Medical Report: Iraqi Male, Baghdad, Iraq re: Pneumonia and Blast Injuries

ICU ADMISSION ORDERS
Circle a ro riate order

Admit to ICU: DatefTime ogtat9
1.
Admitting physician
2.
Ati4,1444(414
3. Diagnosis: 4. Procedures: C1‘4•;C(
VSL
5. Condition
6. Allergies: 7. Isolation: Standard irborne Droplet mal pox, Measles, Varicella, Pulmonary tuberculosis, unknown.All patients Pneumonic plague, Meningococcus, Influenza MRSA, Viral hemorrhagic fevers
Contact
SA02,) every hou

ing:
NursVi Ogns (BP, Pulse, Temp, 1.5 or 98
emp 10
tal T Urine Output 0.5 Gets; 110
Call MDnHourly
60 or SBP 200 or DBP MAP 4
euro checks
eds/SCDS
Foley to gravt
G to LIS
leurovac Chest tube to -20cm Head of Bed elevated to 30 degree
C-spine collar and log roll Incentive Spirometry lOreps athr
9. Di Clear liquids
Regular Advance as tolerated
10. Activi f2c cc/hr.
S/fiSS.D
at car or IVF: LR at (b)(6) -2
11. CXR on admission and QAM (while intubated)
Radiology:12.
(b)(6)-4
CAPTfr-iost,1
r MEDCOM - 5480
13. Labs: On admission to ICU: CBC,Chem7 PT/PTT, Type/Cross or Type /Hold units
ABG QAM
LFTs Amylase/Lipase K 041 (4741 eiel)
PT/PTT Mg/Ca/PO4
_Oxygen: Titrate to Sp02 93-97% using nasal cannula, face mask Pm
(-Ventilator protocolj-

15. Meds: Ancef I gm IVPB Q8hrs x 6 doses Vancomycin I g m IV Q12hrs (if PCN allergic) x 4 doses Mefoxin I gm IV Q8hrs x 6 doses Heparin 5000 units SQ BID Prilosec 40mg slurry NG/po QD oirritac 50mg IV -C-117)
PRN: or kine sulfate 2-6mg IV Q 1hr prn pain
Ativan 1-2mg IV Q I hr pm agitation
Tylenol 650mg supp pr Q6hr pm Temp 1..D
Benadryl 25 mg IV/PO Q 4hrs PRN itch
Phenergan 12.5mg to 25mg PO/IV Q4hrs PRN nausea
Vistaril 12.5mg 25mg FO Q4hrs PRN nausea

U A--S4,1,6( tae403.4
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Protocols Bum Insulin IV drip (milI in Subcutaneous sliding scale Heparin IV drip Enteral Feeding
b)(6)-4
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MEDCOM - 5481
(b)(6)-4
ICU ADMISSION ORDERS (Circlg annronriate order)
jb)(6)-2
• 1./A /lin 2 /a D
1. Admit to ICU: Date/Time 7/ nr_—
1(b)(6)-2

r\2. Admitting physician

44.47-ebi
3. Diagnosis:
v—r--
LJ
4.
Procedures:

5.
'condition: SL VSL

tle24
6.
Allergies

7.
Isolation: All patients
me Small pox, Measles, Varicella, Pulmonary tuberculosis, unkr1

Droplet Pneumonic plague. Meningococcus, Influenza . Contact . MRSA, Viral hemorrhagic fevers
9:
Vital ogns (BP,. Pulse, Temp, SAO2,) every hour
tall MD ! Temp 101.5 or 98
Hourly Urine Output 0.5 cc/kg
MAP 60 or SBI? 200 or DBP 110

Neuro checks
Wei ht QD
Teds/SCDS

o gray'
o S
Chest tube to -20cm H2O pleurovac
Head of Bed elevated to 30 degrees
C-spine collar and log roll
Incentive Spirometry 1 Oreps Q I hr

