Medical Report: 35-Year-Old Iraqi Male Civilian, Baghdad, Iraq re: Gunshot Wound to Hand

Medical report of Iraq civilian re: gunshot wound to the hand. The medical records do not give any indication as to how the gentleman received his injuries or any personal information.

Doc_type: 
Medical
Doc_date: 
Monday, March 31, 2003
Doc_rel_date: 
Monday, May 30, 2005
Doc_text: 

.•41-.....ENT TREATMENT RECORD CONt, • • ..i .
For use of this form, see AR 40-400; the proponent agency is OTSG
1TRFSISTFR NIIMRFR 2 NAME (Last, First MO_( b56)-4
3. GRADE ADMISSION REMARKS
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STATUS DSG BEN

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21. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION 22. HOURS OF 23. CLINIC SERVICE
ADMISSION

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TOTAL SICK DAYS
CARE DAYS CARE DAYS
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CARE DAYS CARE DAYS

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SIGNATURE OF ATTENDING MEDICAL OFFICER
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36. Total Days All Facilites a. ABSENT SICK DAYS b. OTHER DAYS C. CONY. LV/COOP CARE DAYS SUPPLEMENTAL CARE DAYS BED DAYS TOTAL SICK DAYS
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VITAL SIGNS RECORDS
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STANDARD FORM 51.1 (REV. 7-95) Prescribed by GSA/ICA4R, FIRMA (41 CFR) 201-9.202-1

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DOD 010386

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DOD 010387

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T I ENT IDENTIFICATION
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PATIENT IDENTIFICATION
NURSING UNIT
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IDENTIFICATION
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DOD 010388

MEDICAL RECORD - DOCTOR'S ORDERS
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. They may be signed off, as completed, in the far right column.
DIRECTIONS: The provider will DATE, TIME, and SIGN each order or set of orders recorded. T

I ORDER NOTED COMPLETED

Pc-Icf03.0%50
ORDER
DATE, TIME, & SIGNATURE REQUIRED FOR EACH ORDER OR SET OF ORDERS

NUMBER TIME & INITIALS TIME & INITIALS
POST ANESTHESIA CARE UNIT ORDERS
¦
1 OXYGEN: T'it Tlitres via Mask /Prongs to maintain 02 Sats greater than 94%;
Wean to room air.
2 IVF:TCMZT@TI 5 6 cc/hr, bolusTcc x 1
3 MORPHINE:T7...--&-4Tmg IV q 5-10 minutes PRN pain. MAX dose of /Omg

DEMEROL:T2-5Tmg IV q 5-10 minutes PRN pain. MAX dose of 50 mg
5,---Z13PRIM--6. Trryleirirri PRNnausea. May repeat after 10 minutes X 1
6 ; - ; •T•TIt :Ti •Tg.Tre R--1.25 mg (1/2 cc) IV PRN Nausea X 1

REGLAN: Give 10 mg IV PRN nausea X 1
CC) 8 Release from "PACU" when Aldrete score isTTTor greater 9 Call Anesthesia for any questions or concerns Pc/..la..¦\-e__rV-n¦-¦Tl a, s-TRI_i,---6.FRAI (a/3 -12_.9s
SIGNED ---1/*------17--jr-‘
PATIENT IDENTIFICATION —

Complete the following information on page 1 on y. Note any changes on subsequent pages.
'b)(6)-4

Diagnosis:
Height:TWeight: Diet:
Allergies:
Nursing Unit Room No. Bed No. Page No.

MEDCOM FORM 688-R (TEST) (MCHO) MAR 99 .PREVIOUS EDITIONS ARE OBSOLETET M C V1 .00
MEDCOM - 3910

DOD 010389

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:: IDENTIFI DATI•01q:•.• DATE OF ORDER TIME OF ORDER LIST TI ME
ORDER

NOTED AND 0-Z kr? IZ_ 0 HOURS
03-3t
SIGN

:b)(13)-4 /IVA,C g frka-i"."16:;"_ Olf-c5LzArS D(c,T t,;,c,vc1/4 A-Pra
NURSING UNIT ROOM NO. BED NO.
PATIENT , IDENTIF1 ATION DATE OF ORDERC TIME OF ORDER • HOURS

NURSING UNIT • PATIENT IDENTiFir ROOM NO. BED NO. DATE OF ORDER TIME OF C ORDER HOURS
NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFIC AT ION DATE OF ORDERC TIME OF C ORDER HOURS

NURSING UNIT: BED NO.
REPLACES EDITION OF. 1 JUL 77, WHICH MAY BE USED.
DAAPR
4255

1 FORM79
.1,RINTING OFFICE: 1996-409-924 MEDCOM -3911

DOD 010390

CLINICAL RECORD I HERAPEUTIC DOCUMENTATION . CARE. PLAN (NON-MEDICATION) ililit„.
For use of this form, see AR 40.407: Is the Office of The Surgeon Goners!.

