRCULATION Potential for inade-quate tissue perfusion due to anesthesia; traumatic injury; position;•simtt;,.prc.v-itltrs-SMFry r E. NEUROMUSCULAR CONTROL E.1.--Potential impairment of mobility due to sedation; pain; inittry E.2. _ Potential discomfort due to injury; pain F. NEUROMUSCULAR CONTROL F.1. ,...--13Mminished visual perception due to being injury: sedation; F 2 /Potential for decreased communictaion due to language sedation barrier; F.3. Potential injury due to dentures. G. OTHER PATIENT PROBLEMS NEEDS. Or continuation of above problems/needs. 7. PATIENT GOALS AND EXPECTED OUTCOMES --K-Pt. will exhibit signs of adequate tissue perfusion (e.g., color, warmth, pedal pulse). Pt. will be transferred to OR table ithout difficulty. Pt. will not experience unnecessary physical discomfort. Pt. will be made aware of s rroundings prior to anesthesia duction. Pt. will be transferred safely to R t ble. o Pt. will be able to understand tructions. o) danger of injury during intraop period. OTHER PATIENT GOALS AND EXPECTED OUTCOMES. Or continuation of above goals and outcomes. 8. OR NURSING INTERVENTIONS o Check for support stockings or ace wraps. If none, check with doctors. eck that safety straps are correctly applied. o Offer pillow for under knees. o Place and take down legs from stirrups with slow bilateral motion. that rings have been removed. Have sufficient people vailable for transfer. insure proper body lignment. Allow patient to lie in osition of comfort while aiting for surgery. Offer support (i.e., pillows, athtowels, etc.) for positioning. ii Introduce self. Keep pt. nformed as to where he/she is nd what is happening. inform pt. in which rection to move and assist if ecessary. Speak clearly and slowly. Address pt. from -e--;11-01/7 side. b Validate pt.'s understanding of verbal communications. o Verify removal of dentures. OTHER NURSING INTERVENTIONS. Or Continuation of above interventions. 10. OR NURSING INTERVENTIONS COMPLETED/ADDITIONAL INTEROPERATIVE INTERVENTIONS NOTED. DATE 14. POSTO ION: 9. PREORERTIVE EVALU (Signature and Title) 1,14:\ BY 13. PREOPERTIVE EVAL BY (Signature and TitI DATE: —22 REVERSE OF DA FORM 5179. JUN 91 I DATE: 22.24(153. TIME: loll 1 USAPA V1.01 MEDCOM - 20250 DOD-033824 INTRAOPERP' tE MEDICAL RECORD IMENT For use of this tom, see AR 40-407, the pa is the office of The Surgeon General. 1. PATWNITRANSPORTED TO OPERA 2. PATIEN WED AND PR CEDURE VIA 4¦I eL., VERIFIED 4 3. DATE TIM 1 ARRI SUITE 4. PATIE e2.2, TIME, iRy& NUMBER 5. PRE ERATIVE EMOTIONAL STATUS 121CALM . ANXIOUS . EXCITED . CRYING . ANGRY . WITHDRAWN . OTHER (Specify) COMMENTS m twA_ 6 Nt RSTNG PERSONNEL ASSIGNED SCT ,-7-...;-:.---• ----RELIEF SCRUB .. SCRUB ASSIGNED tAkit — RELIEF 1$kf's- — EOC.) CIRCULATOR _ ....,.. ........ . .. __CIRCULATOR :1‘,1:-;• --_ ___ AND _______ AIDS (Specify) cki SUPINE . LITHOTOMY 0 PRONE . KRASKE LATERAL: . LEFT SIDE UP . RIGHT SIDE UP COMMENTS: CIA6 (314_ Ctivin_bc)ctACCO L.-,6 ° Ccete4c,-(2-0 tq 8. SKIN PREPARATION HAIR REMOVAL Er YES 0 NO PREP SOLUTION (Specify) boskot, DONE BY: . NURSING UNIT SITE: Liz,. A p-. vp_e_t, B WHOM: rwij METHOD: ET--_OR . DEPILATORY 42RAZOR ' . SITE:. Li BY WHOM: 111 CLIP ____ _. . •, • COMMENTS: 4$ Ke.k.c_e.5 617 d.i...4.-+ ttimikdiENTS: 9. LOCATION OF EXTERNAL DEVICES • .1*-.011111111 --"'"•---oisimaromp- iropp.4-. 40111111*r • LEGEND et = Correct Incorr RIMS First Closing Final Closing 10. COUNTS Other• • Count Count Sponge 102311 1 M211111/111=1111111111111IN INMYIME 0111M23211111111111MIE1 PM111601111 11111111 Instrument _ Other Yes ­ g" o 11. PATIENT IDENTIFICATION (For typed or written entries give: 12. ELEC OSURGERY OF.VICE(SI (ESU) IZYES 101 NO Name - Last, first, middle; Grade; Date; Hospital or Medical Facility;) Cut-30 coa 3c--/ ESU NO: V &IL-QS &Are CibTI:rr • o GROUND PAD: BRAND' sL C0-4,A LOT NO: —70")/ I J Er.,E$A1 NO: •7'--.