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

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
— ,016,4i-Ve aui43fol) 0A-0,12 -e/xcum 2. ° tot o
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PATIENT'S IDENTIFICATION (Far-typed or written entries give:Name — last, first, middle, Medical Facility ) LOCATION OF MEDICAL RECORDS
(b)(6)-4
LOCATION OF RADIOLOGIC FACILITY
SIGNATURE
NfiT)*IK-
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.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER LIST TIME ORDER NOTED AND
Lg-9-`9b HOURS SIGN
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PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
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PATIENT IDENTIFICATION DATE OF FibER TIME OF ORDER
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REPLACES EDITION OF 1 JUL 77, WHICH MAY BE USED.
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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.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER LlerrIVE ORDER NOTED AND
1 1 "/ '-'10 HOURS
SIGN
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FORM

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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
ORDER

;b)(6)-4
NOTED AND HOURS
30017tg.4 zoo3 0

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NURSING UNIT ROOM NO. BED NO.
PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
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HOURS
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PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
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REPLACES EDITION OF 1 JUL 77, WHICH MAY BE
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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.
'LIST TIME ORDER (b)(6)-4
PATIENT IDENTIF CATION DATE OF ORDER TIME OF ORDER
NOTED AND
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PATIENT IDENTIFICATION DATE OF ORDER TIME OF ORDER
HOURS
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PATIENT IDENTIFICATION DATEE 0 TIME OF ORDS
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PATIENT IDENTIFICATION
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NURSING UNIT ROOM NO. BED NO.
REPLACES EDITION OF 1 JUL 77. WHICH MAY BE USED.

DA F4256
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MEDCOM - 6028

DOD 13240

... THERAPEUTIC DOCUMENTAT1ON.CAREPLAN:(MEDICATIONS)
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
ORDER CLERK/ RECURRING hit DICA TINS, HR DATE DISPENSED
DATE NURSE DOSE, FREQUENCY
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ALL ERGIES-ED YES No
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PATIENT IDENTIFICATION
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DA 1 FEB79 4678
PRIMARY DIAGNOSIS.
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DISPENSING TIMES USE PENCIL, CI RCL E 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
EDITION OF 1 DEC 77 WILL BE USED UNTIL EXHAUSTED.
MEDCOM -6029

DOD 13241

Verify by THERAPEUTIC DOCUMENTATION CARE PLAN Initialing (MEDI CA TIONS) mo. Plig //frit y
0
I

Order Clerk/ Dote to Time to
SINGLE ORDER, PRE-OPERATIVES
Date Nurse Time Given Initials
be Given be Given
Order/ INITIAL
PROPER COLUMN 'FOLLOWING ADMINISTRATION
Clerk/ PRN

Expir
Nurse MEDICATION, DOSE, FREQUENCY
Dote TIME/DATE DISPENSED
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U.S. GPO: 1998464-11095216
imEE1r!rm_g_._6a30,

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
. , DATE DISPENSED
ORDER CLERK/ RECURRING MEDICATIONS, H.R.
DATE NURSE DOSE, FREQUENCY

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AGE NO
PATIENT IDENTIFICATION;

rb)(3)-1 DISPENSING TIMES

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
EDIT! F 1 npr 77 Wll I RF liern ilkiTi I EXE AUSTED.
DA ,FFIr49 4678
MEDCOM - 6031

DOD 13243

Verify by

o..eRAPEUTIC DOCUMENTATION CARE PLAN
Initialing (MEDICATIONS) Mo• /he-cyr 03
Order Clerk/
Dote to

Time to
SINGLE ORDER, PRE-OPERATIVES Time Given Initials
Date Nurse

be Given be Given
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Date

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MEDCOM - 6032

DOD 13244
THERAPEUTIC DOCUMENTATION CARE PLAN (MEDICATIONS)
CLINICAL RECORD For use of thIs form, see ATI 40-407:
MO D (A' D_r.
,0..the propenneRencv is the Office of The Sermon General.

