Medical Report: 50-Year-Old Iraqi Male, Detainee, Baghdad, Iraq re: Gunshot Wound to Abdomen

Medical records of a 50 year-old Iraqi male, Enemy Prisoner of War (EPW) admitted to hospital with gunshot wound to the abdomen and associated injuries. The medical records do not give any indication as to how the detainee received his injuries, but does say the injuries are "War Related". The medical report does not give any personal information on the detainee.

Doc_type: 
Medical
Doc_date: 
Saturday, March 29, 2003
Doc_rel_date: 
Wednesday, June 15, 2005
Doc_text: 

AUTHORIZED FOR LOCAL REPRODUCTION

MEDICAL RECORD PROGRESS NO"¦."LS
DATE NOTES
Fro/473 0, Iia -tle 170J 6s.
Pvt.), Z-.) = "nu i arr...-11 63 iz..,tilta.e it...,4. 0 A) Coid 4....7 )(,;..
&sive ar) = • 41444,....e 6s-ia -Z
• ctvAires Jana It I ret.-&-dep.srk ....4.4‘4.,- p4riapri44.,.... 4-A se.49 q AeAS4aile CA-W.ik. No 0 e„,„,, x j,„„ i,d...i., /
-Sp-Acill 0 h 4.....- 6 5 t.
Phar„2,,,,,k Eys440,2Livry tuptudievri -1-CiVerSeia (1? (do• cero .ysttleuicur ,T.,Ki vy leSeelfg— 1 Ad rcv...„... Cotr,
I,b)(6)-2
Sit letiv¦ S :
/4„4,44.4sa, lb., , (b (6)-2 Ab)(6)-2 I

b)(6)-2
FOL9 5: • Sera muse., or .rvxj ay-y 0 eal&.... — ove,--se---/-
I. 1-Cerp-- 7T-34...stprie Cohn, X,y...1 ( AvO.1) Si-4,,,,..k) w zadira „Ate5d
gei—dow.s. 4- waikiww-e Cins-104.ji....cit iv, -v41 d--.1.6..... a - - r - "ed - Pire44.-e•
iV OA' 4:42pos(4-5 Ar- Avoli.r1 putit-0 pri44.8..... .t- ca. ..-t-0,7,--e s.z Aes,..,4-47 (L, 4-1. !Sala 4J) cll./ ,e-ks-lithr CA 45 6a4..,,Liop...dithi "."W.7 ( A/0 2.041.-.-cit al -Z -6, aLi i° c4.40.,..)
* I.4.-tvh4,e lei.,i.te. - cios.ki tr-"Oka rad,e-a closuve-
- srApArtflakfl 65b, 4., („0 pos4edo -44k4 i poval A.4244... 1,‘,//e.-
441 42.41.4.6.412- 13, FY f et VaSett.10_11 ecu.-pliVr4.1 •-"' IWO 'Po( 4-1
Cowpoc4-r. Of
,b)(6)-2
FAL._ robe,- Noe, uto 1,),,,,, z--+--(P) vtop ., ild 0 e c
Fivji: 3500 cc A/5
RELATIONSHIP TO SPONSOR
SPONSOR'S NAME SPONSOR'S ID NUMBER LAST I FIRST (SSN or Other)
IMI
I
DEPART !SERVICE HOSPITAL OR MEDICAL FACILITY
RECORDS MAINT INED AT . ..
ATIENT'S IOENTIFICATION: (For typed or written entries, give: Name . last, first, middle;
REGISTER NO. WARD NO.
ID No or SSN; Sex; Date of Birth; Rank/Gradel
PROGRESS NOTES Medical Record
:b)(6)-4 :b)(3)-1
STANDARD FORM 509 IREV. 5/19991
Prescribed by SA/ICMR FPMR (41CFR) 101-11.2030)1{101

