Medical Report: Iraqi Male, Civilian, Baghdad, Iraq re: Bilateral Fractures to Lower Extremities; Broken Legs from Motor Vehicle Accident

Medical records of an Iraqi civilian with bilateral Fractures to Lower Extremities; Broken legs from Motor Vehicle Accident (MVA). Medical conditions included, shattered legs and hurt shoulder. Medical treatment included, nailing of left and right tibia, and nailing of right femur. The medical records do not state how the gentleman received the MVA injuries, nor does it give any personal information on the gentleman.

Doc_type: 
Medical
Doc_date: 
Thursday, April 10, 2003
Doc_rel_date: 
Wednesday, June 15, 2005
Doc_text: 

NURSING
ADMISSION
NOTE

NURSING NOTES
CLINICAL RECORD
(Sign all notes)
HOURS OBSERVATIONS
DATE A.M. P.M. Include medication and treatment when indicated SERVICE:
ADMITTED TO: 58W FROM b)(3)-1 TIME ARRIVED: Re --AGE: SEX: 4,1
J DX: 611 4. e...1c pix I . eit,..t.... DUE TO: AVA-
PAST MEDICAL HX:

MEDICATIONS: kiNts46 DISPOSITION:
ALLERGIES: VALUABLES: DISPOSITION:
VS: B/P iP/.., TT:. 901 i tt P: CI ( R: Q.... 0 HT: WT:
trV I I
GENERAL APPEARANCE:

EENT: Ott, .- j.-&k . astr...9-6--05-kr4° -1) 436---&
NEUROLOGICAL:

Mpy.3 ( POPIWAr
RESPIRATORY:
CAA

CIRCULATORY: Litt
2-i- pu.(21..e-A "Jc0 0-.D.J1 ..9.4.*
URINARY:

if op,1 49. GI: m (A.
.t5h\re,
(n3W
MUSCULO/SK LETAL: (17t c....skAL ,,,ANs...ej 0,..4_44_ r D—
SKIN INTEGRITY: el. AO LOA rlSt`t LirC•reA-4)et .
COPING:

SUMMARY AND PLAN OF CARE: 0..k c _ .10 up__/ff (( ( .
1q15.1-t CtiNtk , +0 ri"5" 15-1- '
SIG NA T1JF 362 LfiVe DATE:t4fAAA TIME:
Continue on reverse side/
PATIENTS IDENTIFICATION (For typed or written entries give: Name - last, hist, REGISTER NO. WARD NO. middle, grade; date; hospital or medical facility)
NURSING NOTES
(b)(6)-4

Standard Form 510
General Services Administration and
Interagency Committee on Medical Records
FPMR 101-11.806-8—October 1975
510-109

MEDCOM - 5336

DOD 12548

IRWAY nasal / oral
IXYGEN
USES
NUG:

V SITES
IN/ SOLUTION'
Comments
Results:
ICI¦de —
TOTAL INTAKE
MEDICATIONS Morphine
-
Mefoxin Ancef Tel Tox Hypertet
;b)(3)-1

TICAL TREATMENT RECORD (continue
Incubate nasal / oral Face Mask @ 12 L / min size / site guaiac neg/pos dipstick blood neg / pos
SIZE

-/ AMT
AMT INFUSED

*1 49/4,11 c/ *2 *4 AMT INFUSED
BLOOD PRODUCTS
PERITONEAL LAVAGE

POSITIVE NEGATIVE
CC

Dose Route Time
zi,,w,.maw/Am
• - "(1.5 I OP /9 r. _
.
..
HOUR

DATE TRANSFERRED Time:
A.M. P.M.
;b)(6)-4
Initials
b)(6)-2 .•

mm lube @
OTHER
TREATMENTS
1.
Oxygen-. .

2.
Cricothyrotomy

37—Tracheotomy
*IWO
sure Dressings
6.
MAST

7.
Apply Hemostat

8.
Sutures

9.
Tourniquet

10.
Bandage

11.
Splint

12.
Cast

13.

14.

