Medical Report: 40-Year-Old Iraqi Male, Detainee, Baghdad, Iraq re: Gunshot to Right Knee and Thigh

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MEDCOM -5381
DOD 12593

NSN 7540-00-634-4124
MEDICAL RECORD VITAL SIGNS RECORD
HOSKTAL DAY
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STANDARDFORM 511 (REV. 7-95)
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MEDCOM -5382
DOD 12594

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MEDICAL RECORD VITAL SIGNS RECORD
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MEDCOM - 5383
DOD 12595

CLINICAL RECORD . DOCTOR'S ORDERS
For use of this form, see AR 40 -66, the proponent agency is OTSG

DOCTOR SHALL RECORD DATE. TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD TEM IS USF.D, WRITE PROHLEM NUMBER IN COLUMN INDICATED BY ARAOW BELOW.
LIST TIME
:ENT IDLNTIFICATIC)N ¦ DATE OF ORDER TIME OF ORDER
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ISING UNITqROOM NO Fo-1 APR 79 4256 BED NO. REPLACES EDITION OF 1 JUL b)(6)-2 77, WHICH MAY BE .ZE(15. I

te US GOVERNMENT PRINTING OFFICE 1994-303 710
MEDCOM - 5384
DOD 12596

CLINICAL RECORD • DOCTORS ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG

DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD TEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
LIST I ME
TENT IDENTIFICATION DATE OF ORDERq TIME OF ORDER
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REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
1, 4256
A' U.S. GOVERNMENT' PRINTING OFFICE: 1994-3I33-71D
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MEDCOM - 5385
• , _ _
DOD 12597

Verify by
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Order I Clerk/
Dote wilraw
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Order/ Clerk/
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THERAPEUTIC DOCUMENTATION CARE PLAN
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MEDCOM -5386
DOD 12598

THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
MO. 05 yr. 03
•qFor too Of this hittiviAll 411.40407;
CLINICAL RECORD the • ro • -ruirit i. •oc.is, thirorrio -4 Thii:z -r•. -• nGorleral.
OOLUAIN FOLLOWING EACH ADMINISTRATION VERIFY BY INITIALING . 4 0ES.
INITIAL PROPER
DATE DISPENSED
ORDER CLERK/.RECURRING MEDICATIONS, .D
DOSE, FREQUENCY.

DATE HORSE. MI
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MEDCOM -5387 I.. , L -...1AUSTE D.
r't A FP_T9,.... tiA7R
DOD 12599
. REPORT.INGMfF
MTF LOCATION
ADMISSION AND CODING INFORMATION
1111111111111•1.111 6 7 (State orb)(3)-1
Country Code.) Fdr use of this form, see AR 40.400; the urouoilem agency is Of Sij
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3 . REGISTER NUMBER
NAME (Last, First, Middle Initial)
4. PAY GRADE 5qSEX
1 1
in.ii 1 17
b)(6)-4 b)(6)-4 16.17 I

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RACE 9. ETHNIC RELIGION
BACK­GROUND
19 20

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10. LENGTH OF SERVICE ETS 1 -E MP
12. SOCIAL SECURITY NUMBER
32

37 3R 391 4D I al I AI AI I nn b)(6)-4
ORGANIZATION (Active Duty Only)
13. MARITAL STATUS
46 ADMISSION
Zl Uv
14.
FLYING STATUS

15. BENEFICIARY CATEGORY
16.
ZIP CODE OF RESIDENCE
47

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FAG 0-010 O l
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20. SOURCE OF ADMISSION! AUTHORITY FOR WARD NAME/RELATIONSHIP
-OF EMERGENCY ADDRESSEE
ADMISSION
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'ADDRESS OF EMERGENCY ADDRESSEE
(Include ZIP Code)
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AI MAF nri rrnpl fir njrnir
"WENT FACILITY
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21. TYPE OF DISPOSITION 22. MTF TRANSFERRED TO 23. DATE OF DISPOSITION
YvYMMD 0/
73 74
75 76 7. 7 78 79
81

84 85 86 1 87 88
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BIM l• S
24. CLINIC SVC - A . TING
25. MTF TRANSFERRED FROM
26. DA 1-19-i ADMISSION IYYYYMMODI
89 .

