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

zt /
..
Alo ( ()..?
PAGE 2 OF 4
oftDX
7r-E7OVI?
HOSPI L D
a•
TIME Int-12
ma.1/
BP Arterial line
gullisugam"atians'
BP Cuff Temperature Pulse
:
11111.(i3 111111.
Respiratory Rate
LI
1111103' 'MU 5r3"01 (3c6°1 1U1130 30
11

,
e 111190 --95-1111111L5 ?pet -Loll t
g EZEI n-.II I M too A,
Li. a e,
MIE1111111111111111111111111111111M.MEM
11111.
.'_.
TIME
reatird1774 1,65 be 7.71ffiLl
F
7Wi's 'SIEZZI 8°T
vP 5s6
L411•I IIN/Z
1A-to-iitatits 6 S
MIMI f 0
e 1
1/ 110 t)

111111811MNCI
Ve.c.at ow. it
Li '4
Mrdli1111111111 IMMIERIENIUMMIll
VI SO
UMNIMMILII.MI tv2-
Leo WialiAlqb tle 110 Eiriti.LE
_7 F -MIMElb 14 It) ORM i•.El ,Q6 e— ITIMMEMINIMMEMII.iir
IIIIIIIIIIIIIII.1211111111111111 6%
TOTALS
6 4
MIMI to AMIE
i/

EILTMAINFAMW "
URINE •
SP gr
S/A
OUTPUT

acca

NG PH
GUIAC
EMESIS STOOL
418Po;
84a P70
DRAINS
TOTALS
MEDCOM -23841
•

PAGE 3 OF 4
POST-OP DA
ACUITY LEVEL CLASSIFICATION
P-17/ / 54
e ,26 ,2-1.,2'S
PARIMErtangli

1111111
70 a. MI
IIMEMMESSIMEI

Zr`l
ir tsr 5/
1-11
6 qc R14 0 V 9,i
rararatinnons

',
Simq 3/-At
.143-
fa 413- 1-9— 20 -21 MIESEI
co Illomm=11111111ai
10
to 1A). MINIM
9
1e
YfFY-
e. t-P= (-40
EMI Lu it) MEV
TIME jic rizo it4

, rg ,F. 0 ,
kny
S s

MODE PRINIMPIE ,
FIO 2
vo
°Po

718^ El-
(fp Vto 62-b

RATE 3r, 3o
3z1 1^.) PEEP 5 is-1" t
BEM

A pH ').,0,./1 I-)-3
NMI

PCO2
53.1 qi-1"(V-

PO 2 4c, t, C0-1"
HCO, N I )4) MEM

SAT gl
BASE

-11,,.
—

TIM E sip
CLUCOSE

iN9

Na/K
CWOO 2

AGIMPSIII2V
BUN/Cr
AISIMPAMIMI
1NBC/PLATELET
'..1111MIERIMV
0

Hct/Hgb
0,3
TIME
TIME 63.°

MOUTH CARE BATCH SKIN CARE
FOLEY CARE TRACH CARE ROM EXERCISES
1:161 AIIPE
MEDCOM - 23842
DOD-037420

PAGE 1 OF 4
MEDICAL RECORD—SUPPLEMENTAL MEDICAL DATA
For use of this torn'', see AR 40-66; the proponent agency is the Office of The Surgeon General REPORT TITLE OTSG APPROVED (Date)INTENSIVE CARE NURSING FLOW SHEET QA Appr 8 Mar 89
SSESSM
TIME MMAL YO mamis mnmis
PUPILS
SENSORIUM
5'0 cc .° Ve/Tecc

RESPIRATORY PATTERN BREATH SOUNDS SECRETIONS
-15 "RI) 60 Tv s-operee-P" r
INTEGRITY
LOCATiON rammomme ,ruicia 7: C CONDITION
• . dEL. ero rfNtt -c001/34-e -,py
-
r

r.1

ABDOMEN BOWEL SOUNDS
,URINE: COLOFt/CLARITY •
CARDIAC RHYTHM
ICP • Intracranial Pressure S/A - Fractional PCO2 - Pressure of Arterial CO2 SA1 • Satuiation PEEP, Positive End Expiratory Pressure 1 RACti - if atheOstOlny
MENT/SERVICE/CUNIC DATE

16NOVoc63
written tr or medical ility)
0 HISTORY/PHYSICAL El FLOW CHART
El OTHER EXAMINATION