OUTPUT Chest Tube gig. Gastric if--
Foley

TOTAL OUTPUT
MEDICATIONS Dose
crn teeth / nares
Route Time Initials
,,(b)(6)-2
wwwIrgivoriffilMNIZEEMTA;
-
"1 .
":"MMIIMMIIIIIikEr:
-..-
,
,_

.
BURN
to OR ICU

WARD: 51"141,6 ,c4ew
ICU
CA
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MEDCOM - 5337
(Reverse)
* U. S.•GPO. 1987-161-
DOD 12549

....iirr6)(3)-1
CASUA
ABBREVIATED MEDICAL R •J
RECORD (Sign all notes) MMI¦••¦•••••¦¦•¦•¦.... TRIAGE CATEGORY jack.)
Immediate-1---Irtived on board USNS ComfortTime: t-?70
Pier OtherBoat MinimalAMBULATORY Expectant
Weight (lbs):

HEIGHT (ft In"):
STORY: A4i_r, PAI1 egqi 5 I • /64 ILk.4 it
LERGIES:
JRRENT MEDS:
tST ILLNESSES:
.ST MEAL: (Dale)
rents Preceding Injury:

B/P RESP RATE GCS CAP REFILL (preslabs
TIME TEMP PULSE
iTAL SIGNS
.4 2.-

OMISSION I IMPLIMPFLIMII

ISCHARGE jreact' e / ggish / fixed Glasgow Coma Score (GCS)
ggish / fixed uplls: = OR garde ens) lards ow)
A. Eye Ope Ing
Maio awl

II •• • • • U •• 110

To voi
LAB

• IURIES

Hb/Hct To pain A
*wuy Obalrtztion LTJ
t" 0 No

Lytes/ UN/Glue None 1
bool111 Sands " )
(Total "A")

ABG
'Itomordup

B. Verbal Responses
UA
Locorokin

Ta units
Puncoro

Corfu ed 4
Wound

Inappropriate words 3
Trauma, AmpulatIon

XRAY Incomprehensible • rds
Concussion

None
C-s Ina
Total "B" .

C R
10.

—Abdominal C. Motor Res
It. an

IVP
12. Fiscrrorb
ocalize .aln

Extremitv
IS

^e vis Withdraw (pain) 4
Fle (pain) 3 nsion (pain)
iy;r6yAirtrit
ne
DIAGNOSIS:
. Total *C"

' • _....41.1.L x
ever of Consciousness (LOC) (Cast One)
.12o
-Alert
. - Responds to Vocal Stimuli
P - Responds to Painful Stimuli
U - Unresponsiveness
Continue on reverse skle
I
'WARD NO:

REGiSTE11 NO.

PATIENTS IRENTIFICATION (for piped or written entries give: Name—lest, first, middle: grade;
:ID)(6)-4

ABBREVIATED MEDICAL REGI S TANDAEMAIL43 9
FIRMPL (II CFR) 20145.503
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MEDCOM - 5338
DOD 12550

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DOD 12556

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(b)(3)-1
24 Apr 2003@0846 Page 1 Personal Data - Privacy Act of 1974 (PL 93-579) Flowsheet Results For: 25 Mar 03 - 24 Apr 03
(b)(6)-2
Report requested by:

Collection 1 WBC # PLT CNT
Date.BLOOD BLOOD

I

10Apr03@1619
12Apr03@0535
13Apr03@0604

1928.
14Apr03@0502
15Apr03@0506
16Apr03@0505
17Apr03@0411
19Apr03@0552
24Apr03@0441

7.7 247

10.9 H 326

10.1 377

9.1 426

8.1 456 H

10.4
434

11.5
H 415

12.1
H 517 H

11.0
H 570.0 H

12.4
H 719.0 H

L=Abnormal Low.*=Critical Value.

H=Abnormal High.@=Requesting HCP Only
#= Multiple reference ranges used. The trend may be inaccurate.

*** END OF REPORT ***

(b)(6)-4 Reg #: '13)(6)-4
Loc: 5FP

10 Apr 2003 M

MEDCOM - 5352
(b)(3)-1
22 Apr ..„3@1850 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
PATIENT LAB INQUIRY
For: 18 Apr 03 - 22 Apr 03

:b)(6)-2
Report requested by:

b)(6) -4
(b)(6)-4(b)(6)-4
M/12d.Reg #:
Ph: Military Unit: UNKNOWN

22 Apr 03 @ 1723 (Coll). PLASMA PT.30. 2.(11.6-14.4).
, Seconds

b)(6)-2
Result Comment: NOTIFIED .AT 1832 ON 22APR03.
INR .

2.6

Interpretations:
The current recommended therapeutic range for INR is 2.0-3.0 for all
indications except prosthetic valves for which an INR 2.5-3.5 is
recommended (Chest 108(4):231S-2465; 1995). It should be recognized that
these are guidelines and adjustments may be required based on individual
patient risk factors. The INR is not useful for the first 7-10 days of
therapy.