•7:43DUND PAD: BRAND LOT NO: . BIPOLAR NO: DA FORM 5179-1, OCT 87 REPLACES DA FORM 5179.1 (TESTI, DEC.82, WHICH IS OBSOLETE. USAPA V1.00 MEDCOM -20251 . . DOD-033825 13. PROSTHESIS, IMPLANTS sgt,. 'JO IF YES NAME: ID NUMBEh, .CTURER 1 4. e- `:'1W'''''',:a6.9111440124agiti.(g4VA'MEDICATIONS/ORE)ERSIATii ,r4a, eigr4* IRRIGATION/MEDICATIONS GIVEN IN OPERATING ROOM (NOT BY ANESTHESIA} mtvicATIONS/SOLUTION . DOSAGE ... . ._... TIME - .. METHOD PREPARED BY LJ •-•-• z_NI, GIVEN BY .. li , _,.... ... • --_—.... .... ............ ii . ,, 1; 1 - .. IRRIGATION'MOUND f! 134ES • NO; TYPE(S);. . /\,(•• ... . . _. . . . !OTHER ORDER ticcy wi •., TIME ' CARRIED OUT BY - . . t, ,............_. 1 . t : HYSICIAN'S SIGNATURE . . ... •.t: .....,_„,-,..,„—_,.....„. —, - .,,..¢..rfe.s.....-+4,,,,,,-sier,"-,,......,,,,717......2.14...4.106-07.ern.a.,...}," or. .....-”vs,tow•erntmeateo,o..--tcp,...,,,e.,.. ........wm..."-...hl. .15. X-RAY IN OPERATING Rø IF YES, SITE YES • NO 16. -.''f.'4.LABORATORY SPEDIMENS SPECIMEN (5) azNAME -- --------------4------- -NAME YES • NO FROZEN SECTION (FSVIAME YES • .. .. .. ... CULTURE IC) NAME .. NAME YES • NO p/'' .. „.. NAME NAME NAME NAME /"-------- NAME • 18. DRESSING/IMMOBILIZATION (Specify) . _. ....:_. 17. TUBES, DRAINS/PACKING YES p -NO -ae.A. TYPE/SIZE 1.3(.9 1' . 2. 6..A.14CO('V, 3. fi÷A-,Icse_ SITE 1. 2 I Q A nnrrinki A I II\ 11,,I,D. • w -we ¦-a . tAJC-27 S çivt CLUOVekt41.--k_. 4 FAC '4% 6 V`-ee Ct arit/Kr . 20. OPERATION(S) PERFORMED 21. PATIENT TRANSFERRED TO TIMES. MET 9D CLL RAI 5179-1, OCT 87 USAPA V1.00 MEDCOM - 20252 . • • • • ¦ —¦ DOD-033826 NSN 7540-00-634-4124 MEDICAL RECORD VITAL SIGNS RECORD HOSPITAL DAY POST-MONTH-YEAR 19 PULSE (0) DAY ritr7-11_ !ze • DAY HOUR TEMP. F (•) 105° kitimeram TEMP. C 40.6° 180 104° • • • 40.0° 170 103° 39.4° 160 150 102° 101° 38.9 ° 38.3° 0 cu to' a)cc 140 100° 37.8 ° a) 130 120 99° 98.6° 98° 37.2° 37.0° 36.7° o- 110 97° 36.1 ° 09 a)c.) 100 35.6° 90 95° 35.0° 80 70 pedal data only when so a PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first, middle: ID No. REGISTER NO (S.SN or other); hospital or medical facility) WARD NO. 'VITAL SIGNS RECORDS Medical Record STANDARD FORM SU (REV. 7-95) Prescribed by GSA/ICMR, F1RMR (41 CFR) 201-9.202-1 MEDCOM - 20253 DOD-033827 DRUG (Unite) MEDICAL RECORD ANESTHESIA TOTALS : '''' 3S • O o z I texi./11/1 TOTAL URINE. 1- z z w D I 5 3 z VOLAT rarki dpI AGENT FLUIDS - SUMMARY g % e t. CRYSTALLOID- ;25--d,c 17- IVR LIMen ILI x N20 tJMIn OLLOID- 02 z SINGLE DOSE DRUGS - MARK on ortig, BLOOD- WITH NUMBERS &ENTER IN REMARKS co LINE snit a Warrred REMARKS- O yv5 f 5"-/o O phr....4 5 Code drugs with numbers : we", Warned with totters u. Wormed i/75 74_411) EST BLOOD LOSS URINE - LOSSES . PH,. STATU TIME 'a -, 10e4-01kt._ EmzzioSY MEOLS; 220 WIEN MAW KG 11111111111111M 11•11 BP by cuff LB SIMMENNIENEEMMIGNIM jf) 200 Tooerrm: V /roceje -4e-.4/9x• A 180 (iii Heart rate Ensm-WAIMM'KEE ,lAPe-e1uf''--,c.,- • 160 11101111=111 WIN11111111111 Rasp rate 140 MillIMISEMINOWS1121 MI i , now /9-A-/-1 oil ref R17 120 O 8P U=MW 70, (transduced) 100 wag ' -.di Arm 80 tun= OK?