El OTHER (Specify)OR EVALUATION
DIAGNOSTIC STUDIES
TREATMENT

\D. (61
1 TAT 47 8
DA 4700 -MEDDAC FBg OP 375, I Apr 90 (HSXC—NUI
Proponent: Dept of Nurs MEDCOM - 23843
DOD-037421

1 011101r1
PAGE 2 Or 4

DA TE ' DX
HOSPITAL DAY

EMI
6
TIME 11 18111,11111111111511111M1110 1311
BP Arterial Line
inV10117. "' LVIIIIIENIMMEINEMEMPAMOM
BP Cuff
101.101111111111111111.1111111111111111111111 111111111111111111111
Temperature
MUM
EMIIIIIIIIIII11110111%111a1111
Pulse
MEM PI c cic 91- EligrinlialIER \-1
Respiratory Rate
AMINIENEMIBMINIIMICIESE1111131ffiril Ce4111,1111171/60 bo oD QI.E1111111qD IESUFH1 cia 8-s- •
.111111MAIMINIII S s.milM111111 5 11111 s 1111111EMPINI
115117 HEIWZIFT11111111
J5

pf5P EIBINENEINNIIKINt
,t(i9

C_ af6 atik 01,1
Dz, 8° T
TIME ri .00Dst) Ofsk) mak _ivis
aeu mem -go°
Iv svensomirmermummans maw
r
gam manarii
116 ire ID p 10 -IV Am"8f4 ID /0 =MI h
()
1 (v) 14:5M1151 ID 10 aim
miminnoramilrfflrel (30 (00 11111101111
WIAU1111111
111111111111ME
tsktit-retm,
LASN
TOTALS
HOUR ;46 IdAAGA
URINE
IXO
5/A
OUT PUT Pc•-
ib•

NG -
GU1AC EMESIS STOOL
OFtAl N S
TOTALS
MEDCOM - 23844
POST.OP DAV
z, 03 0 og-
EGILMItlEAREMIRWS
1111111111111111111111111111111111

110111M11111111
[AS PUNIIIIM ix°
EgiNEMBIE12/

runicturnmairm

rorirun Ivo , 11111711
1121PANEMENMEMIE

RI 7D EMI 1511
E1110111911EMIEMMIFill
1211211MBEINIE11611

111111111111111111.11

VAIRMITAVAINIII

Mt /60
PAGE 3 OF 4
ACUITY LEVEL CLASSIFKATiON
TIME
1th 1.014 12,,1 ISov

MODE
RATE
'PEEP
1,02
HCO3 SAT
-X.OZ
GL UCOSE
o0
d

too,°1 90% rarrammm
7,5?)

immumumms

numummium

IS

FB1111111111111111111111111111

S11111•111111111•11111111111
1,1111111111111111111111111111

-13

II I III
EFISMIMIEMISPI

BUN/Cr
Filla1FANIMIUMINEI VAPAPSIMEA1151161111

WBC/PLATE LET

0111.6111111MMIN nc, 152811M1110111 ¦011/2
HctlFi gb
FIMEGWAIAIMMIN 9.4 alliriMPRIMPAIL1

RILIIIMMIPAIPArEkt-0 111111111111111111111111111111

isituffordmatium WASPAPIRTM11111 t,o TIME
goy

WaraffaMFACATML1 r° 176%161111111111
MOUTH CARE
=MIN IMAITIMMO
SKIN CARE
11111111
FOLEY CARE
EIBIATIVINFISTI BATH
TRACH CARE
Nummum R
ME MEM

ROM EXERCISES

Nummummal...
isranwei 0 1111111111111111111

Iv)
.••• • • . . ....
wt Yesterday wt Today
IV INTAKE OUTPUT "7"it
Urine:

111111.1all VO
11.11.1.11111111111

ir ARKIINSI
111 1.111 TOTAL -233.7 TOTAL Rite? 4-6—rr3 BALANCE
MEDCOM - 23845 •
EYESOPE N
go.koGicAkAss.Esmpq
HOURS
11'
SPOP4TANEOuSL Y 4 TO SPEECH
3 TO PAiN 2 NO EYE OPENING I
•_, OMEN TEO
ccw' CONFUSED Lt.°
vERBALILES 3 vOCALIZES 2
Ct.
La=
NO VOCAL IZA FION
OBEYS
COMMANDS
I OCALIZES PAIN
cc
1.1 XION ""Z WITHDRAWAL °O
22. ABNORMAL
tr.
FIEXION
vt,"
E. TE NSiON 10 PAIN
NO MOTOR Pit SPONSE 03
NORMAL POWER
MILD WEAKNESS
11V E RE WEAKNESS
cc
ABNORMAL FLEXION ABNORMAL EX TE NStON NO RESPONSE
NORIAAE POWER
MILD WEAKNESS
.
SEVERE WEAKNESS
t2
ABNORMAL FLEXION . , ABNORMAL EX TENSAON.
NO RESPONSE
.
),)
; SIZE
RIGHT.
REACTiON -r
P 17-
SIZE giC
LEFT
REACTION
-r

• 3 . 6 • 7 mm
PUPIL SCALE • 2
ICP CEREBRAL PERFUSION PRESSURE
.LARASUSS
HOURS
•r#1151551/115§117111KIVAVA

INIMVAIJOINIINNANSPAPIE45

111/511114PIONNINPANIPINNOVIN

•
NOVANNPANINERIP/OFINNUIP/

•
save liANFAMENINIVA

PAGE 4 OP 4
•-
LEGEND
C Closed by swelling
T TrachiEndc S Slurring D Dysphasia R Receptive E Expressive
R Right
L Left
Reccird separately if there is a difference between the two sides.
+ + Brisk
* Slow
- No Response
+
Intact Abnorma'

LEGEND

+
Normal

+
Weak

Absent D Doppler R Right L Left

MEDCOM - 23846
DOD-037424

PAGE 1 OF 4
MEDICAL RECORD—SUPPLEMENTAL MEDICAL DATA
For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General
REPORT TITLE

OTSG APPROVED (Dale)INTENSIVE CARE NURSING FLOW SHEET • QA Appr 8 Mar 89
ES

PUPILS
SENSORIUM
RESPIRATORY PATTERN
BREATH SOUNDS
SECRETIONS

INTE:GRIT Y
LOCATION '
CONDITION
¦ 4‘ •0 . Al ft
NS Ix &At_
'ABDOMEN
Ctsr..+Pirri ri

BOWEL SOUNDS
LIME: .
.1L.r

COLOR/CLARITY •
CARDIAC RHYTHM
&7": ion- i
4-3se_ccapiTAI

ta
Cr - Creatinine
ICP • Intracranial Pressure - Fractional Fi02 • Fraction of inspired 02
PCO2 - Pressure of Arterial CO2 SA1 • Saturation
Ai(
FICO3 • Bicarbonate PEEP - Positive End Expiratory Pressure MACH tracheostomy
(Continue on reverse)
DEPARTMENT/SERVICE/CUNIC • DATE
k PI-Atitiika
written entries give: Name—last, first, . . dical facility)
IMP6( (IS.-
• HISTORY/PHYSIC:a. D FLOW CHART
. OTHER EXAMINATION D OTHER (Specify)OR EVALUATION
• DIAGNOSTIC STUDIES
TR4TMENT

1 MAY 78
DA
FORM 4700 '
liEDDAC FBg OP 375, 1 Apr 90 (HSXC-NU)
Proponent: Dept of Nurs MEDCOM - 23847
DOD-037425
6\J-
PAGE 2 OF 4

DATE DX
HOSPITAL DAY

TIME
rimegrattimuurnarmagramo

8P Arterial Line
BP Cuff
ElligalgiNMAIIIIRVAININIMMVARAMORMINI
Temperature
INGE1111211111146 CEi 0 cn- 1311=4955Mirdi %AIN
Pulse
/131111M01.11
Respiratory Rate
nimmormstini
nom icx num 92. BIC/41M11 Prinial:711185 MUM
ELIMEIMIll to MIIIMIIIENIMMITAI (os
il
arrnilLIMEMPIEMIXIMEINEFECIEMETIMMI 4 ¦11
1111M11
b.,•• IIMITIFfigiffM711
FADYBMrniilllRaiti6M11111
EILSIEMENIMIIN 16 11111
WM21111111EU 40 ELIMPIEURFAMPLEIMMIENFERVEUIVIIMIll
1111111
111711111111111
TIME
EISIIMANEMESIMIUMAIIMIMIEM11111

=kali io r1
MIN" q 6
111111111111111111INIMORMIENVII
va:_m lick\
lo biz) t')
111 EOM Itgl
Bi4tA-)
11241