21 Apr 03 @ 1720 (Coll). PLASMA
PT.22.9 H.
(11.6-14.4).

Seconds
INR .

2.0

Interpretations:
The current recommended therapeutic range for INR is 2.0-3.0 for all
indications except prosthetic valves for which an INR 2.5-3.5 is
recommended (Chest 108(4):2315-246S; 1995). It should be recognized that
these are guidelines and adjustments may be required based on individual
patient risk factors. The INR is not useful for the first 7-10 days of
therapy.

21 Apr 03 @ 0608 (Coll). PLASMA
PT.29.6 H.Seconds

.(11.6-14.4).Result Comment: NOTIFIED ENS (b)(6)-2 0757 ON 21APR03. INR .
2.5

Interpretations:
The current recommended therapeutic range for INR is 2.0-3.0 for all
indications except prosthetic valves for which an INR 2.5-3.5 is
recommended (Chest 108(4):231S-246S; 1995). It should be recognized that
these are guidelines and adjustments may be required based on individual
patient risk factors. The INR is not useful for the first 7-10 days of
therapy.

20 Apr 03 @ 2207 (Coll). PLASMA
PT.53.9..Seconds

H* (11.6-14.4).

Result Comment:
NOTIFIED DR.@ 2300
RESULTS VERI •.

REPEAT ANALYSIS. MVLUMALI
INR .13.5
Interpretations:
The current recommended therapeutic range for INR is 2.0-3.0 for all

L=Lo H=Hi *=Critical.

R=Resist S=Susc MS=Mod Susc I=Intermed
[]=Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult

.--=

MEDCOM - 5353
(b)(3)-1.

22 Apr ,...,03@1850 Page 2
Personal Data - Privacy Act of 1974 (PL 93-579)
PATIENT LAB INQUIRY
Fnr. 1R Anr .

-22 Apr 03

(b)(6)-2
Report requested by:

;b)(6)-4 (b)(6)-4 mn4
M/12d.Reg #:
Ph: Military Unit: UNKNOWN

.

20 Apr 03 @ 2207 (Coll). PLASMA

Interpretations: (Cont'd)
indications except prosthetic valves for which an INR 2.5-3.5 is
recommended (Chest 108(4):231S-246S; 1995). It should be recognized that
these are guidelines and adjustments may be required based on individual
patient risk factors. The INR is not useful for the first 7-10 days of
therapy.

.

20 Apr 03 @ 0048 (Coll) PLASMA
PT.26.4 H.
(11.6-14.4).

Seconds
Result Comment: .
NOTIFIED LCDRmn-2 .

0208.
RESULTS VERIFIED BY REPEAT ANALYSIS. MVLUMALI
INR .

3.7

Interpretations:
The current recommended therapeutic range for INR is 2.0-3.0 for all
indications except prosthetic valves for which an INR 2.5-3.5 is
recommended (Chest 108(4):231S-246S; 1995). It should be recognized that
these are guidelines and adjustments may be required based on individual
patient risk factors. The INR is not useful for the first 7-10 days of
therapy.

L=Lo H=Hi *=Critical.

R=Resist S=Susc MS=Mod Susc I=Intermed
D=Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult

MEDCOM -5354
13)(3)-1
19 Apr 4A3@1916 Page 1

Personal Data - Privacy Act of 1974 (PL 93-579)
PATIENT LAB INQUIRY
Fnr• 1R Anr 03 - 19 Apr 03

(b)(6)-2
Report requested by:

(b)(6)-4
MP-4

M/9d.Reg #:
Ph: Military Unit: UNKNOWN

.

19 Apr 03 @ 1020 (Coll) PLASMA
PT.67.8 '(11.6-14.4).

H*.
Seconds
Result Comment: RESULTS VERIFIED BY REPEAT ANALYSIS. Illk
INR .20.5

Interpretations:
The current recommended therapeutic range for INR is 2.0-3.0 for all
indications except prosthetic valves for which an INR 2.5-3.5 is
recommended (Chest 108(4):231S-246S; 1995). It should be recognized that
these are guidelines and adjustments may be required based on individual
patient risk factors. The INR is not useful for the first 7-10 days of
therapy.

19 Apr 03 @ 0552 (Coll). PLASMA
APTT.27.5.Seconds

(23.8-35.5).
PT.56.5 (11.6-14.4).