Clear liquids
Regular
Advance as tolerated

0. Activi
11.
IVF: LR at cc/hr or AISC • --at 45-P cc/hr.

12.
RadiologeXR on admission yQAM (while intubated)

b)(6)-2
MEDCOM - 5482
DOD 12694
N9 )4.
i(b)(6)-2
13. Labs: On admission to MU CBC, em
T/PTT, Type/Cross or Type /Hold u n its QA Chem 7 ABG b)(6)-2
LFTs Am ase/Lipase
PT/PTT Mg/Ca/PO4

b)(6)-2
14.
0 n: Titrate to Sp02 93-97% using nasal cannula, face mask prn Ventilator protocol

15.
Meds: Ancef I gm IVPB Q8hrs x 6 doses Vancomycin I g m IV 012hrs (if PCN allergic) x 4 doses Mefoxin I gm IV Q8hrs x 6 doses Heparin 5000 units SQ BID Prilosec 40mg slurry NG/po QD or Zantac 50mg IV q 8

PRN: Morphine sulfate 2-6mg IV Q 1hr pm pain
Ativan 1-2mg IV Q 1hr pm agitation
Tylenol 650mg supp pr Q6hr pm Temp 101
Benadryl 25 mg IV/PO Q 4hrs PRN itch
Phenergan 12.5mg to 25mg PO/IV Q4hrs PRN nausea
Vistaril 12.5mg 25mg FO Q4hrs PRN nausea

16. MISC.
b)(6)-2
VA
Protocols
Burn
Insulin IV drip Insulin Subcutaneous sliding scale
Heparin IV drip Enteral Feeding

B
(b)(6)-2
b)(6)-2
MEDCOM - 5483
ICU ADMISSION ORDERS
Lrars1
1. Admit to ICU: Date/Time_n47/
1(b)(6)-2
2.
Admitting physician I

3.
Diagnosis'n

4.
Procedures:

5.
Condition VSL

6.
Allergies: n

7.
Isolation: All patients
Airborne Small pox, Measles, Varicella, Pulmonary tuberculosis, unknown.

b)(6)-2
Dro let Pneumonic plague, Meningococcus, Influenza onta t MRSA, Viral hemorrhagic fevers 044 C. re,. 7u.96 /'
b)(6) -2
P,P;uise, Temp, SAO2,) every hour
8. Nu411112
rsin
all MD I InTemp 101.5 or 98 Hourly Urine Output 0.5 cclkg MAP 60 or sap 200 or DBP 110
(b)(6)-2
check
Weight QD

o e
Ches_-20.03_1120, leurovac
Bed elevated tom degrees
C-spine collar and log roll
wive Spirometry lOreps

9. D
Clear liquids
Regular
Advance as tolerated

10. Activi
11. IVF: LR at cc/hr
;b)(6)-2b)(6)-4
12. Radiology: • • :•_-si. , a.. • AM (whileDntubated)
(b)(6)-2
b)(3)-1

T 1974
;b)(6)-2
MEDCOM - 5484
DOD 12696

13. Labs: /9.ez•j r
n

units
On admission to IC Chem7, T/PType/Cross or Type /Hold_ABG
QAM
LFTs_ Amylase/Lipase
PT/PTT_Mg/Ca/PO4

_ ,;b)(6)-2
14.
OxygeiL:---Ti irate to SpO2 93-97% usiribThissal cannula, face mask prn
Ventilator protocol

15.
Meds: Ancef 1gm IVPB Q8hrs x 6 doses
Vancomycin I g m IV Q12hrs (if PCN allergic) x 4 doses
Mefoxin 1gm IV Q8hrs x 6 doses (b)(6)-2

.crrepann 5000 units SQ BID _6_.,,-- -9 "L"ir--) C.S.— C iS :—/-g
Prilosec 40mg slurry NG/po QD aCZantac 50mg IV q 8 )
PRN: Morphine sulfate 2-6mg IV Q 1hr pm pain
Ativan 1-2mg IV Q 1hr pm agitation