VERIFY BY INITIALING anniagi: ',''''',.??":::'"'7..v.ik,AM1 INITIAL PROPER COLUMN FOLLOWING EACH ADMINISTRATION
HR DATE DISPENSED

ORDER CLERK! RECURRING MEDICATIONS,
DATE NURSE DOSE. FREQUENCY

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ALLERGIES:0III YES MI ND PRIMARY DIAGNOSIS ADDITIONAL PAGES IN USE
Eil YES0Ell NO
r M ta (DSW 40 • C a ( aP PAGE NO.
PATIENT IDENTIFICATION:0 s
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DISPENSING TIMES
103)(6)-4
USE PENCIL. CIRCLE MED TIMES
V 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
78, 1 FEB 7 EDITION OF L GEC 77 WILL BE USED UMW EXHAUSTED. 0 USAPA V1.00
MEDCOM - 6033

DOD 13245

verity ny
THERAPEUTIC DOCUMENTATION CARE PLAN
Initialing

(MEDICATIONS)

mo..Yr Order Clerk/ Date Nurse SINGLE ORDER PRE.OPERATIVES Data to Time to
Time Given Initial; —be1"n—le Given
Order/
Clerk( PRN

hpir .,
INITIAL PROPER COLUMN FOLLOWING ADMINISTRATION
Date NUM MEDICATION, DOSE, FREQUENCY 1 (lip ' b)(8)-2 . TIME/DATE DISPENSED
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USAPA 51.00
MEDCOM - 6034

DOD 13246
M RECORD - SUPLEMENTAL MEDIC A
n-use of this form, see AR 40-66; the props. _Amoy is the OfTice of the Surgeon General
,17

EPORT TITLE artG APROVED Pow
TRAUMA FLOWSHEET
INITIAL ASSESSMENT . I 0 IMMEDIATE fl DELAYED CI MINIMAL

ate: 10 CI-10N, r-cm Arrived Time: IA -D"C F Age: Wt•
Ilergies: Tetanus Status: UTD Unknown
last Meal:

hief Complaint:
vfH: Mediations:
reatments PTA:
ITAL SIGNS 1 I a p..—c BP: t P: RR: E v kf\c-\ TEMP: SAO2: C\,&,
NEST.•:-.;: SKIN .A DOMEN .
RALTMA .YEsON0 Ow ARM . SOFT PERRL . YES . NO R mm
AIN DYES ONO . DRY . DISTENDED GLASCOW SCORE:
JD O TEs Lr] t4C, Lr-3 PALE . TP.5DER

0 DUSKY BOWEL SOUNDS r''
UNG SOUNDS • 3411
4. 5 6 • 8 9

. MOIST D YES NO
S L CLEAR
GUI AC TEST
] . NSE
. WHEEZES 1:3 POS .NEC) i
DECREASED To Voice Confused
. -5
To Pain - 2 Inappropriate

. ABSENT
Incomprehensible-2 Flexion .3
-None - 1

None -kronen
7' 1

3 DISTAL PULSES RT X 20LT X 2 A. Abrastn MOVES aTREVETIES AP . A:mum=
X4 AV. Avu:sion I NO EDEMA B • Burn I NO DEFORMITIES C • Censexo
D. Defokro..-y
XCEPTIONS TO..
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OF • Ow Fracu e ARAMETERS:: CF • Used Fracure G • GSW. fiSies)
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2: LPM NC MASK ORAL AIRWAY • Lacsmicn FW • Parise Wean
NASAL AIRWAY S • Slab Ware
IONTIORD Y ON EKGEYN
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IG TUBE # OLEY: # DPL . POS . NEG TEST TUBE ER CM H20 FRONT BACK
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(Continue eel rrverze) REPARED BY (Signanire & Title) moo A D 111, AMI.TT " rE/Cu-Nic
DATE
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ATTENT'S IDENTIFICATION (For typed or written
. HISTORY/PHYSICAL . FLOW CHART
tries give: Name - last: first:
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'spilt,' or medical facility)
. (7THER EXAMINATION . OTHER (Specify) CR EVALUATION
0 DIAGNOSTIC STUDIES
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IDTREATMENT

