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

Medical records of an Iraqi male of unknown age. Partial medical records beginning with, "ICU Admission Orders." Medical conditions included, Pneumonia and blast injury. Sounds similar to patient from RDI 1266. The records do not state how the gentleman received his injuries and does not give any personal information on the man.

Doc_type: 
Medical
Doc_date: 
Friday, April 18, 2003
Doc_rel_date: 
Wednesday, June 15, 2005
Doc_text: 

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
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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

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3. Diagnosis:
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4.
Procedures:

5.
'condition: SL VSL

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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)

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MEDCOM - 5482
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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.
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Protocols
Burn
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Heparin IV drip Enteral Feeding

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ICU ADMISSION ORDERS
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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
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8. Nu411112
rsin
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(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
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(b)(6)-2
b)(3)-1

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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

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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

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Vistaril 12.5mg 25mg PO Q4hrs PRN nausea
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TRANSFER TO WARD 0.,„.DERS [Circle appropriate order)
1. Admit to,Sle.A on. DATE/TIME 2 4'
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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

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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

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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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PI • .. LI

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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
PUPIL SIZE
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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

FREO. VITAL SIGNS
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IP: 07 08 04 10 11 12 13 is 15 16 17 18 TOTAL 19 20 21 22 23 24 01 02 03 04 05 06
P(
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P'' 7NT 24 HOT 1P INPUT PRESENT 24 HOUR OUTPUT PRESENT WEIGHT

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DEURGERVER
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NIERIUMMIN
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LIMINEVEREMEN MIN

DOD12734

FREI). VITAL SIGNS

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
IVPB !ea Z12)
._
.
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 -
BM x(

MEDCOM -5522
PREVIOUS 24 HOUR INPUT PREVIOUS 24 HOUR OUTPUT PREVIOUS WEIGHT PRESENT 24 HOUR INPUT PRESENT 24 HOUR OUTPUT PRESENT WEIGHT
Neuroyascularnyeuromuscu tar iimaitt:K , AA r s. •n .
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 .
'VE1413AL, ' MOTOR . g. 2 •
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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:

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

Doc_nid: 
3556
Doc_type_num: 
72