93 94 95 96 97 98 99
92 100 101 10 ---..„103 104 105 106
a
27. 'CATION OF OCCURRENCE
28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION
(Battle Casualty Only) /1 Y 1' I'M Mij-141,_
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109 110 111 112 113 114 115
116 117 t118 119 120 121 ; 122
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MEDCOM - 5388
DOD 12600

1 ..REPORTING MTF . I TF LOCATION ADMISSItrIr AI.LY CODING INFORMATION
1 1 1 3 1 4 I 5 I 6 7 8 (State o(b)(3)-1 Country
For use of this form, see AR 40-400: the proponent agency is OTSG
Code.)

I
rb)(6)-4
F
REGISTER NUMBER NAME (Lost Filet, Middle InItlell 4.PAY GRADE .SEX
5..
9.10 11 12 13 14.15.I 16 17 18
b)(6)-4 i

(b)(6)-4
6..DATE OF BIRTH (YYYYMMDD) 7.'AGE AT ADMISSION a.H CE 9..ETHNIC RELIGION
L
19 20 21 22 23 24 25 26 27 2B 29 30 31 BACK­GROUND

LENGTH OF SERVICE ETS 11..FMP 12..SOCIAL SECURITY NUMBER
10..
36 37 38 39 40 41 42 43 44 45
32 33 34 35
-04(6)-4
P
ORGANIZATION (Active Duty Only) 13..MARITAL STATUS HOUR OF BRANCH I CORPS
ADMISSION

46
—
2—(0C
16..ZIP CODE OF RESIDENCE14,.FLYING STATUS 15..BENEFICIARY CATEGORY
47 48 49 50 51 52 53 54 55 56 57 58 59 60 61
17..UNIT LOCATION (State or 18..MOS 19..TRAUMA PREY. ADMISSION
Country Code)

YEAR
62 63 64 65 66 67 68 89 . :
No

I NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
20. SOURCE OF ADMISSION/ AUTHORITY FOR WARD
_. ADMISSION
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ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Codel
---, -' ,,"-,-.1^---h-,--T-ar--A-T-TuW FACILITY TELEPHONE NUMBER OF EMERGENCY ADDRESSEE;b)(3)-1
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21. TYPE OF DISPOSITION. 22. MTF TRANSFERRED TO 23..DATE OF DISPOSITION (Y Y Y Y M M D DI
73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88
2 o 0 ,S en S--Iq'R----
24. CLINIC SVC - ADMLTT1NG 25. MTF TRANSFERRED FROM 26..DATE THIS ADMISSION (YYYYMMDD)
89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106
k /-7" -N f" z ci o E 6 S--6 T
27. LOCATION OF OCCURRENCE 28..MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION IY Y Y YMMDDI
(Battle Casualty Only)
107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122

FOR LOCAL USE
C--/ 3 bt) 12 le vik_e_

1 ADMITTING JDFFIcER (b)(6)-2 (Signature, as requiredi b)(6)-2
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DA FORM 2985. MAR 2000 EDITION OF[ MAR 8, IS-01310LEWE ..-.-. (MAPA V1 A)
MEDCOM - 5389

DOD 12601

1..1-CCrl."111N161,91r ..tar U./UNMAN
ADMISSION AND CODING INFORMATION
1. 1'
1.2.1.3 4.i 6 7 I.8.1.(State or
Counrry

b)(3)-1 For use ol this form, see AR 40-400; the proponent agency is OISCi
4;41. , - - "0'. C o d e . 1'
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3. FtEGISTER NUMBER I NAME (Last, First, Middle Initial) 4. PAY GRADE 5. SEX
9'10'11 12.13 1 14 I 15] 16 . 17 18 I

I "b)(6)-4 — - •-- -1 .i
b)(6)-4
6. DATE OF BIRTH (Y Y Y YMMODI 7. AGE AT ADMISSION 8. RACE RELIGION
19 20 21 22 23 24 25.126 27 28 29 30 9. ETHNIC

—
— GROUND
31 BACK GRO ---
10. LENGTH OF SERVICE ETS 11. FMP 12 OCIAL SECURITY NUMBER
1 1

32 33 34 35 36 37 38 5-9 F40.41 1 42 I 4:1 ! 44 , 45I
,13)(6)-4
I
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ORGANIZATION (Active Duty Only) 13. MARITAL STATUS HOUR OF BRANCH / CORPS
ADMISSION

46
7_t C_)C-.
14. FLYING STATUS 15. BENEFICIARY CATEGORY 16. ZIP CODE OF RESIDENCE
I

47 48 49 50 51 52 53 54 55 56 57 58 59 60 61
I --C)
17. UNIT LOCATION (Stare or 18. MOS 119. TRAUMA PREV ADMISSION
Country Code)
62 63 64 65 66 67 68 69 70 I 71 YEAR