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DOD 13247

i CLINICAL RECORD 1 nertArtu 11U IZMOUMENTATION•CARE PLAN,(MEDICATIONS)
For Om of this for_ ...

in goo AR 40-407ro e Is the Ottleioof Trio Surpoon Gone/wt.. Yr,
the pponent or : Mo.c
vER/PY BY OVITTAUNG c

1,77741q3119)!Ott:61.009.-PO4010111O'EXOR ADMEOSTRA .MI41 ORDER CLERK/ RECURRING MEDICATIONS, HR DATE DISP ENS DDATE NURSE DOSE, FREQUENCY
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ATIEN . • . DISPENSING TIMES _
USE PENCIL. CIRCLE MED TIMES
D 7 8 9 10 11 12 13 14
E 15 16 17 18 19 20 21 22
......._ P4 01 14 01 02 03 04 05 M
EDITION OF I no
DOD 1324E

1l 1,0.,DICAL RECORD ICU FLOWSHEET
-

SECTION I PATIENT ASSESSMENT DATA
-
b)(6)-4

PATIENT NAME: DATE: qi--7 -e) -5 DIAGNOSIS: ' PATIENT ACUITY: HOSPITAL DAY: POST OP DAY:
TIME: i? 6 0 6t-060 ;it AZ— 73 24 Or C) 7-03 ,,)--( c)-( 6e BP ARTERIAL LINE
Respiratory Treatment Key: HEN t­-Hand-held nebulizer MU= Metered-dose inhaler CPT = Chest physiotherapy IS= Incentive snirometcr

TIME:

/700 An 00 ?,i GO IL L3 zL( a/ 0 7--03 0Z/ 0 r c? 6, / a i00 la ,‘19 ia/100 ',(et) 429M t -/°A6 i) 1'4).YW "I)/801) 11M-ildec'' Xsoo 1 11,4
f

PO
TOTALS
URINE /7 5---- /5
. ...
STOOL
TOTALS
Page 1 of 4
MEDCOM -6037
DOD 13249

BP CUFF P/6*, 4 ,(z-4.
MAP
TEMPERATURE fa, , i1 j' I

i'-'

PULSE E5 /CO
RESPIRATIONS

;Z(0 34' ZB
PULSE OXIMETER

e) 77 /Z.-F z-
cvp ,3 ip-, f-Az
1-24e,,et _.

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PAIN (0-10) feacv,

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j,4450/64p0-t-,
OXYGEN (L/%) Y L. i i // i, til---Y L
02 METHOD PIM " /c // tilieik
VENT SETTINGS:

1
F102

MODE
1

TV
RATE
PEEP

PS -',
1
Respiratory Treatments

---[ Oxygen Method Key: NC = Nasal cannula NR= Non-rebrtather FM = Face mask VM = Venturi mask V = Venflator TC ¢ Trach collar
—F 0
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SECTION I - PATIENT ASSESSMENT DATA

PATIENT NAME: b)(6)-4 DATE: q-7 -o. PliNkS
TIME: BP ARTERIAL LINE 67 10, 63.. oil / 0 / / /3 /Y /5— /7 /&)
I BP CUFF "1-W
T MAP
L TEMPERATURE WV
S G N S PULSE RESPIRATIONS PULSE OXIMETER CVP fat 4*A9° V/.

PAIN (0 - 10)
OXYGEN (L/%)
ii L
02 METHOD (41L VENT SETTINGS:
F102
MODE
TV
_J
RATE
PEEP
PS
Respiratory Treatments

24 HOUR I & 0: TOTAL IN TOTAL OUT
TIME:

d7 a3. Dif /0 ( I (4._ 1,3
1 N T _
A K E PO
TOTALS
URINE
OD

0 U
.-

T P U T STOOL
TOTALS

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
/' c I _
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Page 3 of 4
M EDCOM - 6039

DOD 13251

,
ICAL RECORD - ICU FLOWSHEI

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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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Page 4 of 4
DOD 13252

MEDCOM - 6040

Doc_nid: 
3573
Doc_type_num: 
72