USAPA V1.00
3 M 172613
-2­
MEDCOM - 6041
DOD 13253

.
FIRS? NAME MIDDLE INITIAL 10 NUMBERLAST NAME
DATE NOTES
? 9/3 _Su&
,-„,,.., L...i-,-.1) VV:i4,-1. k4— , Li oP ten"-es.,± 3 6 0 eel 4.e.rfre, nie
-
0-, -(4)i.....e.,k , . Ct,-,zai— f .5- 2., e,(,e,.:.,,,...1
cfndir,,-714. Z—Ae
41,1 -G22447 C , -9 7 E-.-jl _ Qe id pi....
-1- , Fore.....-;0, - - -, - -d /4 #1--ce_ee,—_44.-2..;,,
4/P- -7-.4..y.....14,i,,,,,e,-. /).- -y, .i.2.;.. £'i// 0...a.d, 71--&-4,--A v-1, t a? .5 ALL eg,4...
b)(6)-2
7 /
li- 4 4 k 0 Oz 7c /1 Nag?, 0,4,,,5,5- 7 6,-7-)„4--„,_z-ILir A4 ,A,7,,,.,?ao„ 6a,(4,,./1C .)..47.7,. Ao/yr,s- sy_A-,tei,,,,6, It7-_, ka,j., 0 61.0/Y: /lit-rc C. lv ,d.dgc --
2, 14113 5•_,_
,,,a
r ' 1g -4-iviy4 304- U.4-4 V& a Un.....0,4 tt,/,, ,te,,,,z,..6,
4ciptii,...1 25p Ate — fri 7 l ficc.),;.. PO
We .i.,_te -.14‘4.e +^ Fz. :. 4koliel if 141-414,4 . , ,-0., K`-- 4/6, N-1-
Ickz q, 7 fe.,*.14 ,o tee,„.__,),,,...4 4---_,4. lobi-c-op AT F..-44,9 /70-at at ,fit ,c - P-4 he do .e-ofez -'
.b)(6)-2
/it j124/e)
4I Al .' Vt C-ii elgwri4Y¦ i5' Ilj-iVe( Sart S 10 ,.cliii We 202)frAi, ee-f-ximi t'c .ls"? -t c1 1 5--
STANDARD FORM 509 (REV. 511999) BACK
USAPA V1.00
MEDCOM - 6042
DOD 13254
REPLACES OD FORM EUS PREVIOUS tIZTION5 ARE
DD FEB EJ ;0a
REAP }ACE DD FOfVA 4132. I ot CC.
LES WIMPS Pe( FMR DONT C. .4

...._.•............


.
PATIENT EVACUATION TAG — FICHE D'eVAC UAT ION DE PATIENT
(lie this tag to patient — Attseher sotto fiche DU patient)

I FROM (Mralcul ..en,facillt))
ON113 I NE riNgellidf i11 ¦1 de tn. 131(3H

NAME.(1•;frlint—m•Idle t NM
NOM /Nam fie Jot ilk -premier prettom—iniethdp • s ...I —.

.4;".
SERVICE NUMBER RANK1RATING/GRADE CATEGORY OF PERSONNEL Oa Ikr or employer and
1 &Quirt° MAT•CLILE GRADE watiettalltyj

CATEGORIE DE PERSONNEL (Scr•icr uu remplayeur el ItationtLittS (2).:i
...
DIAGNOSIS
DIAGNOSTIC

.01SEASE sArrss aoSissurr INJURY
MALADIE EILESSE AU COMAE BLESSURE
IA RA

CLASS—CL ARSE
113 211
IC MN"

ROTELISP2MTUIVINNT ;125El""a
j
3 4 CDUCNETTE
WI
T FiE• GRAY. MAI.

BAGGAGETAG NUMGERIS) NUNESO1 dTIOliiTTES BAGAGE
0 11. 71 Oran
DESTINATIO sERFI SNIP/AG (Number/type) .
OE STINATIO NAVIRE/AVION (MagrindaLllype)
TREATMENT RECOMMENDE9 EN ROUTE (If ye ...Ai. is 'equine/ a aaaaa kr re this rff.ct it mar)
TRAITEMENT R Ea/MS*110E EN ROUTE(OLSq•er ;Iowan traftentent .t .CII ...noire)

A
I
SIGNATURE OF McDICAL OFFICER DATE
SIGNATURE DU MEDECIN DATE

REGULAR DIET
REGIME SPECIAL (Dateriptios)

. 101EN.:RI M.. SPECIAL DIST (DrocrEtc)
I
. . .
SHIPS RECORD OFFICE TAB — FICHE POUR ARCHIVES TRANSPORTS
II
FROM Medical fragment faelliiy)
ORIGINS (/ tut4114 don tit treliemeni medical

NAME ( LW fief—middle (MIK) .
NOM (Nom de )unalle—ptelnierpteworti—Nitiale deux••••prinem)

SERVICE NUMBER RANIURATING/ORADE OF,PPBER
SZIENEE
CATEGORY D
FAJMEROMATRICUIE GRADE PERSONNE L

BAGGAGE TAO NUMPERIS/ •DATE Of CHIPMENT
NUMEROS ETIOUETTES BAGAGES DATE DEPART

DESTINATION ARRIVAL DATE
DESTINATION DATE ARRIVES

I EMBARKATION TAB — FICHE D'EMBAROUEMENT
.
MEDCOM - 6043
DOD 13255

REPLACES:60 FORM CO2/
• - ettomenOttations ARE
DD 1 FEBas 1,02
EMPJ 0 05'.
.ACE 60 FOI*5:12, LACS midi:teas sarr
7. . 1.
ArI CGRP -.SDls trig . • It t.'
PATIENT EVACUATION TAG — FICHE D'OVACUATIONAIE. PATIENT (Tie this tag to patient —Attacher ante fiche au patient) . . -
. ... ,
........... _ . .
FROM (Froliral Pediment Malty) •
0 RI 0 I N E (in.. Wis. is I:13)(3)-1
NAME'( /.01..'first...nsdelk odidl •