-.If utmanampummilli um i i MI TOURNIQUET 60 IMEWASPERNIMIMinuismaffis::::::.:::::K::: ,.SIEWAM1114 T MMIIIMISIMIMIIIIMMINUI i i IIIMMIHIIIINI OK tor 40 EZEIMPENZIMERMIEMMNIM MORMININ PROCEDURE? =MOM ATIMVAIIMPIMI ANES- x-x mmIIIIMM TWE- 2D WE ASENDEVORIAMMERN :A.:V:: MUM= KM PR000-0 MINIMA ; I : - , 1; iqr WM ; ; ; ; IMIMIIERMIIIM RECOVERY AT BP/Auto Cu PACU ICU 02 (toff) ISP•cIPP) 131, / oth OTHER I ART line k pp Ing blkt EM.Aallill=nrtat •NDmON: graMENIMINIIISTarE s analyzer TEMP- she *ESP- 1/ cit;;1 ¦ N4A Block T14 BP-Sdf HR- .. Start Room End ISA Conv wanner Me• with letters s ayrnbets. EVENTS End "Mein wider REAfARKS posidon /83 ig_ff /9 PROCEDURES and CPT Codes AK tiSTRETIC TEC HNIQU ES: 044edb• bkck AKIK,Atio wide Remertia 777 Cle5kre---- ---,Pekdke 410/ kiPce4.- AIRWAY MANAGEallip. blade, technki" comments PATIENT I NT1FICATION-Typed...arm sneer GredwRet.. Medics, belly 99A/It SURGEONS: PROCEDURE LOCATION ANESTNE DATE re)} -AilII IP PAGE / OF WAMC OP 376 REVISED . 1 Jan 99 MEDCOM - 20254 DOD-033828 ANESTHESIA PLAN OF PRF c=RAL ASSESSMENT (Sedaties-/Ar sial Age 3 113AYS MOS Sex KMALE, FEMALI .0A Physical Stat 3 4 37 '4- PROPOSED PROCEDURE: e . 12.1"0 Fx WT: 7o..C1.4..B HT: .IN. 14 SURGICAL SERVICE: NPO SINCE: ALLERGIES: ,S:Er glyG2+-¦-1 HABITS: PREOPERATIVE TOBACCO: PAST MEDICAL HISTORY/SYSTEMS REVIEW ASSESSMENT ETOH: Cardiovascular: PAST SURGICALJANESTHETIC DRUGS: Hypertension N Y Angina N Y CURRENT MEDICATIONS: MI NY ( ) = ordered as premed CVA NY Other NY Pulmonary System; () Asthma NY () Bronchitis/URI N Y PHYSICA,L. EXAMINATION 0 COPD NY Bp T bifIR 224 R i ( ) Other kr...,) N Y Pain cale 0-10 Renal System: HEENT - Teeth M-e Acute/Chronic RF N Y TracheaPREMEDICATIONS: Gastrointestinal: TMJ/Neck it2None Yes (0 Mrs) /CC Hepatitis N Y f-z3 Oropharnyx mg IV IM PO Hiatal Hernia N Wares .it- mg IV IM PO PUD/GERD N CHEST: .• 13SCTlf mg IV IM PO Endocrine System: Diabetes N Y CARDIAC: AA( $4,.--k LABORATORY STUDIES: Steriods N Y Thyroid N Y EXTREMITIES: 1113/HCT: I Neurological: U/A: Seizures N Y IV Access: (C) eh/ 4., OTHER: Neuropathy N Y. Dinar Filling: Other N Y Gynecological : BACK: Pregnancy N Y Other Significant Hx: OTHER: N N Familial HX N NPO Since 070 C) 4 rk lea4451Ayt ANESTHETIC PLAN: { ) LOCAL { } MAC { } Regional (Specify): General: Mask Intubation INFORMED CONSENT/COUNSELING STATEMENT: Plans, alternatives and risks of anesthesia including death have been explained to anddiscussed with the patientllegal guardian. [co) —1_The patien ms to understand and agrees. Questions answered. Signed: Date: Time: Hrs POST-ANESTHESIA EVALUATION AND NOTE (NON ASU) SEDATION KEY: } NO APPARENT ANESTHETIC COMPLICATIONS { } OTHER 1. MINIMAL {Anxiolysis) Patient responds normally to verbal commands Signed: Date: Time: Hrs 2. MODERATE (conscious sedation) Patient responds purposefully to verbal commands alone or Patient Identification: (Ward) accompanied by light tactile stimulation. Airway assistance is not " j° necessary. -CA1t2 ,e4. 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. WAMC Form 2300 (Revised) 15 Mar 01 mckpi pos Previous edition is obsoie e ANESTHESIA SERVICE RECORD 'U.S. -SPO: 2001429483/40002 MEDCOM -20255 DOD-033829 MEDICAL RECORD - DOCTOR'S ORL. 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 COMPLETEDNUMBER DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS TIME & INITIALS TIME & INITIALS .---, 1 j t. t.. ' POST ANESTHESIA ORDERS (circled Items) ab '2_ 1 tk? Cf g--X--1 2 Stip21e4neutal-elefgen, ,3 Morphine / Meperidine mg IV now and mg q 3-5 min pm pain for a max dose n1_, mg. 5-rain itdischarge. 4 _ ' • q 1 , -. • -. ; • 1/V x 1. -,____.6—Bracerttlar mg IVprifIcrtra-1-r---al Phenergadi.s't {rng IV pro N/V x 1. t: - - .. • 9.g !Pc! p , : • .--'ACU. VF -4----ec-Ahr,—, 10 Discharge from recovery status when PACU discharge criteria met. S1A-.53 C 2.4,---..