H*.
Seconds
Result Comment:
DIFFERENCE CHECK. RESULTS VERIFIED BY REPEAT ANALYSIS. MVLUMALI
INR .14.7

Interpretations:
The current recommended therapeutic range for INR is 2.0-3.0 for all
indications except prosthetic valves for which an INR 2.5-3.5 is
recommended (Chest 108(4):231S-246S; 1995). It should be recognized that
these are guidelines and adjustments may be required based on individual
patient risk factors. The INR is not useful for the first 7-10 days of
therapy.

19 Apr 03 @ 0552 (Coll) BLOOD
WBC .11.0 H (4.8-10.8) K/UL
RBC .2.6 L (4.7-6.1) 1X10 6/UL
HGB .8.2 L (14.0-18.0) g/dL
HCT .23.9 L (42-52) %
MCV .91.8 (80-94) fL
MCH .31.5 (27-32) pg
MCHC.34.3 (31-37) g/dL
RDW .17.0 H (12-14) %
PLT CNT .570.0 H (150-450) lx10 3/UL
MPV .6.9 L (7.4-10.4) FL
NEUT/100 WBC .69.5 %
NEUT% .7.6 1x10 3/UL
LYMPHS/100 WBC.17.4 %
LY# .1.9 lx10 3/UL
MONO/100 WBC .13.1 %
MONO% .1.4 1X10 3/UL

R=Resist S=Susc MS=Mod Susc I=Intermed
[]=Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult '

L=Lo H=Hi *=Critical.

MEDCOM - 5355
MPH

19 Apr ,...)03G1916 Page 2

Personal Data - Privacy Act of 1974 (PL 93-579)
PATIENT LAB INQUIRY
Pnr. 1R am 113 19 Apr 03

M(6)-2 -

Report requested by: i.

(b)(6)-4 (b)(6)-4 M(60
M/9d.Reg #:
Ph: Military Unit: UNKNOWN

19 Apr 03 @ 0552 (Coll) BLOOD
ANISOCYTOSIS .1+
POIKILOCYTOSIS .SLIGHT
MACROCYTES .1+
SCHISTOCYTES .SLIGHT
SPHEROCYTES .SLIGHT
STOMATOCYTES .SLIGHT
TARGET CELLS.1+

18 Apr 03 G 0506 (Coll). PLASMA
APTT.26.6.Seconds

(23.8-35.5).
PT.18.9 H.
(11.6-14.4).

Seconds
INR .

2.0

Interpretations:
The current recommended therapeutic range for INR is 2.0-3.0 for all
indications except prosthetic valves for which an INR 2.5-3.5 is
recommended (Chest 108(4):231S-246S; 1995). It should be recognized that
these are guidelines and adjustments may be required based on individual
patient risk factors. The INR is not useful for the first 7-10 days of
therapy.

R=Resist S=Susc MS=Mod Susc I=Intermed
[]=Uncert /A=Amended Comments= (0)rder, (I)nterpretations, (R)esult

L=Lo H=Hi *=Critical.

MEDCOM - 5356
2 ,/
(b)(3)-1

16 Apr 2003@0756.

Page 1

Personal Data - Privacy Act of 1974.

(PL 93-579)
PATIENT LAB INQUIRY
For:.- 16 Apr 03

17 Mar 03.

(b)(6)-2
1..-port requested by:

M(6)-4 M(6)-4 M(6)-4
M/6d Reg #: Ph: Military Unit: UNKNOWN
(Coll)
WBC .11.5.(4.8-10.8) K/UL
RBC .2.6.(4.7-6.1) 1X10 6/UL
HGB .8.0.(14.0-18.0) g/dL
HCT .23.6.(42-52)
MCV .92.3.(80-94) fL
MCH .31.3.(27-32)

16 Apr 03 @ 0505.BLOOD

pg

MCHC .33.9.(31-37) g/dL RDW .15.0.(12-14) PLT CNT .415 (150-450) lx10 3/UL MPV .7.2.(7.4-10.4) FL NEUT/100 WBC .71.1 NEUT% .8.2 lx10 3/UL LYMPHS/100 WBC.18.4 LY# .2.1 lx10 3/UL MONO/100 WBC .10.5 MO# .1.2 lx10 3/UL E0# .0.7 lx10 3/UL BAS# _ 0.2 1x10 3/UL
*=Critical R=Resist.MS=Mod Susc

L=Lo H=Hi.
S=Susc.I=Intermed

MEDCOM - 5357
MP-1 15 Apr 2003@0911 Page 1
Personal Data - Privacy Act of 1974 (PL 93-579)
PATIENT LAB INQUIRY

For: .