NOM (Non. ik /rod& -prrokr )(6)4 ' ",
SERVICE NUMBER RANK/RATING/GRADE CATEGORY OF PERSONNEL (Simkr ri. employer and

NUMERO MATMCLAS 0 PA GE or doTrIlly)

CATEGORIC DE PERSONNEL (Soviet au emplane et
noneenfei) 0t:)
DIAGNOSIS

DIAGNOSTIC
CLASS-CLASEE

' MilLEAU
' MILA1STEIE CA'CUALTVT ITLEUSV1FIE
1111111111111111.11:111.
15 25 •I •
IC
. Car. tilgrP
OUEI0P321111122,Tr 12?ealrIVI" I
3 14 iCCIU
VIRS'IES GRAY. MAL.

BAGGAGE TAG NUMItERI9)
NU5IiROS iTIOUETTEB RAO AGE
. '6.1 EI:DrI
DESTINATIO 10(3)-1 SHIP/AC (Number/type)
OEST1NATIC NAVIRE/AVION (1.42”15.1rhyP,2
TREATMENT' T RAE:0 M %TX: ETRE:LW/47a Le n.i.Uurezionnirol, . e• mir.iLto di ii¦ effe sr 4 made)

TRAITEMENT
R EA
SIGNATURE OF MEDICAL OFFICER ' DATE
SIGNATURE OU 255DEC IN DATE
RIIGGIUMLEAIET

NORMAL :'IzattgivErfirkv,,,,,...i
SHIPS RECORD OFFICE TAB — FICHE POUR ARCHIVES TRANSPORTS .
--....... ...-......--
FROM (A fediod Inoftsenr facility)

ORIGINE Naga/Elsa Is mitoses, naTlles0 ,.
NAME (Lao Pot-middle Wad)

NOM Mom dr finals-prmierpeinan-Inlikle delainlee prinom) I SERVICE NUMBER GFIRANADIC/R. ATING/ORADC CARG01:400F,PARIONNNEA.
I
DATE OVENIFAENTNBAUI7e62171'll'INUETT(SIGAGES
M3:SRIADATE DEPART I DESTINATION
DESTINATION enimmutiukt
EMBARKATION TAB — FICHE O'EMBARQUEMENT
MEDCOM — 6044
DOD 13256
Standard Form SOB
DOCTOR'S ORDERS
CLINICAL RECORD
(Sign all warn)
DATE AND TIME
DRUG ORDERS
START sror
(Another brand of a generically equivalent product, identical in dco•
NURSE'SDOCTOR'S SIGNATURE
age form and content of active ingrechent(s). may be administered
SIGNATURE
13t
UNLESS checked here)
,V4413—hoa Postop
0
d'SiA., aid ..cifs Tva—sverse C ter' ,7
0;
Vs= Yid,611014.4.4.-q 62 / 6 4c-ihro4 A42,J_Ast
(6) Athirst-. *,Dti.
a) Aiwv-sr, ztvs
f
:b)(6)-2 zt. b)(6)-2
dY -le g mvii? -Nailt?
b)(6)-2
L4C3 P ee 11,
•tea 447 Art SS A.: 1144r
• No.PT dies t,d+-spine- 57 6A a—t-
pst isarg Arafnit 541,2._ rFas
.71,Ak
CQ /0 %P/ pL1c4V (A) 1+-st...0d rv4to2 fkisq
cip 'D141 , ma
-TVPizez,/ CC L.

-
fr.alst Ci f-01 .) — -Tv 06° )c 434.-
.0.0, 5S f. 111Sty 51101 Ti! ro 1)=.411.4-- ( rW
(b)(6)-2
htS- (9,6"....5 XV M 14`)/), 11
(b)(6)-2
/*id Atfirtly C /"Ivrt
(Comma, an nrivnt sae)
REGISTER NO
PATIENT'S IDENTIFICATION (For typed or 'written entries give Name—last, first, muddle, WARD NO
grade, date. hospital or medical facility)

-z-x ,762.7-07v. pie) DOCTOR'S ORDERS
Standard Form 108
:b)(3)-1
$08-109
44, a 3
General Services Administration and
Interagency Consonttce on Medical Records FPMR 101-11.806-B October 1975
(b) (6)-4
MEDCOM -6045
DOD 13257

CLINICAL RECORD DOCTOR'S ORDERS (Sign al orders) •
DATE AHD WAS
DRUG ORDERS

STAR POP (Another brand or a generically equivalent product. identical in dos. age form and content of active Ingredient(s), may be administered-UNLESS checked here) DOCTOR'S SIGNATURE NURSE'S SIGNATURE
-2) 15 Aigis5l-W.149-2 tV1-.47- Se-P
1q15 , 4-C at (9-0 TV 6)5­0 Fr...100 tO P660 5
( A v v /3(.; c- tb A I--, .
t,,, ea.-_ 0 ,......5­0 Al . • 3 /0 C±1( . Fa 76
,b)(6)-2
— - - - - , p
- -
! • .
. .