- ( 1 ( (4())-7-- PATIENT IDENTIFICATION Complete the following information on page 1 only. Note any changes on subsequent pages. Diagnosis: *IVO ((o)(13)'-L1 s. Height: -Weight: Diet: 1 Allergies: Nursing Unit Room No. Bed No. Page No. PACU, 28th CSH 1 of I -iS t t 1 S I J UVIGIiUI MAR 99 PREVIOUS EDITIONS ARE OBSOLETE MC Vt .00 MEDCOM -20256 DOD-033830 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 TI ME ORDER NOTED AND HOURS SIGN NURSING UNIT ROOM NO. io)( c2)--1-0 • NO..102113. P2)(s) 2'13 a . PATIENT IDENTIFICATION.qk WI 7­6 21.I 2f 6,4" DATE OF ORDER. TIME OF ORDER 0 0 lig./L1)°0_......„%.2 dc)L.mi . ?, — 1%-.7d.-- 1L'? HOURS .hti I • t4 NURSING UNIT ROOM NO.4 =.0 NO. PATIENT IDENTIFICATION DATE OF ORDER. TIME OF ORDER r Z-(77f i915,-.. HOURS ransmi pow ,,,i-,___,.,,,,,,,. ,e, ..... _..f--e1/4. NI . ra b .a.-.4,-)fr-"ir rOi /) W 2,-).g 4 NURSING UNIT ROOM NO. B E 0.0..r .,..2_ xsiz.,,,,6- ... A e. .04-U IZAC--ft 42)L., i', 14­PATTEN.IDENTIFICATION DATE OF ORDER TIME OF ORDER pz ‹.,4,44.s. 447., ersl,c1,-,vk-/ igivl- KZ OURS. VIIr in.,)Z Cri.'/OL ... SOLE AO. 0 # '4,65 it.,./ 44.8 es"-., 4 WI., ..­ Mr-,O, e V--e4) /t) e- 11/P 40 ) A),z. OW rie.-1-Cci7-r '.2 -./Lie I" . 1111 NURSING UNIT. RO.NO. BE0 N Ipplin A of . ..., ..... REPLAC F 1 JUL 77, WHICH MAY BE USED. DA 1APR 79 4256 MEDCOM - 20257 DOD-033831 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 J TIME 0)279 LIST TI ME ORDER h) .5.,4)7/2) HOURS NOTED AND ((,1cov`k tO, eon-SIGN -;),6. 4 K ces )17/Z9,d-1-a-2 x25"L'i)c AO, • Jo' vi-­ )c-) . )2. 0.)-I4 -6 /3v vi4770A) IBJ NURSING UNIT )00. PAT TE OF ORDER TIME OF NURSING UNIT ROOM NO. BED NO. PATI ENT IDENTIF IC ATION DATE OF ORDER TIME OF ORDER HOURS NURSING UNIT ROOM NO. BED NO. PATIENT 00ENTIFICATION DATE OF ORDER TIME OF ORDER HOURS NURSING UNIT ROOM NO. BED NO. REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED. DA 4256 , FAOPr4 79 MEDCOM - 20258 Watms./..ziares DOD-033832 THERAPEUTIC DOCUMENTATION CARE PLAN (NON —MEDICATION ) CLINICAL RECORD For use the proponent ageneyotstitre f .SC=On General. yr. 2003 fgrieSOMIFIt 4MO. VERIF T BY INITIALING iliMert! .tzs,A=;Z., ,,,' 4 itt INITIAL PROPL1? COLUMN FOLLOWING EACH COMPLETION ORDER DATE COMPLETED DATE cu_ 9(7 Daaq c9RAu.2) -1111. \I5 t-c i a)-11111krxi, rccs\l-- \e, a---1:) ;D-illik7-kur. ( aa Olo. WWI- ... 1 , _ OrFie-Vate (0 l-.-c. . - __ ...... tiP) ... ..... ...... ... sN, (,)( . . -. . 4 . . " . . . ALLERGIES: MI YES IN NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE: we YES IM NO 4:31 (C) e-1—0 -TAB\ k\- 15c / i-A0 PAGE NO' PATIENT IDENTIFICATION: ACTION TIMES USE PENCIL. CIRCLE ACTION TIMES 1111111. (9 (C.) —1 D.8.9.10.11.12.13 14.15 E.16.17 18.19.20.21 22.23 N.24 01 02 03 04 05 06 07 M DCOM - 20259 ___ LISA PA I/1.00 DOD-033833 Verity by THERAPEUTIC DOCUMENTATION CARE PLAN' Initialing (NON-MEDICATION ) Ain .Yr 2003 I Order Clerk Date to Date Nurse SINGLE ACTIONS Time to be Done Time Done Initials be Done - Gc'c'cv --Tr) oL7 C) - ICW\ 1 AzOdic2 ?4- ( Ft_r-ca3c-\-es/ambtAJN-Do \i\x-sf7r a+ _ Soruce.s )¦r, 99- — – Order/ Clerk/ Expir PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION Nurse Date ACTION, FREQUENCY TIME/DATE COMPLETED •¦¦ MN MI NO MS USAPA V1.00 MEDCOM - 20260 DOD-033834 MEDCOM - 20261 DOD-033835 (- ;• 1'2: _ +MeCt'..(c-z-,Q5)"0 Vc 1cD ' • r :-; .17; Y.; MEDCOM - 20262 DOD-033836 MEDICAL. RECORD-SUPPLEMENTAL MEDICAL DATA For use of thio tom. see AR 40.66; the propellent agency is the Office of The Surgeon General. . REPORT TITLE .....i OTSG APPROVED Water Post-Anesthesia Care Unit (PACU) Flow Sheet • IIMIII•¦•••M¦, Date: .27 Sacp Anesthesia Type (Circle)): General Spinal Epidural Apr— Drains AirwayTime In: ri/ IV Sedation Nerve Block movac asal 'Lk-DA Allergies: OR Intake: Crystalloid i41 .Colloid . NG Pre-op V/S: i7-`11 C OR Output: UOP . EBL . ..JP Procedures: iffiE012, Meds/Times: . . T-tube Trach Foley Other Pre Op Meds Histor NA) TIS , Time 7.1k Pacu Intake . Sa02 Time Solution Amount.Site. Infused Fi02 11C:A7.1 14S tor)0 Methods •• 4 *426. 