Mo. Yr.
VERIFY BY INMALING .:...:c

INI77AL PROPER COLUMN FOLLOWING EACH COMPLETION
ORDER CLERK/ RECURRING ACTIONS, HR DATE COMPLETED DATE NURSE FREQUENCY, TIME
'b)(6)-2 31 0 1 0 7-in
31 MIK--ft7s/C, 1 [anal lu Q g° /b)(8)-2

aerz...
,, U 1A44444-101T1 4r-filTa...1Ta 1. 0 11 S.—1//
31frifm--60-47k1-01.00,1 q000..a... V/ al) le)

Ft Me-
t.2 /50ccia A 14,pri) as zy3 07 bc'd
_1.9._ Q..50 -y,ultit.F. z_15-

. 11 3 i 1/3 ? J'ier—T..--c) 2... eg t 13"
..t9r/' /
1 Ili 1_ virb -irk A.,/ 1i :7/7 sr i_ri-ta D a- -12,1,-A/

I . 1 Avgoia. — 1 r aa i dr, I Axil ci ...,(-- 1... 4-,...i 4 j fa '.
ALLERGIES: YES NO PRIMARY DIAGNOSIS: ADDITIONAL PAGES IN USE:
YES NO
1..CpiNi i PvciAit do k. PAGE NO:
PATIENT IDENTIFICATION:
(b)(e)-4 ACTION TIMES
USE PENCIL. CIRCLE ACTION TIMES
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
ED I TI ONEDITION OF 1 DEC 77 MAY BE USED. USAPA V1.00
MEDCOM - 3912

DOD 010391

Verify byT THERAPEUTIC DOCUMENTATION CARE PLAN InitialingT (NON-MEDICATION) Ma-Yr 0.3
Order Date Clerk Nurse 31 MAI..-bX6)-2 MO SINGLE ACTIONS D?c ,--0^ i•-t-TToTic-vv --2...Tdi•-A7A-e) — 6...Svu TO © 14/N1 -Y Oats to be Done .3 f illike_... 31oviii- be Time to Done lEfre Avi-P Time Done j 0, (mi /(4ti Initials bX6)-2
UAW- (,pt¦lb i . 17 op..? S-rrraL.-6 .... 31 r,irt._ 1SA-P Alocp
;Mg- VS & SitiF-1---- •i) r' -- 1ce,i00
31/4/4, 3irkite, M v_ A 2. t ie--7--NPO /i1-iev._ miwy,,*-1-tp. ot hp12_,15 3 i lhota--3i Ivy 1615114) 31t4417-- WI 15119
3;,, 1a, 31/4,401/ fir;lida‘ AO GCB turAIU om 14,1\J_47%1061 8'4 7),4,04. 5-1,1_,Ayr- 31 ,44--31 iiimt fiVr-Q Pr5lif )10.00 /la 30

Order/ Clerk/ PRN INITIAL PROPER COLUMN FOLLOWING COMPLETION
Expir
Date Nurse ACTION, FREQUENCY (04 "ICTIME/DATE COMPLETED

5 1 iei fte, b)(6)-2
di'd 1 6P^1 IP-eft
1/K0v-wt.-I 'TP4:00' PA,P-f

I Al b04-1 X -41....TV
. ,

USAPA V1.00
MEDCOM - 3913

DOD 010392

1. LAS NAME. EMT NAME /NOM ET PREMOM RANK(.DE
4,0ALE
41./HOMME ,.-..Ir.-42., Ue'l--. FEMALE/FEMME
101SU...
SSN / Numtno MATRICULE SPECIALTY CODE/GPM RELIGION (RELIGION
................."."--.-.

L UP11 .........--------.