"b)(6)-2
n su_r Q6hr pm Temp 101.
Benad 125 m I -1 II • 1_N itch
Phenergan 12.5mg to 25mg PO/IV Q4hrs PRN na

• r:DA50g_._2pp --.
usea
(b)(6)-2
Vistaril 12.5mg 25mg PO Q4hrs PRN nausea
16. MISC. (b)(6)-2
r-c_Dc). 7-c/_7c„ 5 -7
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-
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C 5 s /r -4,74-
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Heparin IV drip Enteral Feedin
b) (3)-1
PE37741 TiA1A2_111V ACT 1 974
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MEDCOM -5485
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TRANSFER TO WARD 0.,„.DERS [Circle appropriate order)
1. Admit to,Sle.A on. DATE/TIME 2 4'
b)(6)-2
2.
Admitting physi. an

3.
Diagnosis: Akr,p0-4

4.
Procedures:

5.
Conditio VSL

6.
Allergies:

7.
Isolation: Standard All patients

_
MRSA, Viral hemorrhagic fevers
ntac
8. N
Pulse, Temp,) every 1.-"" ours n
Call MD Temp 101.5 cr 98 Hourly Urine Output 0.5 cclkg MAP 60 or SBP 200 or DBP 110
Weight QD
Neuro checks
Teds/SCDS
t•-:ley to gravity
NG to LIS
Chest tube to -20cm H2O pleurovac

c—Herarcirta-1 elevated to 30 degrees rri sys.0,C, (-74e_4-7c collar and log roll
b)(6)-2
Thit
ntive Spirometry lOreps 0:11
9. Diet: NPO
Clear liquids

egu
vance as tolerated

10. Activity: ___
Out of bed with assistance
Ad Lib

t 3arinTD
(.....12., IVF: LR at cc/hr or at cc/hr.Hei-------_ock
(b)(6)-2
;b)(6)-4
MEDCOM -5486
n
42, (G.-1AZ 7 eB4-07
1(b)(6)-2
11. Labs: ABG
ClAr )n
LFTsn Amylase/Lipase
PT/PTTnMg/Ca/PO4

:b)(6)-2
13.
Radiology: n

14.
Oxygen: n

(b)(6)-2
15. Meds: Ancef !gm IVPB Q8hrs x 6 doses total
Vancomycin 1gm IV Q12hrs (if PCN allergic) x 4 doses total

Mefoxin !gm IV Q8hrs x 6 doses total
Heparin 5000 units SQ BID
Prilosec slurrey 40mg NG/po QD or Zantac 50 mg IV q 8 hrs

PRN: Morphine sulfate 2-6mg IV Q I hr pm pain
Ativan 1-2mg IV Q I hr pm agitation
Tylenol 650mg supp pr Q6hr pm Temp 101
Benadryl 25 mg IV/PO Q 4hrs PRN itch
Phenergan 12.5mg to 25mg PO/IV Q4hrs PRN nausea
Vistaril 12.5mg 25mg FO Q4hrs PRN nausea

16. MISC. (b)(6)-2
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PRESENT.24 HOUR INPUT 2- (.1 PRESENT 24 HOUR OUTPUT_AE1 PRE SENT WEIGHT
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PUPIL SIZE
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Neurovascular/Neuromuscular Check (MEDTREFAC 6550/12/Temp Form)
07 08 09 10 11 12
13 14 15 16 17 18 19 20 21 22 23 00 01 02 03 04 05 06
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TIME EYES OPEN 07 08 09 10 Neurovascular/Neuromuscular Check (MEDTREFAC 6550/12/Temp Form) 11 2 13 17 18 19 20 21 22 23 00 01 02 03 04 05 06
VERBAL
MOTOR
TOTAL .3
PUPIL REAC R/L LI 11
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STRENGTH
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MEDTREFAC 6550/12/Temp Form
07 24 01 02 03 04 05
Time 08 09 10 minnomouna 16 In 18 19 20 ®®®
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DOD12732