240 220 X-rays: Labs: Post-Anesthesia Recovery store 200 Criteria ADM I 30' D/C Codes ACtivily AIRWAY 180 (I) Moves 2 Extremities A= Ambu (2) Moves 4 Extremities 2--z, (0) Moves 0 Extremities BB = Blow-by M= Mask Airway 150 FT = Face (2) Cough, Deep breath (1) byspnea. limited breathing Tent (0) Apnea RA = RoomAir 140 NC = Nasal Blood Pressure Cannula (2) SBP =-/- 20 of Pre-op 120 (1) SBP =I-20-50 of Pre-op (0) SOP =1-50 of Pm-op V/S rd X =A-line BP Consciousness 100 V ' =Cuff BP (2) Fully Awake, audible dying = Pulse 1 1 (1) Arousable to verbal or pain 80 TEMP a a Color S = Skin . 12) Baseline cam & appearance 60 a NA (1) pale. mottled. jaundiced 2--L 0=Oral (0) Cyanotic A = Axillary A . T =Tympanic 40 A Circulation (Peds 5 Years) R = Rectal (2) radial Pulse Palpable A (I) Axillary palpable, not radial (0) Carotid ordy reliable pulse LOS 20 C = Cervical N TOTALS: Must 45 =Thoracic greater to DIC. otherwise RR 13 16 lz 11 =Lumbar 13 needs anesthesia approval for DC. =Sacral 4 9 9 Time 'n done: Wound Care. Pain Ma nagement, Pain (0-10) T. . ncentive Spirometer, Comfort Measures LOS Sa ely: R up X 211s Preca . Privacy Maintained IL Ofirnlut Oft *wen* PREP DEPARTMENTISERVICEICLINIC DATE ? Cr' cf.7 7 PATIENT'S IDENTIFICATION (For typed or mitten en Name -last. fiat middle; grade; dare; Ample or medical faulty! D HISTORYiPHYSICAL D FLOW CHART P OTHER EXAMINATION 0 EITHER turd/ OR EVALUATION .; • 1111.1(9( -I CI DIAGNOSTIC STUDIES El TREATMENT OA FORM 4700, MAY 78 WAMC OP 173-E. (Revised) 1 Apr 01 (MCXC-DN) . MEDCOM - 20263 Previous edition is obsolete USAPPCY2 00 DOD-033837 MEDICATIONS Allergies: NURSING NOTES Time Pain Medication 8 Route Pain I/E By1-10 Dnsant. 1-10 j )( VI. .ti-i'l-,c 1q3C-PA ) I 1,8 1117._111 oi,)-- Lic--1­ NEUROVASCULAR A4)A Time Site Range Sensory P Cap T Color Of Refill Motion Adm 4- -1-- P ,.., 15' 30' --f- ÷ 1 13 C P 45' 60' 90' DIG ( t_ -_ p ,e. c Pi — Movement/S sation: + =present.- =absent Temp:C = Cool, W =Warm Pulses: P= Palpable, D = Doppler, A =Absent Color: C p Cyanotic. Capillary Refill: B-Brisk, S= Sluggish P= Pale, Pk =Pink C-SECTIONS 15 30' 45 60' D/C .,.......,_ Fund.'Height . Lochia Peripad# Fund. Cond. DRESSINGS Time.Location Type Drainage Adm.its • . _ 4. 30' VOMIIIIIMMTAllimii111111 604 DIC MN •4. • II III,Il PACU OUTPUT Time Source ' /Appearance Amount Discharge Criteria: Date: 9.2-?z)3Time(2-0 PARS: BP: I ryciT: q77 HR: Loa Mit/ Sa02: ID 6 Pain Live! At D/C 10-101: Intake: U0 0 additional Data: Output: \ON CARDIAC RHYTHM Transferred To: Time 11.-15-- Rhythm 1.-). , e--- Symptomatic? Rhythm Strip Run? t--k-) Report Given To: Transferred Via: W/C Transferred By: Cleared IAW Recovery R Et Signature. WAMC OP 173-E MEDCOM - 20264 DOD-033838 1 . REPORTING MTF --2. MTF LOCATION ADMISSION AND CODING INFORMATION 1 2 3 4 5 6 7 8 (State or Country For use of this form, see AR 40-400: the proponent agency is OTSG Code.) A 1 , 3 . REGISTER NUMBER NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX 9 10 in 12.13.14.15 16 17 18 Al • ,.. H (V " ' 7. AGE AT ADMIS ION 8. RACE 9. ETHNIC RELIGION 19 20 21 22 23 24 25 26 27 28 29 30 31 5ACK-GROUND 1) N) k 7.-- 10. LENGTH OF SERVICE EIS 11. RAP 12. SOCIAL SECURITY NUMBER *i'L 32 33 34 35 36 37 38 40 41 42 43 44 45 -110 ORGANIZATION (Active Duty Only) 13. MARITAL STATUS BRANCH I C ADMISSION .-----. 46 14. FLYING STATUS i 16. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE 47 48 49 1 50 51 52 53 54 55 56 57 58 59 60 61 -.•••--.. •-____________________--.