TOTALS

11111 i
URINE
Fro: EFAWARNMVAMENCE
S/A

5D9r 111111111111111111111111111111111
OUTPUT
NG
GULAC
I I
EMESIS
STOOL

OFtAINS

I Nil I
TOTALS
MEDCOM - 23848
PAGE 3 OF 4
PoST OP DAY
ACLIETV LEVEL CLASSIFICATION
ME1110101010011111111

EMMA= MIMI
711391P1191271INIC111
DIUMNIETAIGNI2111
MI No MEM 89
IN11211121121MMIIIIII acp glIMINVEMIET,11111111
T
ED z; EMEIMMIMET111
MIE1113111=1111.11

11111111111111111111111
1110111111111IMME211

EINESUMErill Immunmno
woo
TIME
aN
MODE
Ei02
TV 91'1) 93".)
RATE
9-g 3-x)
PEEP
is' Ps
pH
A PCO2
PO2
B HCO3
SAT
BASE

TIME
GLUCOSE
Na/K

.4110311511rMi IAN
CLICO2
mismirroacirmammo

Agesordmarizari
ALPAPINIPILKIME
11111111111
TIME
oci
BATH
SKIN CARE
FOLEY CARE
0
TRACH CARE ROM EXERCISES
0
ImmemmomImonsmialImmmummis !NIA% IV .402/4._. Urine: 14070T wt Yesterday OUTe T / 2 wt Today INIT IALS
po
TOTAL TOTAL
BALA NCE____a_e

MEDCOM - 23849

--
.
PAGE 4 OP 4
kiA55.E SS MpA.
LEGEND
HOURS
Ni)Red I I I I I I
Z spOpirANEOuSL. y 4 C Closed by swelling
ti 10 SPEECH 3
i0 pAiN 2
2-

... NO EYE OPENING
T'TrachiEndo
(MIEN IED
A
S Slurringmy' CONFuSED 4
=z
13 Dysphasia
vEittiALIZES 3 R ReceptIve
dte.. vOCALiZES 2 E Expressnie
NO VOCAL IZA riON
T—itC1
OBEYS
COMMANDS
LOCALIZES PAIN
FL EX-ION
winiortavvAL
°O
ABNORMAL
.L;!:
- Fi EXION
• EX !ENSIGN
10 PAIN

no MOTOR
HI SPONSE

:•• NoRMAL POWER
R Right
MILD wEAKNESS
L Left
SEVERE WEAKNESS
ABNORMAL FLEXION
Record ABNORMAL EX TENSiON separately if there is a -
NO RESPONSE
difference between the
NORMAL POWER
twO sides.
"V•
MILD WEAKNESS
•
SEvERE WEAKNESS
M
ABNORMAL FLEXION
ABNORP.1AL EXTENSiON
. _
NO RESPONSE
r Brisk
SIZE
2 Lb
RIGHT •
REACTION

. Slow-
.4- .4-
-NoSiZE Response
LEFT
REACTION
• •6
PUPIL SCALE • 2 40 3 . 4 7 mm
+ Intact
1CP --.
-Abnormal
CEREBRAL PERFUSION
PRESSURE
CtitAitA $E$S AtteAr4.4:
LEGENDHOURS 10
. + Normal
E
herAnorlormovireAreArionevorA
FIVINIMMINVIIIVAVAININFION Weak
Absent
D Doppler
OVINSFAINIVII411/12:14111/§1111
Right
WINVIONNONNIVAPAINFIAVM
Lett •
/14/07 111P/GINVAPIP11
¦•¦ MEDCOM 23850
DOD-037428

PAGE 1 OF 4
MEDICAL RECORD—SUPPLEMENTAL MEDICAL DATA For use of this form-, see AR 40-66; the proponent agency is the Office of The Surgeon General
REPORT TITLE OTSG APPROVED (Dale)
INTENSIVE CARE NURSING FLOW SHEET QAAppr 8 Mar 89
ES I
INI INITIALS
TIME INIIIAL
10, fLactI
PUPILS
a-leY1 el •
- • .vi•A Aro •
AIM .MPIAMPIRMIll
111111M
pa) L; J. •
Q t
cxect.
ICP intracranial Pressure - Fractional PCO2 :Pressure of Arterial CO2 SA7 - Saturation PEEP - Positive End Expiratory Pressure 7 RAO1 - Tracheostomy
PREPARED BY (Signature & Title) DEPARTMENT/SERVICE/CUNIC DATE
lak 15 itou0S PATIENT'S IDENTIFICATION (For typed or written entries give: Name—last, first,middle; grade; date; hospital or medical facility)
•
HISTORY/PHYSIOAL CI FLOW CHART