. .
• • -
75. GPO : 1984 0 -451-275 (290) DOCTORS ORDERS Standard Form 501I
(Reverse)
MEDCOM - 6046

DOD 13258

Pftcy.0.0.0 132121 2*DERS
Standard Form SOR
CLINICAL RECORD tSigN et')
DATE AND TIME
DRUG ORDERS
STA RT STOP (Another brand of a generically equivalent product, identical in dos-DOCTOR'S SIGNATURE NURSE'S age form and content of active Ingrethent(s), may be administered SIGNATURE UNLESS checked here)
X )..L. IT) • -s
-Irk._ 0L) ? - -6+v. e—••¦^-• _s
_
keT„
2(7_,
7LxZ -5-
v)St--1- 4w-

L t(Gfr. A4'4
)c)c -
(Comm., en reverse side) Az)
PATIENTS IDENTIMATION (For typed or ientten entries give Name—last, Rest, middle, grade, date, hospital or medical facility) REGISTER NO WARD NO
DOCTOR'S OROE, Stamina Form 105-109
General Services Administration and interagency Committee on Medici FPMR 101-11406-S

MEDCOM - 6047
DOD 13259

50S-111
-..1,.."•••••¦ NSN 7540-00-6
— ..—. -- —.
-
--- -- • --- • --

Wan allorders)
i I 1 RX DRUG ORDERS DOCTOR'S 1 NURSE'S
DATE AND TINE 1
S LAM 1 6' TOP
SIGNATURE
SIGNATUIR.
.....
1
‘,..74_,.........er_...„-7,,.

g247 ik-A, 1)5
1 .. -...., ... . ... ... . . I . . .

ao 9-6 r-2 yQC.. a n r,A) _zi,/,,_ ..-„2„6,...)
f 1
.---( w
) ccrys_44
.01--'2 4"'
I
.
f\-0-t,,.—-e. 6.--.74—. -
.. .. [
-
7--)
/(;-(
I " 6,¦••1"....... I

.„.._..4._ .. ... ....
il-ca ‘JS a 6s 1...)
. . .
L • -' i i/...-4-7?6-a ez_ 7v-s
.,,,'__.-y zre:2 c.,_,,/ e l"
. . . -
. . .
...
I,
. . EP
. '' 1/.a.
• ... .. .
.. L i'-e) /2_ b
A--vN-j
)1---
•. - , vo„....4- ', v ro 0/ 0/, ii) r)(6)-2
— Viett"4"11' 4.~.- S----"Y" /iV,-7— t)(6)-2
. f.)-Do L . ;V 1-im 0.3 P.A. 1,-­- 0........,;-____ctizzt, crtzted.,..,_„....r_e± tkN.r.csaL-ri n a -CT- (
5A 1-1P i f¦ 111.4". .11, C.,14 1-1—;j9 ( 6 .c AA IN
. r I / , /
I ¦.... .
I . - - i : --- A i
ir .P.4V 1541;17 • 2.)
• ;1,), icirhe; „Ira*: ae-• 464, 1?; ¦"" PKii;pjleli fir Prier/Ira! kty..1!i-i') 77:1"17r;
b)(6)-4

DOCTOR'S ORDERS Medical Record Fcgil0 SG6 ;Nov. 3-94)
• ;', '
MEDCOM - 6048
DOD 13260

Trauma te
Ion Form
b)(6)-4 SSN:
Oak and kw al Hwy:
Dale and lips ofaftst Mewl 3 olq 44140lA 3 Chil complaint
14,1-e
(.Fress)
Pre-hoepital linkmenVon --kloclumisrn of intusy: EreWalla wound
0 Stabbing
0 Sum
.
Menke casualty

.
Other:

.•• ¦•
Procoskires Were salved 0 Akway: typo else 0
.
01

.
IV': location and

. Chest tubs: loo tion
aka •
7.¦1 *anis: Type
. Medkatkne
o Chantal casisser
. Oscenteminalkos delallne
-
Meow Oeleilme
. Mopes:
. 1.-PONt
. Other
prcoalu

l ass:
AMPLE Idatery
Alsrakse
Aleiketlens:
Post Masses: pep( v.) ji4,40/64.v.,
Last meat
Last Tetanus:
Events:

krelfW esommeenont Airway
. Potosi
rcoA)
0 Obstructed
Bneathine
.
*0 Nomwl
. Labored
.
. SWITIlltriCal
redoes nedlles7 . Yes . Asymmetrical . No
Fbala lalt