NATIONALITY I NATIONALITE AM AF/AI.NM MC/A1 BC/ BC I.NBI/ BNC.DISEASE/MALADIE.I.I PSYCH / PSYCH
FORCE /ELEMENT
1
J. INJURY/BLESSURE • AIRWAY /MACHU
FRONT /DEVAN7 BACA /ARRIERE HEAD/TETE
WOUND /BLESSURE
NECK/RACK INJURY!

BLESSURE AU COU/AU DOS
BURN / 5ROLURE AMPUTATION / AMPUTATION STRESS /TENSION OTHER CSpecifyn AUTRE (Specified
7
/9-71201A—C7

4. LEVEL OF CONSOOUSPIESS / NR/EAU DE CONSpEPECE
ALERT / ALERTE AIN RESPONSE / REPONSE A LA MULE UR
B.,..04F.LBAL RESPONSE /REPONSE VERBALE.. UNRESPONSIVE/SANS REPONSE
S. PULSE /POULS TIME /HEURE
E. TOUR.ET/ GAIRO7 TIME / HEURE
Zrt-' Zr7CC, -CNO /NON_IT YES /GUI

7. MORPH(./MORPHINE DOSE /DOSE TIME /KURE B. IV/IV TIME / HEURE
NO/ NON n YES f OUI ..... .

I. TREATMENT/OBSERVATIONS /CURRENT MEDICATION/ALLERGIES/NBC
/ALLERGIES /NBC IANnoon)
TRAITEMENT f OBSERVATIONS / PRESENTE MEDICATION /ALLERGIES /ANTIDOTES

/e..4_7‘,..exzEic
0 toiir,4
,r,..:5,sc., C .....,:_rT..._2_,,pc..,e0.76_
ci,,,,e,_sz 0 '44_ '0 6# 0-7141-

-1hT--ev),-4._ /473 c /0:7,c,
10. DISPOSM011 /
DISPOSMON

(/RETURNED T001117/ RETOUR A L'UNITE 711.1E /KURE EVACUATED / EVACUE
/4.) 3-'Z
DECEASED / Oki DE
t(b)(61-2
DAT
321 ei
al
U.S. FIELCMECCAL CARD'
Es a.a
1380 (TEST). which Are obsolete.

MEDCOM - 3914

DOD 010393

. ....- - -...-. '1.Cis..:-.!,ORTING MTFC., RAW le
:00)-1

.ADMIS.C4 AND IC.NG INFORMATION
.le or
i 2 3 4 l 5 6 1

For use ut this lurm, see AR 40-40D; proponent agency is OTSG
Code)
Code) b)(6)-4

3TREGISTER NUMBER NAME (Last, First, Middle kiltis4 4 4. PAY GRADE 5..SEX
0(6)-4 9 1 0 I 11 2 I 13 I 1 o 15 16 17
I l

93)(6)-4
G. DATE OF BIRTH (YYYYMAIDD) 19 20 21 22 23 24 I 25 C) 26 1 7. 27 AGE AT ADMISSION I..RACE 28 29 # RI i C . 1 9..ETHNIC BACK-GROUND RELIGION
10CLENGTH OF SERVICE ETS 11..FMP 12..SOCIAL SECURITY NUMBER
32 33 34 35 _ lirl 37 38 39 4• 41.1 42 43 44 45
dr EP 'b)(6)-4
ORGANIZATION (Active Duty Only) 13. MARITAL STATUS HOUR OF BRANCH / CORPS
ADMISSION
46
0 30

14.CFLYING STATUS 15.CBENEFICIARY CATEGORY 16..ZIP CODE OF RESIDENCE
47 48 49 50 51 .. 53 54
Iril 55 56 IMI 58 59 60 1111
.1.01 LIPAIrd Fa/am 3 u..jr; Eilifori
17.CUNIT LOCATION (State or is.CMOS 19. TRAUMA PREY ADMISSION
Country Code) YEAR
62 63 64 65 66 111 68 69 70 71

NO ak/
20. SOURCE OF ADMISSION./ AUTHORITY FORCWARD NA DRELATKINSHIP OF EMERGENCY ADDRESSEEC• ADMISSION
6.----
,i)o...i ADDRESS OF EMERGENCY ADDRESSEE (Include LP caw)
llT

h )(3}1NAME AND LOCAT TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
21. TYPE OF DISPOSITION 22. MTV TRANSFERRED TO 23. DATE OF DISPOSITION (YYMPADD)
7 - 75 76 77 78 79 80