_72/D N O
F.1___ _
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I
20 SOURCE OF ADMISSION/ AUTHORITY FOR WARD NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE
ADMISSION

72
ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)
------'-'-
.TMENT FACILITY I TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
b)(3)-1
I

21.qTYPE OF DISPOSITION 22. MTF TRANSFERREDTO 23..DATE OF DISPOSITION (Y Y YYMMDDI
73 74 75 76 77 78 79 80 81 82 t_83 84 85 F86 f 87 8 8

.9 /1 l e') .c."---1q'---? 1
34. CLINIC SVC - ADMITTING 25. MTF TRANSFERREDFROM 26. DATE THIS ADMISSION (Y Y Y YMMDD)
89 90 91 92 93 94 95 96 97.98 99 100 101 102 103 104 I 1054 106

27.qLOCATION OF OCCURRENCE 28. MTF OF INITIAL ADMISSION 29. DATE INITIAL ADMISSION (YYYYMMOD)
(Battle Casualty Only)

107 108 109 110 111 112 1131 114 115 116 1 117 118 119 F120 121 122
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MEDCOM - 5390
DOD 12602

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MEDCOM - 5391
nal 14
Name: ,
CHCS Name (b)(6)-4
(b)(6)-4
Date of Admission: 4/18/2003 Date of Transfer:
Proanosis: Good
Lihi9a: 40's something year old Iraqi Man admit from Field Hospital with poor records, but at best as with the diagnosis as below, admitted to b)(3)-1 Patient admitted intubated. apparently injury, unconcious and incoherent.
Hospital Course:
Admitted to ICU 2.Extubated. Abx as above. Transferred out of icu 4/21103 to 4 For STB. Continues c Candida rash. Signed out to medicine, for primary care. Cont PT NEUROLOGY : EVAL 4123: exam mc diffuse axonal injury. Priorities are mobilizati
Diagnoses:
1.Right knee gsw: soft tissues only, presumptively on 4/9/03; I &D'd at some point and now skin closed fracture; Sutures due out any time, week of 4/28/03.; Right arm small skin defect: dry gauze only need'
2.Concussion: CT scan Brain: negative here (no prior ct done) , flat affect, probably has rue weakness All other fine. PT working with pt. 3.Pneumonia vs pulm. contusion : patient admitted intubated; extuba
4. FUO: febrile on admit: unclear source: pancultured; started on Rocephin and tobramycin, dlc'd 412 Extensive Intercrural Candidiasis Dermatitis with extension to perianal area, upper LE and mid back, c
Suraeriesrfreatment
I&D Right knee, skin closed; date unknown
Recommendations:
1. Continue Diflucan and Nystatin for Candida dermatitis. 2. Will need PT for strengthening, probably weakness, needs rehab facility.Neurology: Priorities are mobilization, PT, rehab
SpeclalNeeds: Rehab facility
b)(6)-2
Physieg CDR Dept of FAMILY PRACTICE
MEDCOM - 5392
Name: ,
1(b)(6)-4
CHCS Name
(b)(6)-4
SSN:
Date of Admission: 4/1812003 Date of Transfer:
Pro•nosis: Good
Histo M 40's something year old Iraqi Man admited from Field Hospital with poor records, but at best as with the diagnosis as below, admitted to (b)(3)-1 Patient admitted intubated, apparently injury, unconcious and incoherent.
Hospital Course:
Admitted to ICU 2.Extu bated. Abx as above. Transferred out of icu 4/21/03 to 4 For STB. Continues c Candida rash. Signed out to medicine, for primary care. Cont PT NEUROLOGY: EVAL 4/23: exam mc diffuse axonal injury. Priorities are mobilizati
Diannoses: 1.Right knee gsw: soft tissues only, presumptively on 4/9/03; I &D'd at some point and now skin closec no fracture; Sutures due out any time, week of 4/28/03.; Right arm small skin defect: dry gauze only nE
2.Concussion: CT scan Brain: negative here (no prior ct done) , flat affect, probably has rue weakness
All other fine. PT working with pt. 3.Pneumonia vs pulm. contusion : patient admitted intubated; extuba
4. FUO: febrile on admit: unclear source: pancultured; started on Rocephin and tobramycin, d/c'd 4/2 Extensive Intercrural Candidiasis Dermatitis with extension to perianal area, upper LE and mid back, c
Surgeries/Treatment I&D Right knee, skin closed; date unknown
Recommendations:
1. Continue Diflucan and Nystatin for Candida dermatitis. 2. Will need PT for strengthening, probably weakness, needs rehab facility.Neurology: Priorities are mobilization, PT, rehab
SpecialNeeds: Rehab facility
Physician: I TLCDR Dept of FAMILY PRACTICE
MEDCOM - 5393
Date of Admission: 411812003
(b)(6)-4
CHCS Name: 1 Date of Transfer:
(b)(6)-4
EPW Age:qGender: M
History:
40's something year old Iraqi Man admited from Field Hospital with poor records, but at best as gathered: with the diagnosis as below, admitted t4 b)(3)-1qPatient admitted intubated, apparently since day of injury, unconcious and incoherent.
Hospital Course:
Admitted to ICU 2.Extubated. Abx as above. Transferred out of icu 4/21/03 to 4 For STB. Continues care to Candida
rash.
Signed out to medicine, for primary care. Cont PT NEUROLOGY: EVAL 4123: exam most C/W diffuse axonal injury.
Priorities are mobilizati