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P(
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DOD12734

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TIME BP HR
RR TEMP SAO2
Notes:
INPUT/OUTPUT
IN 07 08 09 10 11 12 _13 14 _ 15 16 17 18 TOTAL 19 20 21 22 23 24 01 02 03 04 05 06 TOTAL
PO 30
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.
OUT 07 08 09 10 11 12 13 14 15 16 17 18 TOTAL 19 20 21 22 —23 24 01 02 03 04 05 06 TOTAL'*
FOLEY UOP 305. 3(tb-- 305 150 40 -
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MEDCOM -5522
PREVIOUS 24 HOUR INPUT PREVIOUS 24 HOUR OUTPUT PREVIOUS WEIGHT PRESENT 24 HOUR INPUT PRESENT 24 HOUR OUTPUT PRESENT WEIGHT
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TI EYES OPEN 07 . 08'. • 4 09 • 10 11 • 12 4 13 14 ' 15 16 18 19 20 21 22 23 • 00 01 02 03 . I 05 06 .
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MC VEMENT • STRENGTH .. • - •
--=­ I - .
RESPONSE .n1 '2 . .3 4 ..._. 5 6 . . LEGEND I
• • EYES CPEN -VERBAL ...n. IlefoR Never • Nom None • Ton• Pain' . To Sound timet ySpontan-incoepre' hens I bl e Ineppro prints Confused Converse-Extension Fl exi cm' Abnormal .n.n. . Flexion- • Withdrawal-. PUPIL 1111 SCALE 1 • • •• . Oriented Localizes Pain . • . ' Obeys Commands. . Movement:n. • -Reflexes:n. Strength: 0 - +5/5 -¦ Absent . P = Pronator Driftn• ¦ Present FY • F tex 1 onAll thdrawalnPupil Reaction: E • Extensionn•n'nS ¦ sluggishFL .• Flaccidn•n- + a -Reactive FA al F lexion Abnoraisin- • Nonreact lye _ • • . •

SELZ I, 000

n
MEDICAL RECORD I VITAL SIGNS RECORD
HOSPITAL DAY
POST.nCAT _
I Mk'? . NIV D9).0 153, km% p
MONTH-TEAR DAY ...0n.•) r, .., %,n1•

V! al, .• 11 c•
DI HOUR

C" .iftaihw"0111.11111:11WAIIIMail
• • . -'n' " "
. ...•n
PULSEnTEMP. 11 . • " • • • •
(0)
TEMP.n

41 .n. .n: .n: .n. :n. .n. .n. C

.n. .n• .n• .n• .n• .n. .n. .n. .n. .n 40.6°
. . •
.n. .n• .n
.n. .n. .n• .n• .n. .n. .n. .n. .
180n
104 .n. .n• .n• .n. .n• .n. .n. ,n. .n. .n. .n. .n 40.0° .
•• •• . • .n• •• •• .n• .n. •. .n. .n•
. 170n103 'n• " • •
•• :n• •• •• -n• .n. .n. .n. .n.
39.4°
.n. .n. .n. .n. .n. • ' " . • .n" • 160n102° • " ,
.n. .n• -.;
._. ._. .
. . ._. ._. ._. ._. ._.
• ._• ._--_. ._. ._. it
._. ._. ._. ._.
150_' •• c
101 '_.
._. ._.
140n • . ' n. • t;
100° ._. ._. ._-• •• •• •• •• ._•
37.8°_,.,.. '
. :_. ._. ._.
130_