--- __ 17. UNIT LOCATION (State or 18. MOS 19. TRAUMA PREY. ADMISSION 62 63 Country Code) 64 65 66 67 68 69 70 71 YEAR NO ,---- = I 20. SOURCE OF ADMISSION) AUTHORITY FOR WARD NAME/RELATIONSHIP OF EMER ENCY ADDRESSEE 72 ADMISSION I awl ADDRESS OF EMERGENCY ADDRESSEE INK (include ZIP Code) NAME AND LOCATION OF MEDICAL TREATMENT FACILITY QF Elt)ERNCY ADDRESSEETELEPHONE NUMBER 21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION 1Y YMMD01 73 74 75 76 77 78 79 80 81 NCI 84.85 86 01 INNIAMIlal 24. CLINIC SVC -ADMITTING 25. MTF TRANSFERRED FROM 26. DATE THIS ADMISSION WY MMD01 87 f 88 [ 8990 92 94 95 96 97 { 91 93 A E. A .A11 1 27. LOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION (V YMMDD1 (Battle Casualty Only) 103 104 105 106 107 108 109 110 111 FOR LOCAL USE DX it OP) 1----ri 6 FrE), P r DC ??.(0(a -Cro un‘q 9 -tv_J -q - ADMITTING OFF1 SIGNA 9p-z. MEDCOM - 20265 DOD-033839 • INPATIENT TREATMENT RECORD COVER SHEET Fur usa of this form, see AR 40400; the proponent agency is OTSG MC IJI I CM 41J,• -,1 F I DAME am; ,7Hr.1, Eau GRADE ADI,IISSIFS ',IRA:PAS -- 11 K — A/1HO .,-... EPtA) SE. AGE 6. PACE REX.; Gli LENGTH SF 7216 EIS ID. PREVIOUS 1 ACMiSSION II EMP cici I 5 Ft TING STATUS 1 II OSG tU t•iri DEN 1 13. ORG4 -84f(3) aRANCKCDSPS ! 19 UICIZIP IA. WARD J_Taic2. TO. TYPE 6250 .• ¦ I i k 70E3 1,1)1A 71. SOURCE OF ACIARSS,Crt'Au THOR TY I;ORADMISSICS 72 HOURS OF 23. CLINIC SERVICE _ ADMISSION b 1 r eC•i- rr-or, Elie _ I900 0-01- —reir . NA ME:RELATLC.SSHIP IF EMERGENCY ADDRESSEE TO TYPE OISPOSITTON 26 DATE OF aisecw DiC 70.6frfte 'a7 ac..-+ Qoo3 27, 4COPESS CF EMERGENCY ADDRESSEE 110ciudf ZIP CAM) i 220. f TELEPHONE NO. 23 SATE OF TH ADMITTING OFFICER 1 ADMISSION a? Set, aoc2 ONAME ANO LOCATION CF MEDICAL TREATMENT FACILITY 3a. DATE OF TIM. 32. UNITS OF WHOLE ISAAC;ADMISSION COMPONENT TRANSFUSED 31. STP! TM OA TA E DVC11 0 Cumin/4 An PAMIR 33. CAUSE Of INJURY 3 4 0:AGNDSES:GPERATI12IS ANO SPECIAL. PROCEDURES 1J'X.-. sb9 • Ex LAP Gro/ .1-0 /fish ......., Di c( 7 s .47) P.„,r 172 A 9 -7 q. 2. ¦.( .5" q ct 1 Z. sq,11 cc, -441 'ci et 3.ski gt*.a Li Gtct.0t-t j 3:. Total Days This Facility ASSENT SiCk CATS i b. OTrif: DAYS RT LV.CCOP i I. SVELEMENTAL I A. EEO CATS 1. TOTAL 5160 TR IO1 CAPE DAYS 1 CARE OATS 00 . ... 36. TEl Oa -s All , acilites • • .., • '---------' • IEN,AL I. 051 :ATS )61-4. rout, SCR EAT; „4,41 ' CIPS. CA IS ti pr 30 I•-5,E , N. ,Z C ,rr I. F:0 RN1 MEDCOM - 20266 L.G121+: VS DOD-033840 AUTHORIZED FOR LOCAL REPRODUCTION . PROGRESS NOTES MEDICAL RECORD I NOTES DATE . -1 1/1,1Vrt -or , /-7 rt_r4-0 . Milk (07A_E4,t, a-(6 c1( I 52 vaatt Tvoli EPA).6 ,CWFact - I/I bd,- fh t',a1/1-d l(4) F'ecu doi4 s IA 11-1,-(1 ‘ in1-1-a ..),.c .)--______:______ - — 90e...1, _:_----7.-.Nr/ e.-icett4-aes--ei-t,a__‘1611-6j ;s ir-c ce-et4 S' (j° ee/ Lei. k) -Sr) 4/4 di0-0-614 A.pri A's c: cd -6779--7krii-C-'wail, 16/e._.‘clie-y• - --ik „flea 1,1,,)2: .& . 4,179$,4 1-e 1...0.4111 1.411011.-• forv-ea v.-47 - pf—1 A 1,/-cch "e114-1 e a i -er /-434Ai C„velo / kg/WA./-1--A-06t4/ a cri/ CiAl-J •..02 I-- / ait4e. ¦-1 / •G.,11/Amiii• 6 , ed4. A- leA., kg": t .,06(2-frei5 —f•-ve-ezes.40,--(L--c •(f/a4---acze ,a-44. 00P a cc )Z . --.(ori -bs..5-4-? -_:di-vi-i-e-ta atdcon,/ •,-c rf i Ast, ia'P-/ic suCr4 c ../tA-e-y/44--e. ,t ,,.., A . 5-1.1v c jg ctl, hi-tt iry-lat w- rITif,f/t_clf I/ r( //tPti it-16 , wit/ Lok, A of-) t,,, ft. pi/ - — vedit,e,c_ si • RELATIONSHIP TO SPONSOR SPONSORS NAME LAST FIRST en DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT PATIENT'S IDENTIFICATION: (For typed or written entries, give:Name • last. first. middle: I REGISTER NO. WARD NO. ID No or SSW; Sex; Date of Birth; Rank/Grade, PROGRESS NOTES Medical Record STANDARD FORM 509 'REV. 511999) Prescribed by GSA/ICMR FPMR I41CFR) 101-11.203(b)(10) Ntu uSAVA v1.00 MEDCOM - 20267 DOD-033841 AUTHORIZED FOR LOCAL REPRODUCTION MEDICAL RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE DATE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (Sign each entry) 'Cy-yip-5 ?,r-1 c..