Diaanoses:
1.Right knee gsw: soft tissues only, presumptively on 4/9/03; 1 &D'd at some point and now skin closed; Xray here no
fracture; Sutures due out any time, week of 4/28/03.; Right arm small skin defect: dry gauze only needed qd as of

4/22/03..
2.Concussion: CT scan Brain: negative here (no prior ct done), flat affect, probably has rue weakness, but moves it. All
other fine. PT working with pt. 3.Pneumonia vs pulm. contusion : patient admitted intubated; extubated 4119103; off abx
4121103, 4. FUO: febrile on admit: unclear source: pancultured; started on Rocephin and tobramycin, d/c'd 4/21/03 5.
Extensive Intercrural Candidiasis Dermatitis with extension to perianal area, upper LE and mid back, on Nystatin powder
and Diflucan oral

Surgeries/Treatment:
I&D Right knee, skin closed; date unknown,

q
1. Continue Diflucan and Nystatin for Candida dermatitis. 2. Will need PT for strengthening, probablyhas RUE weakness, needs rehab facility.Neurology: Priorities are mobilization, PT, rehab
Special Needs: Rehab facility
Prognosis: Good
(b)(6)-2
Physician: qILCDR Dept of FAMILY PRACTICE q 4/24/2003
MEDCOM -5394
(b)(6)-2
Name: ,
:b)(6)-4
CHCS Name:
M(6)-4
Iraqi civilian
Date of Admission: 4/18/2003
Prognosis: Good`'`"":. Date of Transfer:
History:
40's something year old Iraqi Man admited from Field Hospital with poor records, but at best as gathered: with the diagnosis as below, admitted to ',13)(3)-1 :.Patient admitted intubated, apparently since day of injury, unconcious and incoherent.
Hospital Course: Admitted to ICU 2:Extubated. Abx as above. Transferred out of icu 4/21/03 to 4 For STB. Continues care to Candida rash. Signed out to medicine, for primary care. Cont PT NEUROLOGY: EVAL 4/23: exam most CIW diffuse axonal injury. Priorities are mobilizati,
Diaanoses: 1.Right knee gsw: soft tissues only, presumptively on 4/9/03; I &D'd at some point and now skin closed; Xray here no fracture; Sutures due out any time, week of 4/28/03.; Right arm small skin defect: dry gauze only needed qd as of 4/22/03.; 2.Concussion: CT scan Brain: negative here (no prior ct done) , flat affect, probably has rue weakness, but moves it. All other fine.. PT working with pt. 3.Pneumonia vs pulm. contusion : patient admitted intubated; extubated 4/19/03; off abx 4/21/03; 4. FUO: febrile on admit: unclear source: pancultured; started on Rocephin and tobramvcin, d/c'd
Surgeries/Treatmen
I&D Right knee, skin closed; date unknown; ;
Recommendations:
1. Continue Diflucan and Nystatin for Candida dermatitis. 2. Will need PT for strengthening, probably has RUE weakness, needs rehab faCility.Neurology: Priorities are mobilization, PT, rehab
SpecialNeeds: Rehab facility
Physician:
.
b)(6)-2
LCDR Dept of INTMED/CARD 5/3/2003
MEDCOM - 5395
(b)(3)-1
CASUP' 11116F TV TNn
ABBREVIATED MEDICAL Nerit.t! •-1
(
utlicAL RECORD (Sign all no es)
(-/,.arrived on board USNS Comfort
Time:
A-P R.03
DelayedPier Other
'sported by Halo I.Boat.rota. ow)
MinimalAMBULATORY
taus ow)
ExpectantWeight (lbs):
1.40` 5.HEIGHT (ft' Inn:
TORY:.S 4e4 •tt1ta11h.
—r .ERGIES:.( RRENT MEDS: (12.-1C.f_ 02_7 -r\ e.
7
ST ILLNESSES:
(lime)