0
.
.
0 Toe 0 No
Inkiel assesement
CIrcutedon
Skinknucous Membrane color

)01%1k . Flushed .. Jaundiced
Pale
. Aaiun . Cyanokc
Skin temperature:
&M em

.
Not 0 Cool Skin moisture

.
Dry . Mold Pulses:

Carotid Ractki
Fernand R I R
L R L .. Pk . .
.. TO . . 0
O
00000
. 0
. . . .
Glespow COMB Eici (drab sopeeprios solaria):
t. Eye elieekIF Scenic Spaniesswees
4 Te Was
3 Te pain
2 Nene
2. Vastest
Mme.:

5
Cookmail
4 Inapprovdere woods 3 Inconwleis words
2 None
1
3. Motor.
Obeys nam ands

6 localkos to pan
5 Willukowle to min
4
Fkabn
3 Extension
2 None
1 Total GCS
• Puplikuy moons*
Pupll reaction: mom Lett
Risk
Constricted
.
SWUM
MOW
NosireactIve Sirs cj 111/11 AIM

I. t• 30 40 5410 se 0 le
Page 1 of 4
Merck-April 1997
MEDCOM - 6049
15
DOD 13261

ti 01 1 Trauma Resuscite2. )c.D Form
Physical examlnatioi: • API (Yens):. Height (inches): . Weight (kg's):. Head, eyes, ears, nose, throat:
Neck Tift -4\4fi-tEd Lf-t eLtrd
Chest: rv.4,j, (1.-1 ¦-4V•4.) v,
Back:
C.ervicaVrboracir./Lumbar spine:
Abdomen:.\AX. L er...e 1K.A4-N-V
/2 t-C 6s LA)
Perineum and rectum:
Extremity: .`V`,2.-0-."-1/14.. 6 s \,L)
Skin: kok,2,..
Neurologic:. (.11„Atrvx j.at)
Other
Magnum for dommenting Inturies Mandy Inaury ebb by numbest
1.
Laceration

2.
Abrasion

3.
Hernatoma

4.
Contusion

5.
Deformity

6.
Fracture

7.
GSW(s)

B. Stab wound(s)
9.
Pmin

10.
Cold injury

11.
Edema

12.
Amputation
13 Avulsion

14.
Bum

15.
Other (Describe)

(Wm pormuran Prom AI Loprum Carnpany. Mr Ikerding RH. Bane Ix Gresnr.k11..1. leAvoll.nd 114W. darn Kr. o'd Zeknost GB. •ds S.Verr Sarialle Perriolsa and Prick. Philiektal.
Mal
Page 2 of 4
NAVY MEDICINE
MEDCOM - 6050
DOD 13262

Trauma Resuscitation Form

Procedures performed by trauma teem ModlcatIons
Time: Pr000duro: Drug:
Verel, iiiitr211 rvm

Tram* WO 0111111 tolimallad eallal peallount N NEM raquimmarit
I. N bid et desion: hassled Rivers solution.
(use don Ielmoing mais6ions)

2.
Total Add requirement (M):
TER u 4 nil x vet (Ws) K % burn (26 and 3°)

TFR M CC

3.
Estimated fluid raquimmont 1 51 • Items poet brant:

(TFR/2) = oc
4. Estimated 11,411 oaquiammod mod 16 home poet bum:
mwep
row
ISc'4 C2
Pula:
Temp: Reap: GCS:
Motes:
Impression:
Plan:
0, Oil!
Aiisuatiiilon ansa iliiiiiiiitiNa amid eaaput

Waft: aft&
IR ml Stood ml Pf1YC ml Urine ml FPP ml NG was ml Nalalala ad Chart NW ml 011ow wd Olhar ml TONI UAW ml
morallum:
Wit COMP. of &noon. C0000lom oo Trams. Adoorceof Num LNo Support MOM Almost. MN odola, I
Page 4 of 4
NAVY MEDICINE
MEDCOM - 6051
DOD 13263

,cedures performed by trauma team Aktr11,7,atirme —,-.... .-Pragedu..e. , .:,: itne'l Grog: T Dosage: 1 Route 1' I f
4._7 Po
AgegillPXNAM2Wir4d 91111.N111MilidlIMINV -
summiraimmengiummor

' simmormis
..........mamtwrimuranurnaurrmorrannwa l

Trauma fluid resuscitation data
Estimated initial postbum IV fluid requirement Resuscitation area fluid Intake and output
1. IV fluid of choice: Lactated Ringer's solution (Use the following equations) lR intake: i SW ml Blood output: mt
2. Total fluid requirement (TFR): TFR = 4 ml x wt (logs) x % bum (2° and 30) PRBC ml floe /5-0 ml