-c-cylP t.-) cm-yrc, 2-3 Ste, 03 Tom. cP c G--_,sLo -viz) Q-v-._e_ -vz1c,c) Tc,.-T-t--4::::. p c9,4_ , 5 4Q—..,...A.... li).3-1.aA.3-‘).4L _0 ,-1--4--cis-.;Ek-,--,-e..›.. 0--'1fkrk,..T-4:e'rk._ _ •-___./..C.._.. 0.---Q1,N4--4 ...&_,-r._i..'.0------4ig..C__LoCs-k---IN-.....CC- 4-L\r1-. ,_ ND MA-\......--.(1. '. mrLeth:...t.....,C) ( iv-..._,Elt.,..)...s,t IrtuR-Ar,a)3.-.1.40..._ .....4.4& S. _A.A._.,.. -.3...-2•....-.J6....A.L.A\i" C_....A3C. 2F c e. t.A.10 1 .1•I CC) e- 0 ' _ . r. . 3ooL.R, 2..L.A. ?te_it,c, ocx:=) cc, k..1424, 0_, ---.. 4) .e D.,7uA.I.. Skr:Al—sUL.ls1—,,,,,--.c-, ..-....47.` ¦A-lfejia+2..YaiZI:r_90 1 ''‘I`-• 1C-3CL•VI ,‹p .b.St..S1,_ ' \'ZZ. ,„.SL Cki. -2_ ----4.).,-(_—_,&-- 6-1--.55--e-)------.41ep ,..9 Niv•-,-,-:r.,., (00 HOSPITAL OR MEDICAL FACILITY STATUS.•, DEPART./SERVICE RECORDS MAINTAINED AT SPONSOR'S NAME SSN/ID NO, RELATIONSHIP TO SPONSOR OM (For typed or written entries, give: Name - last, first, middle; ID No or SSN; (REGISTER REGISTER NO. WARD NO. " Data of Birth; fienk/Onide.) 41111111160,)(Gy-i CHRONOLOGICAL RECORD OF MEDICAL CARE Medical Record STANDARD FORM 600 (REV. 6-97)Preseriled by GSA/ICIAR FIRMR (41 CFR) 201-9.202-1 MEDCOM - 20268 DOD-033842 AUTHORIZED FOR LOCAL REPRODUCTION ' MEDICAL RECORD.I. PROGRESS NOTES . DATE NOTES it/ friiO3 arvpio 1141-# 1. .AssAic herAi d Cowt. Mitotfri wkeve sr idt( t;10 &A-174 .' 4444. Coic eiated---( r_ dy 544-0Pob r 696oe ‘Stic) 140 ta-79/ licV • (4.0. i515-td /fro% aR RELATIONSHIP TO SPONSOR NSOR'S NAME LAST FIRST 05)(L)-Z DEPART/SERVICE HOSPITAL OR MEDICAL FACIIITY RECORDS MAINTAINED AT PATIENTS IDENTIFICATIOlk /for typal or mina, tot* g girt. Nome•kst, fiat risiddlc REGISTER NO. WARD NO. 1016 a Ige Ser Dote of NA' Roakaashr) PROGRESS NOTES Medical Record STANDARD FORM 509 IREV. 5119981 Prascrated by GSAIICHR FPO I41CFRI 101.11.203041101 USNA VIDO MEDCOM - 20269 DOD-033843 MIDDLE INITIAL ID NUMBER DATE NOTES T4,171 -0. t (DJ" t 703/ 3 gig 3 /f7th rigil c 7,4 Sct) 03 -1:4 1.291 4 3doito.t? ei) vittseil6t4 Vte. 3401. intsaimE › a of pot t +6 (tatIti4 ItA it i' 1 '1 Vlud-491 ; ' t Aid-: :1'61i-to P . -S 3—zo1 e. 6 Nan 4 ii.1-44 ° @Alt 61134, ' 4 . s‘ 1 4dCfek LIE CatibrriSat, AVidie 01141444344 as WY as Ea w. PI f 0 -c-, • i Ai _1 . ,„ det_ uAaf 0 sst5 c.ilz Try,t_--Tut ,0 i , e fit, c.ita,4 z102 z-34ecs. ktfts tig i---62_, coact% tto i Witte ctio4 cox .6.6061-, Ktrvia4 it; miz -I, -?,tA"Vwt t -{ „ 2,1sEt bhattyRkiell) jotivAlt od (7.6-ita (t4--er), ackS ri,6€0 Z4 s4 03 okt c tact lc it IDLE S.SlaDit OK 1,(944. t up:1)6366p e triakithc -h (Ow btr OncleAta etChil 4 .P'7r, PIO I !limit CotAse. CALA3 is .MciliketSk rAl. i‘Vt t.61ik f 114461' IC) b L1C STANDA USAPA VI .00 MEDCOM - 20270 DOD-033844 AITIIIDR1210 FOR LOCAL. REPEDIDUCTNIR 'MEDICAL RECORD PROGRESS NOTES DATE NOTES (24-SE49 03) fetWi-covviimu.-to A* tA fiat—xxt44410L i iko 3 Sak Ril, OA 01 tE' IMAS-e-.at,e ts-15110 ks Y 1.it4 taiii kott-ta5 1+40p --t-ivIt-ciriptc ii s -1". • Cha 1444 .-0 ctikaP , . a/4444 leo , 3 Poe-Itt-tamti, 466, goad * ac-g t,t.),.I #49 ttarptu, 4i36 itatiats. 1 fii- 7. 34.re02.-44.7.POI-(Th.IJC07 -26 BE-0',s PA - ldle filadt E SAN- C Cllg• 4 s Atra) cUrr ,,ieel& ets act -,-„,-, 2Y SEPTV • — 4 • ' i ..e. . .,..• AL-/ , tt, a _,, If _Air iri j.,.e/ Cg , /gi:AVNdr IF '_;.4M W... *, - -; or , ,.-. "P...f —...kw,. , 4. --‘3(9 le-tt (01jo Air ,o(tuimitAt.ofrie., uzilut 19 , „iv.