ST MEAL: (Date)

ents Preceding Injury:

CAP REFILL (pros/abs)
TEMP PULSE BIP RESP RATE.GCS
fAL SIGNS.TIME (MISSION 1111=11111 Kra1PA71111111=:z: -3IVIA MEM
re.•
OUr1/1RUC
(pHs: 'Circle ors) , OR RI • • luggish / fixed mule ono) U active /./ fixed Mink sot) • irt c, • Eye Opening.. Spontaneous.4 rob% 'Glasgow Coma Score (GCS)
JURIES Ainvsy Obstructoon Smith Sounds 'Hornorrhaga 11:1-0 No (4 +- ) L'utTlrbArima-PaidkHb/Het Lytes/BUN/Glue ABG To voice. To pain. None. 3 4 97N \--)(Total "Al
LK:melon UA. B. Verbal Responses
Enputsdon T&C (2)( units iM Oriented Confused Inappropriate words 5 4 3
Coneusskon Frame 41)cfct/6, L 04-t, Incomprehensible words None 2

Total '13'
Disioesion
koka
Bum C. Motor Responses
Obeys commarid 6
I. Extremity or Localize pain 5 Withdraw (pain) 4 Flexion (pain) 3 Extension (pain)
None
ilAGNOSIS:
Level of Consciousness (LOC) talk 4r44 A.- Alert
. - Responds b Vocal Stimuli
P-Responds b Painful Stimuli
U - Unresponsiveness
Continue on reverse side
PATIENTS IDENTIFICATION (For typed or written entries give: Name—fast, first, middle; grade: REGISTER N°. date; hospital or medical lacilly)
(b)(6)-4 :b)(6)-4 ABBREVIATED MEDICAL REC'9 STANDARD ZZIttkj,„3 9
FIRMA (41 CM) 241-45.505
MEDCOM -5396
510.110
DOD 12608

1
(b)(3) -1
CASUALTY RECEIVING
MEDICAI kTMENT ECORD (continued)
.mm I be © 0961g1 10( C cm teeth I nares IRWAY.nasal (IOC).('-nctt asal oral.3r S-–
Room Air.Face Mask ® 12 I_ / min.OTHER..XYGEN.
USES.CHEST TUBE:.size / site guaiac.neg/poo vvoureC 'bp_CL)mare()
FOLEY:).dipstick blood neg / poo
. TES SIZ
PA -\)
Oxyged 'oath • omy
3:—Tracheotomy--
AMT INFUSED . .ressure Dressings
Ai SOLUTION. It i Lif2-OIC VO. 6. MAST
T. Apply Hemostat
.1000C. #3 . C11. - Suturiig
9. Tourniquet.R vok.e., . .
its .
10. Bandage
. VA)t •c vivr 1 i
BLOOD PRODUCTS. AMT INFUSED 11. Sp 1.12. Cast
13. .
II.
14. .
PERITONEAL LAVAGE
Comments

OUTPUTResults:.POSITIVE NEGATIVE
(Clucl• ant)
Chest Tube cc Gastric cc
OP83-4-frierril CC
.
TOTAL INTAKE CC TOTAL OUTPUT . cc
MEDICATIONS Dose Route Time Initials MEDICATIONS Dose Route Time Initials
L u tz
.
Morphine roAti n I /,,,-, 1 . /36 ii 6
:Pc-0pacircml I 1 ju P 14YY-1 RC
.
Mefoxin•
Ancef
Tel Tox
Hypertet

•
11%.,611N
BURN
TRANSFERRED 71K. to OR ICU. WARD'
AM. I P.M. ICU
g#102, 12, i24-- .-(r) CT il4 i -e) (17/
1 ft' jell.•.AS111101. &A... 1 O. " i Is_.,/ • I.. ir
'I4 6.A. ii ...-qels .
1. 73 °I Ree 41011 eA4( fA ) 0 44
k
/ s - • . ti--0 1 4

'fir U. S•GPO: 1967-181-247/60056 I
MEDCOM - 5397
(Reverse)

DOD 12609