TFR = (4 x .x.) FFP mi 853 tube a7‘4', ti `^'m(
3. Estimated fluid requirement 1 5I 8 bows post bum:
1212en.4-Platelets ml Cheit tube, ml
• i .• 1- • 11.111-1 1 -4.i • • • -• •I
rah.,
Total ml Vital signs
ROM IMMO NOM 11%11/ 51/1
Pulse:
W= M
NOMMUMWAIN MI=
MUNI
orrimg-Wff.411 11FROM.MIMI
oX3rl
Pi Fxio ( cAfori7ari .4'n d * 0757w-n-¢ i el
' "
AIMEICIMLWAITSP IMMIPMSCIC° -
NIFIMI /MMM.
Ingi , ll

M. .A. i V 4 0 Jarlit4W-MAMaiMEAMIN
Fa%TWA r WA 1Prai lI r. . A ITIPMMEragrarAE a rrAlat7RINEMII
117 lr-1-4 i PIIIMINIWAMWMNA lit- /14192.1111.11

b)(6)-2I0(6)-2
)(3)-1
INOM pomission from Na Airtortan CMoso M %spoons Commillo• On Trafirn
Page 4 of 4
MEDCOM -6052
DOD 13264
_...:Irlitiry:
Dale and time of Drente: .3-114/t1.10 Chief Cod iplaint G--.,57/1)
Pre-hospital information
Mechanism of Injury:
O....Outlt/1ot wouno

0 Stabbing
. Bum
. Chemical casualty
. Other:
Procedures before arrival
. Ainvay: type.
size tt
location and Z.y•ek-t, /ce.
O Chest tube: 1

size a
..._
1-9-41ints: Type
.
Medications:.

.
Chemical casualty:

.
Decontamination date/lime:
Dosage.

Dateftime
0 Atropine:
0 2•PANZ
0 Other,
0 Other procedures:.

AMPLE history
Allergies:
Medtions:

Past illnesses:
Last meat •
Last Tetanus:
Events:
1/1/ eri." tvt)
Initial assessment
Airway

. obstructed
Breathing Normal.
. Labored . . Symmetrical.
0 ASyrrunetrIcal Trachea midline?
es . No
Breath sounds:
Right • Left
Present
Clear

o .
Decreased
. o
Absent
Crepitus:
Pigel of 4

4nttal
CIrcala
.'Sliintrii*.us membrane.rf

nk.. Flushed Pale.0 Jaundiced
Skin temperature:
Warm . Hot

. Cool Skin moisture:
.0-gormal
. Dry . mots
Pulses:
Carotid.Radial.
Femoral R
Normal
Bounding . . .
. C
Weak
. . 0 0
Absent
. . . .
. C
Disability
Glasgow Coma Scale (circle appropriate scares):

1. Eye opening:.
Score: Spontaneous.
r4
To voice.
3
o past
Oriented
.
Confused
4 Inappropriate words Incomplete words
2 None
3. Motor:
Obeys commands Localizes to pain.
5 1Nithdrawls to pain.
4
Flexion.
3 Extension.
2 None.
..1 Total GC114....,S.,_ Pupillary response Pupal reaction:.
Right.
Left
Brisk
Constricted
Sluggish
Dilated
Nonreactive
Size lb-

,mm
te Z • 3 • 4 5 fill0 CID
MEDCOM - 6053
DOD 13265

Physical ti'
Weight (kgesi &AP (4
Height (inches)4Age 711 9,20Head, eyes, ea's, nose. throat:.
? NJ-4 -T Ceact-IWY)---CP*‘frvw "
Back:
Tho
Cervical/ThoracieLiimbar -1-)-'
Slki) 641
Abdomen:

0,4 I ZU 6-
Perineum and rectum: IN” 64-v sr.)-,
(4.cdficrn
ExtreinkY: .R" V 'C'Ofte
wovrfols
Skin:

ea 9
ethdeAte/
rs*-
-tc-t
U41eZ4Z-
Diagram lor documenting injuries (Identify injury site by number)
1.
Laceration

2.
Abrasion

3.
Fleinatome

(3C g' St\
4.
Contusion

5.
Deformity •

S. Ftacture \t\.1
7. GSW(s)
61
5,
B. Stab wounds)
9.
Pain

10.
Cold injury

11.
Edema

12.
Amputation

13.
Avulsion

14.
Bum

15.
Other (Describe)

pintY11111114110,16Tan WI Inwinreelt nnmainu aaY Muni,. RN Rum. Ge..nR.Idl1 LI.J/...kond YW mon.. VT
and Zolovock Ga. ads. Surgery: Seised& Prrecles and Pilau. PIVINdalphl• J5 Lipprco3 Compaint 1993.)
Page 2 of 4