101. IMP 82 119111111511

li

0 C9 1E:ir)
•CCLINIC SVC -ADMITTING 25. MTF TRANSFERRE 26..DATE THIS ADMISSI •.. • VliffitD0)
rgi

8 88 89 90 91 92 94 95 96 97 98 99 100C101C102 ihi

CIA MI Mi .A ',l5111k.ilrAMIltillril
27.CLOCATION OF OCCURRENCE 28.COF INITIAL ADMISSION 29.CDATE INMAL ADMISSION (YYPANDD) (Battle Casualty Only)

Ira 106

103 104 107 108 109 110 111 112 113 114 115 116
a-
a

FOR LOCAL USE
• liC°

2-auma_.-1......._

I)CERR rte. Alto Pro fCfix., 1

, • --)9. 6 3

61,/,1 er_,
(6)(6)-2

ADMITTING OFFICER (Signature, as required) (b)(6)-2 SIGN
.6)(6)-2

I
W4DC14.41 440ter,(

L ...• DA FORM 2985, MAR 89C LEN I luN Lil ' MAY 79 IS OU
MEDCOM - 3915

DOD 010394

'I.CrvcrvORTING MTPC AC.:ATION
ADMM.... ..111 Ai .CCODING INFORMATION

1 ITITITOwe or

2 3 4 5 6CI7 8C
COUrItly

;6)(3)-1
code) For use DI this term, see AR 40-400; proponent agency is OTSG
b)(6)-4

3.CREGISTER NUMBER NauF II ate Mimi UMW, Initial) 4
16)(6)-4 . PAY GRADE 5.CSEX
9 10 IC11 12 I 13 I 14 15 16 17 18
;6)(6)-4
6. DATE OF BIRTH (YVIVMMOD) 7. AGE AT ADMISSION 8.CRACE 9.CETHNIC RELIGION
19 20 21 22 23 24 25 26 27 28 29 30 31 BACK­
GROUND

10.CLENGTH OF SERVICE ETS 11.CFMP 12.C
SOCIAL SECURITY NUMBER
32 33 34 35

36 37 138 139 1401 141 42 1 43 1 44 1
45
,b)(6)-4

ORGANIZATION (Active Duty Only) 13. MARITAL STATUS
HOUR OF BRANCH / CORPS ADMISSION 4 6 1
0 E.30

14.CFLYING STATUS 15.CBENEFICIARY CATEGORY
16.CZIP CODE OF RESIDENCE

47 48 49 50 51 52 --53 55
54 56 57 58 59 60 '61
17.CUNIT LOCATION (State or
18 . MOS 19. TRAUMA

PREY ADMISSION
Country, Code)
62 63 64 65 66 67 68 69 70 71 YEAR
NO
=AO.

20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAME,RELATIONSHIP OF EMERGENCY ADDRESSEE ADMISSION c...----'
04)61.j d........_ ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Coils)
..C

NAME AND LOCb)(3"
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

21. TYPE 0 _ _C.,-... ......C
....C........ ERRED TO 23.CDATE OF

DISPOSITION (YYMMDD)
73 74
75 76 77 78 79 80 81 82 83 85 86
r-'
0

C
24.CCUNIC SVC - ADMITTING

25. MTF TRANSFERRED FROM 26.C

DATE THIS ADMISSION (YYMMOD)
8 88 89 90
91 92 93 94 95 96 97 98 99 100 101 102
C6 -4, (2 .5 0 3 I
27.CLOCATION OF OCCURRENCE 28.C
MTF OF INITIAL ADM SSION 29.C

DATE INITIAL ADMISSION (YYMAIDD)
(Battle Casualty Only)

103 104
105 106 107 108 109 110 111 112 113 114 115 116
FOR LOCAL USE

4016 N /
/041,
. cisa ef.k• .C
(b)(6)-2

ADMITTING OFFICER (Signature, as required)
SIGI
b)(6)-2
ktiAld."40
t----

r-TA-INaffIVI-zutsivtAR 89C , .-,.I., .., , .. -A,. in t¦-• r,
MEDCOM - 3916

DOD 010395

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MEDCOM - 3917

DOD 010396
Lu

Doc_nid: 
7026
Doc_type_num: 
72