Mar 03 - 15 Apr 03

b)(6)-2
Report requested by: .

(b)(6)-4 (b)(6)-4
(b)(6)-4

M/5d.Reg #:
Ph: Military Unit: UNKNOWN

15 Apr 03 @ 0506 (Coll) BLOOD
WBC .4,0.4 • (4.8-10.8).

K/UL RBC .\d° 2 . 1 (4.7-6.1).
L 1X10 6/UL HGB 141‘,,,6.7 L*.
g/dL
(14.0-18.0).
Result Comment: ENSIGN :filOTIFIED @0651
HCT .09.6 L*.
(42-52).%
Result Comment: ENSIGN 44IIMP NOTIFIED @0651

MCV .92.0 (80-94).fL
MCH .31.2 (27-32).pg
MCHC.33.9 (31-37).g/dL
RDW .15.5 H (12-14).%

PLT CNT .434 (150-450).lx10 3/UL
MPV .7.8 (7.4-10.4).

FL

NEUT/100 WBC .73.6 %
NEUT% .7.7 lx10 3/UL
LYMPHS/100 WBC .16.4

LY# .1.7 1x10 3/UL
MONO/100 WBC.10.0 %
M0# .1.0 1x10 3/UL
E0# .0.7 1x10 3/UL
BAS#.0.2 lx10 3/UL

15 Apr 03 @ 0506 (Coll)

SERUM

NA+ .128 L (137-145) mmol/L K .4.2 (3.6-5.0) mmol/L CL-.100 (97-107) mmol/L CO2 .30 (22-31) mmol/L BUN .9 (9-21) mg/dL GLUCOSE .119 H (76-110) mg/dL
CREAT .0.7 L (0.8-1.5) mg/dL

L=Lo *=Critical R=Resict s=clicr MS.Mnd susc

H=Hi.
I=Intermed

MEDCOM -5358
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(b)(3)-1
Name: ,
CHCS Name (b)(6)-4
(b)(6)-4 Iraqi civilian Date of Admission: 4/10/2003
Prognosis: Good_ Date of Transfer:

History: MVA,
Hospital Course: Pateint addmitted after MVA underwent initial I&D of wounds. Subsequently underwent IM nailing of bilateral Tibias followed by the IM nailing of right femur. Patient is cuurently in rehab portion of recovery.,

Diagnoses:
Right subtrochanteric femur; Right open tibia; left closed tibia
Surgeries/Treatmen IM nailing of right tibia; IM nailing of left tbia; IM nailing of right Femur

Recommendations:
Will need crutch training. Partial weight bearing right lower extremity
SpecialNeeds:
Physician:
(b)(6)-2
LCDR Dept of Orthopedics_ 5/3/2003
MEDCOM - 5363
DOD 12575

:b)(3)-1
(b)(6)-4 Date of Admission: 4/10/2003
CHCS Narrie: Date of Transfer:
(b)(6)-4 EPW Age: Gender: M
History:
MVA,

Hospital Course:
Pateint addmitted after MVA underwent initial I&D of wounds. Suliseguently underwent IM nailing of bilateral Tibias followed by the IM nailing of right femur. Patient4e.critire-nryirr rehab portion of recovery.

Diagnoses:
Right subtrochanteric femur, Right open tibia, left closed tibia

Surgerlesffreatment:
IM nailing of right tibia, IM nailing of left tbia, IM nailing of right Femur
Recommendations:
Will need crutch training. Partial weight bearing right lower extremity
Special Needs:

Prognosis: Good
(b)(6)-2
Physician: LCDR Dept of Orthopedics
4/24/2003
MEDCOM -5364
DOD 12576

(b)(3)-1

MEDICAL TREATMENT FACILITY
:b)(3 )-1 LIFT OF OPPORTUNITY
SOCIAL SECURITY NUMBER1AME (LAST. FIRST, MIDDLE)
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ENLISTED BIRTH DATE SEX
LANKTATE OFFICERS ONLY DESIG NOBC NEC SHIP HOMEPORTMANCH OF SERVICE NAMED AND ADDRESS OF PARENT MILITARY COMMAND
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MARITAL IS SPOUSE STATUS ACTIVE DUTY DEPENDENTS IIC BLOOD TYPE RELIGIOUS PREFERENCE
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RIM&
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(b)(6) -2
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MEDCOM - 5365
DOD 12577

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Doc_nid: 
3552
Doc_type_num: 
72