-manic_ M i At, . Nuii&Z R4gc/77/2/27.tr-o6 ayweivitizi)(), fix/pi/IS-le-Wu/ antudaAla a vth fiti 6,41L 3,W2z.) er7. ,A/d //e I I '14u i / 1 1.1'.'an i.e _ , , k.i la •0 ch curl.. • I d.(i) diMess /7,94ed WI ii &AL 7:) inoviS -42-1.664,... ,fiz;). • Asp.Imo,.cex.A.40 A.A..... 42 ab# 441/4 7. 4/e05..v (4/aive iff 0/7S(..a VS5: da-LN9 at,60. Q-A/064 a nge- RELATIONSHIP TO SPONSOR SPONSOR'S ID NUMBER SPONSOR'S NAME MI . =I or Ow) LAST FIRST DEPARTJSERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT PATIENTS IDENTIFICATION: Geo typed or Mitten writs, AT: Nerve • INA list Pali* REGISTER NO. WARD NO, ID no er SW; Sex Date al Ilirk itsakIresdel PROGRESS NOTES Medical Record STANDARD FORM 509 orEv.5/109) Prescalad by MAMMA FPAPR 141CFRI 101-11_2020331111 USAPA V1.00 MEDCOM - 20271 DOD-033845 AUTHORIZED FOR LOCAL REPRODUCTION 'MEDICAL RECORD PROGRESS NOTES DATE NOTES , .iNc v% c.c..--f. dc.3 DrnF-5.- k)cpb± 2 ,710._.....,. TA-• Jp.. • _ . • ...... - -AD a...•(0 .• 111 CeCCI Mill iMil'.gb. , 11, lar.1111..ja•-•-ANMINPALALA¦ •••._..4 Allemilk 4. .. 1..-. •..--.1 .m. ajaL.....-... U. -re ..14.--k L4-1,-37 cx-4 €. SV—A---+—¦.Co'—‹—A—ci¦—Q-. • /braver/110'w. ...••¦.•.--._ —a .. DA:.-41•=11... 41 -.MM. • I % ....a...........&._.-...-AP!, -...Arls.... -..... A. ---. \..Vs I-"C5-\5-2. 1 Alb \ c-.452. Crt CA-T c\-3-0 it) V-42. 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PROGRESS NOTES Medical Record STANDARD FORM 509 IREV. 5115051 Prescribed by GSAIICMR Rao MUM 10 1 41 2030V USAPA V1.013 MEDCOM - 20278 DOD-033852 LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER DATE NOTES OSS -Pt).1) va. (0 ..¦•¦¦¦ ANL •I • • STANDARD FORM 589 [REV. sneasi BACK mum vim MEDCOM - 20279 DOD-033853 AUTTIORIZED FOR LOCAL REPRODUL1MN MEDICAL RECORD PROGRESS NOTES DATE NOTES kir Ow* '16 A.0 ot.Lei 0 49.44 141..._ di .62 its OA 170.t•. 'kg*.la I O Its 1, t_l Att. 6 ', • iffiAAta ta4 CA Aib)ae01AN ulLPitgrA _)&Z-RL sA--r a_ L.61N-c1/4co 4,1\ienJ 65\ RELATIONSHIP 70 SPONSOR SPONSOR'S NAME =Net Dried DEPARTJSERWCE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT PATIENTS IDENTIFICATION: 'or type/ or warm wax giro: Nom- int fist Rd* REGISTER NO. WARD NO. . 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AREA COD MBER MEDICAL HISTORY OBT. ED FROM NAME OF INSURANCE COMPAN CURRENT DICATIONS Ln INJURY OR OCC T1ONAL ILLNESS EMERGE ROOM VISIT WHEN (Date) DATE LAST VISIT 24 HOUR RETURNa1 u ITEM YES NO V n YES n NO IS THIS AN INJU - ? WHERE TETANUS ALLERGIES v ott_ INJURY/SAF-FORMS DATE T SHOT COMPLETED INTITIAL HOW SERE! YES MI NO CAVICWt CHIEF COMPLAINT " CATEGORY OF TREATMENT VITAL SIGNS TIME TIME I LI (--"LJ • EMERGENT BP I Vigil 1 Li( c.)--' PULSE /1.057 91:RTE-NT INITIALS RESP ¦ NON-URGENT TEMP '02 614i. I LABORDERS P•F'rt'SC/DIFF ABG I PT/PTT BHCG/URINE/BLOOD/QUANT XR PA & LAT/PORTABLE C-SPINE c74--eHEM: 1 2...•E I y IT URINE Ca SCC/CATH ACUTE ABDOMEN LS SPINE BL?00 S X & SI:130H0 SINUS HEAD CT ANKLE R/L ORDERS PULSE OX MONITOR TIME ORDERS BY COMPLETED BY TIME /.¦ PATIENTS RESPONSE DISPOSITION DISPOSITION QUARTERS /OFF DUTY PATIENT/DISCHARGE INSTRUCTIONS n HOME ri FULL DUTY n 24 HRS. n 48 HRS. n 78 HRS. MODIFIED DUTY UNTIL RETURN TO DUTY CONDITION UPON RELEASE ADMIT TO UNIT/SERVICE 10. TO WHEN REFERRED IMPROVED • UNCHANGED DETERIORATE TIME OF RELEASE I have received and understand these instructions PATIENTS SIGNATURE PATIENTS IDENTIFICATION (For typed or waten entries. give: Name - last, first, middle; ID no. (SSN or other); hospital or medical facility) EMERGENCY CARE AND TREATMENT (Patient) Medical Record STANDARD FORM 558 (REV. 9-96) Prescnbed by GSMCMR FPMR (41 CFR) 101-11.203(b)(10) USAPA V1.00 MEDCOM - 20286 DOD-033860