Medical Report: Iraqi Male Detainee, Baghdad, Iraq re: Gunshot Wounds to Abdomen

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Medical report of Iraqi detainee, including a Radiological report. Medical conditions included, gunshot wound to the abdomen.

Doc_type: 
Medical
Doc_date: 
Sunday, March 30, 2003
Doc_rel_date: 
Wednesday, June 15, 2005
Doc_text: 

NON 7540-01-165-7294 Sor
519-30
RADIOLOG IC CONSULTATION REQUEST/REPORT
(Radiology/Nuclear Medicine/Ultrasound/Computed Tomography Examinations)
EXAMINATION(S) REQUESTED AGE SEX WARD/CLINIC
SSN (Sponsor) REGISTER NO.
FILM NO. PREGNANT
111 YES El NO
REQUESTED BY (Print) TELEPHONE/PAGE NO.
I,r-4-abh) kW
?? REQUESTOR DATE REQUESTED
SIGNATURE OF
SPECIFIC REASON(S) FOR REQUEST (Complaints and findings)

ca-g.04/VU-.0; 5.,ip 65K) -10 abd C orectrA7
hr.)
DATE OF EXAMINATION (Month, day. year) DATE OF REPORT (Month, day, year) DATE OF TRANSCRIPTION (Month, day, year)
-r
Arri
RADIOLOGIC REPORT
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LOCATION OF RADIOLOGIC FACILITY
SIGNATURE
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MEDCOM - 6024-• STANDARD FORM 519-B (8.83Prescribed by GSA/ICMRFPMR (41 CFRI 101-11.806-8

DOD 13236

CLINICAL RECORD - DOCTOR'S ORDERS
For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORO DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
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MEDCOM - 6025
DOD 13237
CLINICAL RECORD -DOCTOR'S ORDERS
For use of this form, see AR 40.66, the proponent agency is OTSG

THE DOCTOR SHALL RECORD DATE. TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED, WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
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MEDCOM - 6026
DOD 13238

CLINICAL RECORD • DOCTOR'S ORDERS For use of this form, see AR 40-66, the proponent agency is OTSG
THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD
SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.

PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER LIST TIME
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MEDCOM -6027

DOD 13239

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

THE DOCTOR SHALL RECORD DATE, TIME AND SIGN EACH SET OF ORDERS. IF PROBLEM ORIENTED MEDICAL RECORD SYSTEM IS USED. WRITE PROBLEM NUMBER IN COLUMN INDICATED BY ARROW BELOW.
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MEDCOM - 6028

DOD 13240

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CLINICAL RECORD For use of W. fOrm, saii.Ali 40407; . -Mo./4'Yr. 0,1
the proponent agency Is the Office of The Surgeon General.

VERIFY BY INITIALING . INITIAL PROPER COLIIMIV FOLLOWING EACH ADMINISTRATION
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MEDCOM -6029

DOD 13241

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DOD 13242

THERAPEUTIC OCICUMENTATIONCAREPLAti (MEDICATIONS)
CLINICAL RECORD For use of this forrn, see AR 40-407; MO. 3 Irr.C_23„,the proponent erne is the Office of The Surgeon General.
VERIFY BY INITIALING INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
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USE PFNCIL. CIRCLE MED TIMES D 7 8 9 10 11 12 13 14 E 15 16 17 18 19 20 21 22 N 23 24 01 02 03 04 05 06
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MEDCOM - 6031

DOD 13243

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MEDCOM - 6032

DOD 13244
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HR DATE DISPENSED

ORDER CLERK! RECURRING MEDICATIONS,
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MEDCOM - 6033

DOD 13245

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DOD 13246
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TRAUMA FLOWSHEET
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DOD 13247

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DOD 1324E

1l 1,0.,DICAL RECORD ICU FLOWSHEET
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SECTION I PATIENT ASSESSMENT DATA
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TIME: i? 6 0 6t-060 ;it AZ— 73 24 Or C) 7-03 ,,)--( c)-( 6e BP ARTERIAL LINE
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MEDCOM -6037
DOD 13249

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Page 2 of 4
MEDCOM -6038

DOD 13250

MEDICAL RECORD -ICU FLOWSHEE 1' SECTION I - PATIENT ASSESSMENT DATA
f b)(6)-4

IPATIENT NA ME:s DATE: (.? - 7 - /7.; IV SITE ASSESSMENT:
LEGEND: WNL = NO REDNESS/SWELLING/OTHER S/S INFILTRATION/INFECTION R = REDDENED P = PUFFY I - INFILTRATED CL = CENTRAL LINE
LOCATION CONDITION _ LOCATION CONDITION
I„, SITE # 1
IV SITE # 2

IV SITE # 1 G)livd-a , bud cril.e..04be I ) 6.-) AC-ealffat'
IV SITE # 2
IV SITE # 3 IV SITE # 3

TIME INITI4LS
6-"Yre) b)(6) -2
IV PATENCY CHECKED /faz.9_`7,7-4/ IV PATENCY CHECKED
IV SITE CARE PROVIDED IV SITE CARE PROVIDED
IV TUBING CHANGED IV TUBING CHANGED
COMMENTS: COMMENTS:

AM STRIP
,e At ye,y

PM STRIP0
0b)(6)-2

/;6"„, SECTION III - SHIFT NOTES
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Page 3 of 4
M EDCOM - 6039

DOD 13251

,
ICAL RECORD - ICU FLOWSHEI

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.;F -

i
b)(6)-40

PATIENT NAME:
NEUROLOGICAL
Alert and Oriented to time, place and name;
Responds appropriately; Communication is
adequate to express needs; Pupils equal and
reactive to light.

CARDIOVASCULAR Age appropriate Rate, Rhythm, and Pulses;Capillary refill 3 sec; No dependent edema. Nailbeds and mucous membranes pink. No calf tenderness. Pressure monitoring
PULMONARY Respirations within normal limits for age; Breath sounds quiet and regular; Depth is regular; No dyspnea; No cough; Suction; Secretions; Oxygen; Err; Trach
C.I.
Abdomen soft and non-distended; Bowel
sounds active in all quadrants; No difficulty
chewing or swallowing; No abdominal pain;
Frequency and type of stool; Na diarrhea;
No constipation; No NN; NG Tube
placement; Type of secretions

G.U.
Voiding; Catheters; Urine clear yellow/amber
No odor, discharge, frequency, urgency,
nocturia

MUSCULOSKELETAL: Normal muscle mass and development for age; No deformities; No assistive devices needed; Normal movement and tone; Normal active ROM without pain; No joint swelling, tenderness, weakness, or paresthesia
SKIN
Color; warm; dry; intact; Turgor; No Wounds; lesions; rashes, inflnmmation, ulcers, breaks in skin; No redness, blanching, irritation, over bony prominences; Mucous membranes moist; Wounds —location, condition, drainage, dressing
PAIN No complaints of pain/discomfort; Note Location; Duration; Intensity
PSYCHOSOCIAL: Behavior is appropriate to the situation; Anxiety is controlled or mild and appropriate to the situation; Interacts appropriately with others
DATE:
TIME: /7 Y) INITIALS:70W
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TIME: n6L.z.). 1NITIA
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Page 4 of 4
DOD 13252

MEDCOM - 6040

Doc_nid: 
3573
Doc_type_num: 
72