MEDCOM - 6054
DOD 13266

76.1.0.48-824-4I7G 6U1
vcomazaftiop...1a.V0rAat•IONSM..1117.11.0191Tall.F.1.1.1211
01,11A1V.9.-,T2IMIRCIIWICOO9
HEALTH RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE SYMPTOMS DIAGNOSIS TREATMENT TREATING ORGANIZATION (Sim each entry)
Scu-
(b)(3)-1
ui d /0.--A9-1\ixfec.4
tA)
L
04,4-4- S-84,0 C.-ire...M. '1 Ari.-Al
AID
(-4-1Arvx 0-4.nsi--7. -
Sy; a Ake_ E s_rv
04° YN•0 LS:LA-0__VPS l713 674./2:410./YV-14
,
-z
ktik Irkw)
)
os— 2°/1_ 9 S-X (cr "0-zo, NC. Cr (L"P
-9L-4-32.
/i\JAT), L Q' U- ft -9. yvj ct,1 , itl-c3 ()Su) c, 6,3(A3 ci".4--tc/ '47
)./•-oe d—J2
0/7,d,c.,4;t4e/
(b)(6)-2
PATIENT'S IDENTIFICATION (fits this space for Mechanical
RECORDS
imprint)
MAINTAINED
Cobet A,
AT
PATIENT'S NAME (Lott, First, Mkidiot IS EX
1,1C, A
RELATIONSHIP TO SPONSOR (STATUS RANK/GRAD
SPONSOR'S NAME 9:TRIa LLATTCI N
DEPART./SERVICE ISSN/IDENTIFICATION NO. DATE OF IT.
MEDCOM - 6055 iF MEDICAL CANE STANDARD FORM Otgo. cREv. 5.12,
DOD 13267

z'sm) ‘Ljd

J.s-t—
(1,4 0 2— //\.°-° /--%•^-212Aie.
r
-/61-Na-RA 6S0 oCvv v,4,e
MEDCOM - 6056
DOD 13268

NSI')
[
ViEDICAL RECORD VITAL SIGNS RECORD
-- --.. HOSPITAL DAY

__I 7
T-DAY
• 6AMOS ill-I.-YE 4R.1 DAY i I . D. a° .ou
(110b t7E.A.W CaCAD ,C,,(.5b
tile

L • --
..,--1
HOUR
nvu rl
go, 40 MIMI
ik• CO
;Al*/A
4.

19 I
r.:.• ••
5

: .
•: TEMP. C
40.6°
PULSE TEMP. F
.
(0) (*)
• ......
. .
105 °
..
Nr •
O

C
39.4°
S.

°-c
36.7
al " • •
. ....
firILINEM11=-1•111d11E1111111111111111111=111LICA.11111—.37.0-•••

u.i
cr Gom m . ... ...
....
woT -• • • • • •
....
•• .... " 37.8° C •

....

°40.0
130 104 °
. .. .... 1
.... •••••

Ne

•-• • •
(1
...
0
170 103° 160 102°
C'
ciaoam
.
a
°38.9
c.)
a)
. . . . cu
• : .F.

-
**)
-
C
.• •••

Liarajat
0
38.3°
0
.
06 V

:•
c..)
.. .. ....,
••-¦ -1 -• .636.1°
. .
¦f:,.4
• .• •

(Ta
•..
. .
cc
150 101. °
. , , , .....
' -

O

lua len!nb3a
;,..6 If
peiaRuao)

c\RD.r 0 0

..

000
.
• ;1! : •
' • ' • , .: ,./ A.;
140 100 °
......
..... # .
130 99 ° 98.6 ° • ' . • . • • • • • • •
120 98 °
. : ... : .
110 97 ° ..... : 0 : 0 :
100 96° ... . . .
....
90 95° • • • • A. •• t¦ .
80 A A •

...•••.
• • e•

.•..•IF
coonc
43:
• ra0 CD Li
........
Q. A


CO ¦03

.••. -•
•••• • • • •
...
. . . .

. . 35.6°
.. ..! ....
...4

...

35.0°
-••
I. " • ' " 1
-4•

-•••
• • • I

. .
... . . .
. . . .
-


• '
" • " •

. . . . . .
I . ..
. "
-•• 1
..
......
. •
1' /1.ii
'N RECORD.. ., In .17., In 11,, IL.
• i 0 lb t0 i r, tyl
BLOOD PRESSURE 5p0 21 ilj 9 5 eti 9z. Cm a is 15 ofi-n 93 '
I
11,19313

;
¦

3 0 So go Seo 9,D 3D 2,-, Jr) .70.Xi. a k
Got ga, ,7­
gi mizumuggn
3 31 a
'1 f.3
;14% P

HT:

10131=11,arrIELAIIIIIIIIIIFAI
ara . ,:. ,
¦•,,,A
in

0 *V
. -r i....\0.)5 ) 0 MU=.Men \JC5 0-9' loo P° 01111"11E ...
111111
L1/4 0
. 1., B ,•. .111 0 , ,.
111

-tf isd( ,1 •• '
KATION (Fortyped or written entries gisfe.: Name—last first, middle; ID No. (SSN or REGISTER NO.
WARD NO
r
other); hospital or medical factli0
. 4-
.1/
•¦•••¦ ',b)(6)-4 uo 01/ VITAL SIGNS RECORDS
loco Medical Record
= )
AAA.
STANDARD FORM 52.1 (REV. 7-95)
Prescribed by GGA/CM/ FIRMR (41 CFR) 201-9.202-1

MEDCOM - 6057 qY)
DOD 13269
AUTHORIZED FOR LOCAL REPRODUCTION
ICAL RECORD PROGRESS NOTES
,
NOTES
ATE
Cr/C q. _
la., c:-.; '4,76e) f ._..,, ma 0 '. • , -4 4. i) , -/i/ ' 1 Y liz, ' ___
II4 A u.
r . i
I
b)(6)-2
kle •fL.e...4_04,X1Z 41/, .r?,4,0r71 a6 .,„ d).., /3/' - , -, e .,-C(AK, V U
(}14.14¦4•L,....:3 ; ..., . y ---4.4%-t.--,,,,,
-tituk. _2,„,4\g,,, ),e,a ) 1(2A,6 y-, 1nviikiiitla
4.9_Gvyr.--- k,14.9)(01 CWP-40'._ ,4-
( L
o

DIAIIIJ-f ---i)11)1 PIA V 4Alkket-c4 li'lla-nr61\51 Ati-eL
) ) 1,14
-
‘,er)i-v-Ae_. w-eitil ltkoA\ t6t 4-1,1_, do-ea ilq---wei
J
(912__ nA .SCI (Il' e7;2,01...0-it-i 4714/.6&.-157-1-7600 b)(6)-2
• 1 ----1/trill-Ltd [AT 11,64c-o 1? b)(6)-2
I1
I
k
'6)(6)-2
_
o-701 MS /1.-,-tipiAtimi c c 1 (..,,J-----
b)(6)-2
-V
* 0:- „, ,
w P svu A
b)(6)-2
0926 "PI n L4 5.4) .... V.A...., 5 .•.. ttNAAr, . —
CO 0 Ai44...4 :pi „y„,..,144 h,c_ i ,i., 46,-e AL.,,_,,D /0 OC) e-c-Z.
. I i .

_ A r. .4,z,.... i, eix,
.blit • elan" ... 0,

RELATIONSHIP TO SPONSOR SPONSORS ID NUMBER
SPONSOR'S NAME ASSN or Other,
LAST FIRST
MI
1
DEPART./SERVICE HOSPITAL OR MEDICAL FACILITY RECORDS MAINTAINED AT

PATIENTS IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; I REGISTER NO. WARD NO. ID No or SSN; Sex; Date of Birth; Rank/Grade)
PROGRESS NOTES Medical Record
STANDARD FORM 509 IREV. 5/1999) Prescribed by GSA/ICMR FPMR (41 CFR) 101.1 1.203()1110)
:6)(6)-4 USAPA VI 00
MEDCOM -6058

DOD 13270

FISN 734G-OO-$3l-&t
mEDCAL. T PRoeFIF3S NOTES
1-ik._LS
313—Q14
1U 4ALAc,.L— 5,415-..) M5d,l 5A1 -_-_ •U .14.il,--
1--1S
1 c
o 03D Ps O Lk Zi6---ii3j f . (b)(6)-2
01u 6 iif/o-, ZD Tki
0 /OD -7,4-49-c-vF_A: so"? .-7:­--­V 0-• . ia.....r 07...41-0--1.--/a-¦ (b)(6)-2 r
0 1 'ZS- 0 .#1."- ...._.1__4.nj--C--•.,

14)(6) 2
Cr-Z, 0 /1 so q L rio I L. 5
;b)(6)-2
bS61-0 1110-9) ZAA-Lo 1 (/A.
0330 lAi.'L/ 1"1 51-? 1 I/ ty,-I( 1.54 . 0(0 0 lil5 oti 71,, O ly
. ...
(Conti •ue on reverse side)
PATIENTS IDENTIFICATION (For typed or written entries give: Name—last, first, middle;: ..e: rank; ;ate: REGIST R NO.. .. WARD NO.hospital or medical facility)
PROGRESS NOTES
Medical Record
b)(6)-4
STANDARD FORM 509 (REV. 7-91)
Prescribed by GSA/ICMR, RRMR (41 CFR) 20i-9.20:

MEDCOM - 6059
DOD 13271

Doc_nid: 
3574
Doc_type_num: 
72