•:_' :_: •.
99° • 37.2°_Z
._.
98.6 4(
._.
37.V_i
..120_••
98 . ,
•• . 36.7'_' S
.
:_. ._:4 S' •
.n.
Vir 4?
-n•
110n97° :_0 , 1.4n • • • */n• . • . 43_V: 0 ._:6 ' • 36.1°_ 1 . 0* •' ••
...
•eo loo 96 n .
. .
35.6° .. 0: : : : : : -: : : : : • U 90n.n• •• . .n.95
a:
.n. .n.
35.0°
•. N • ••
8t, •• •-•• . • • •• . • •• . • . • . . . •. • • •. .
• " .
.
IV. : : : ' : : :0; : •. •-•• •• ••
. .
70 .n• .n. .n• .n• .n •• •• •• ••
. .n. ,n. .n. .n. .n. .n. .
.n .n. .n.
.n. .n•
60 .n. .n. .n.
.n• .n. .n
• •• .n• .n• •• .n. .n. ••
.n• .n• .n. .n,
.n. . . . . . .n.
50 .n. .n• .n• .n. .n.
.n. .n. .n.
.n. .n.
.n. • .n• .n•
.n• .n• .n.
.n• .n-.n• .n. .n. ,n. :n. ,n. ,n. :n. .n
.
40 .n• .n. .n. .n.n.
. .n.
..
RESPIRATION RECORD
2. 19 \ .n• 1n•n-• • I2.kn• Iii•
_ G
Vi411 jolifilli(11Y.30 tilyiil \XIV \ Ni liyaf ffir----------------1---
BLOOD PRESSURE
T
4 I 10,48,7
8
a
a
2 HEIGHT:nI i„,.....r_461q5
nuto in_i
4 7'16 g..
..
._..
-a
7; _
E. r
o'_1 . 1)DcC DovA, 7DDL. Et goo c.,....,
i
PATIENT'S IDENTIFICAT ON
1
(For typed or written entries give: Name—last. first. REGISTER NO. l WARD NO.
(b)(6)-4_ rnk; rate; hospital or medical facility)

VITAL SIGNS RECORD
i 1 1-1
STANDARD FORM 511 (REV. 9-79) +scribed by GSA and Interagency 'reittee on Medical Records R (41 CFR) 101-11.806-8
MEDCOM - 5524
DOD 12736

INSULIN PROTOCOL
SLIDING SCALE SUBCUTANEOUS
ISTAT EG8 Q6hrs
(Glucose Action 1/
0-75 give 1 amp D50 and call MD
76-150 no action
151-250 2 units regular insulin SQ
251-350 4 units regular insulin SQ

351-450 6 units regular insulin SQ
450 give 8 units regular insulin SQ and call MD

INSULIN DRIP
Start Insulin gtt at 1 unit/hr
ISTAT EG8 Q lhr

Glucose Action
0-75 Hold insulin drip and restart in 1 hour at 1 unit/hr less ?6-150 No action 151-25 0 increase rate by 1 unit/h!r 251-400 'ate by 2 unit /hr 400 increase rate by 3 units/hr and notify MD
Insulin gtt range 0 to 6 units/hr, if need to exceed this range, notify MD
MEDCOM -5525
RESPIRATORY THERAPY TREATMENT SHEET

I DATE: C-1( / TIME: c TREATMENT:
dvac

PRE TREATMENT: HR-'25) RR-'76 , Sa02-POST TREATMENT: HR-7.7) SaO2-
,
LUNG SOUNDS:
PRE-(&'
POST-le-4-k-0.
COUGHISPUTUM: MMENTS:

Vv Y
THERAPIST SIGNATURE: _ j
I_4
DATE: ( ( 2' TIME: / 7et_TREATMENT: -5eck .4,
PRE TREATMENT: HR-Sa02-_“1- POST TREATMENT: HR-, RR-le' , SaO2-

LUNG SOUNDS:
PRE-,C-4-v..t, /5/7cri
POST-S S ../e/e4/4"02-,-g-C L

COUGH/SPUTUM: COMMENTS: /17,
(07
--ix . C ". 7.'9Y -tcetrussrd THERAPIST SIGNATURE: tx63-2
DATE: 1.1,4 TIME: /46-.5BTREATMENT: eioq PRE TREATMENT: HR-RR-, SaO2-97 7 POST TREATMENT: HR-'3/z, SaO2-LUNG SOUNDS: -4,(cct
PRE-
POST-0
COUGH/SVUTUM: /r,e5 COMMENTS: /7.(

bX6)-2
THERAPIST SIGNATURE:
DATE: (..//0 b3 TIME: / 5-53 TREATMENT:

PRE TREATMENT: HR-/ /, RR-20 , SaO2-POST TREATMENT: HR-/ SaO2-r, 12°'
LUNG SOUND: PRE-B4(c#41-44f0A POST-0 A COUGH/SPUTUM: OW ...e4 (9Z (ja,ilicommENTs:
P­
b)(6)-2
THERAPIST SIGNATURE:
ADDRESSOGRAPGH: ORDERING PHY

b)(6)-4
DIAGNOISIS:
MEDCOM -5526
)(3)-1
CP/RT V ntilat • r Check Off Sheet
Daten 11M11
1-4 jr9EMEMPt
Time ) St)
Vent 7 -get) Nc-0
Mode e Ale -Psi(
VT set/actual 7/70 '73-o
VT spontaneous 1300 6-"g 72,0 9g7
Rate set

Rate total
)' Z 2
Peak flow
`'10
Sensitivity
Peep 1c) lc NL/
PIP .20 .21
Insp_pause

1351
Sigh volume V, V.1. 2
Sigh ratentv,( )9 ¦ D

aq
Sigirkequemy p3 a 112 .1/
Sigh PIP

Fio2
SD% 3or,
-1)
Waveform
High PIP alarm
c't)
Low PIP 1 c2
Low volumen

-36a 300 DeD. 144
Det. delay
Apnelc period a O b

Low PEEP/CPAP
High rate ifo
4-0 D d
Volume check qS
Temp/set
Water level HME 0. OIC e:JL OIC OIL K Pt/secretion check ft
02 sats
ar /064 97% (9% ti!SC tr-49. / Do% Cuff Pressure V1AL-(
n
b)(6)-2
Initials
NAyne/Siqpature, , !Initials 1 a nPt .rifSrmation/Addressoqraph
b)(6)-4
(b)(6)-2
MEDCOM - 5527
Dat-Time
V

• WODIrAUgerawilittialountiffr
IIILIMIIIILIMMINIA111111111 111WOMMIL04011•11ILML.M.B
dr.
7.ftr. et c,(Jki •B e-r Jc_§-AA) f_Le..1.vt. ir 15/rBS 4AJ
6)(6)-2
4.1.(4.) cut PA
'
-C-i"-e4./w1.1---1;:-.
:b)(6)-2
• lk&—f4., &AL.-
?(T ..PVT,'ba r cn't-; VI_,yer rm/r f1go-).
6ehat_ - via& /_p/-0-t. /41 1,11 eff, 1,0(06-t4-73.4
ktfiriA_4 _C ,/,, may, 4,/`)/af%e. 11/accl,
6 b 1 l'_ cLiexQ 171 o-./ ix e , --",. ( 1,,,pI.. 4 . / Ya/ A''ed-e-Zi /a-te
Ilf -0 -f-r I / ......„-,.
- ., /a . —''e...--2.__i24B-i.,
.
0 P-4.4 ar--":/e.e,/, ie, 4 I.7c.,-/_-e.e.i...0-jB' --e.ie.--e,10". 4 .ell,---/---
ca--, C--_t ,J,- 1_ ii if irePfLe ' -.0e.c. 4, 7.­
,zel.----(rt)--,12 _-7-est-f ....2--el
:b)(6)-2
I.1
MEDCOM - 5528