•
OTHER EXAMINATION

OTHER (Specify)OR EVALUATION

•
DIAGNOSTIC STUDIES El TREATMENT

YM7 8
DA 4700 -MEDDAC FBg OP 375 , 1 Apr 90 (
Proponent: Dept of Nurs
MEDCOM - 23851
DOD-037429

PAGE 2 OF 4
HOSPITAL DAY
°A" 151k-WO D X
TIME 110 III isi-BP Arterial Line
rallEMAIRMAIRMISMINZAWNIEBIEWSZAKEIIN
BP Cuff
Na11111111111M111111111111•11111111111Mi 1111111111MNIIIIII
Temperature
Pulse

MI166 MEM tot IMEMIERIVEraM1 tits gm Im
Respiratory Rate
-
24,
itliiIMAN111111111M11111111EMEMILIIIIMPRIYAME11111
ccD 11/StaNSMIIIIIIIMEMbill
WIEJIMIEININImM1111111M111 MI 5 5 MAU
Alb° 11111INIMIEMBIFM 11111511111123E11
I A RIIIMIBILINIIMIE11111111111MID10101 • mug
EnlgrmaiffewmatimisanrAMMILTERMaimailli
•
TIME ao• T
cr II
Ant 112-°')*-As'- 1111( 115 MEI
1VP6 MIMI NMI. AL 6 IMOng cog
isira musuryca pu• JD Re 10 to pa6 Cr6
kL
MICE111111111111111111 Miff 11111111111131M1
II
k6t47A t 6 I
pm NW)
TOTALS (,623,
HOUR AlAtAIALWA .4
URINE
sP
mumml
immanosno
OUT PU
,7Brill11 El
NG
GLIM C
EMESIS

111 II I
STOOL
MO MN MI II
NMI
DRAINS
MI IIIIII
TOTALS
INSE

MVP MEDCOM -23852
PAGE 3 OF 4
POST.OP DAV
ACUITY LEVEL CLASSIFICATION
FEUZIE111,11/11 CP 3 IINIFIP"
MaiiiMME awo MEM=
Milliffill111111110111
1111101EINIMAIEDIEMMIll
RATE
EIF111111RICERIE1F11111 macimusrainffl

PEEP
reMLEDIEVAIMMINIVAI IMINIMIREMIONIN
pH
ITMEMIENI% too/ MIRAN
A PCO2
1111M113111111MMIIIMIN1111
11111111111111111Le ELMO
MI 1121111EIKOZIEtill
.f5;
MIE1111111111111116 MEM
111112115111TRIMIMIERIM p02
B HCO3
61511111111111111 MOM
110 • SAT
12110111111EIMPSILIII Eignimmormannurd
tv..4
MEMEM=
pagirearransm r

MINIERVIO121111 8° T rid 111 IN 111 Iri
1111:g11.111111111111111111
BUN/Cr
111NRIM1111111M1 is ISPZEINIMIZIMIN
WBC/PLATELET
MIR e IMO KIM FA Pli M-
HctA4gb
nun to EI/ IPA El Si LIMA
14
ON
KOW:MIEMIESM1 .
111
TINIE
TIME MOUTH CARE

MEM=
SKIN CARE

IZEMPARBERE BATH FOLEY CARE
TRACH CARE
111111111=1111111111111
ROM EXERCISES
EMMEN
. .
.
INITIALS
wt Yesterday
wt Today
INTAKE IV
11111111111111R1
1;?..b
1111111111111= unne: ozga) hormim1111111111
111111111111111
1111111111111111
TOTAL
111111111111111111 BALANCE 4-110tOS

MEDCOM - 23853
"4,
PAGE 1 OF 4
MEDICAL RECORD—SUPPLEMENTAL MEDICAL DATA For use of this form, see AR 4 0-66; the proponent agency is the Office of The Surgeon General
REPORT TITLE OTSG APPROVED (Date)
INTENSIVE CARE NURSING FLOW SHEET QA Appr 8 Mar 89
.....
I oroTiALS
"" TIME (a SO 1-4iYIkTh
INI "A
PUPILS
SE CRE TtONS
CARDIAC RHYTHM
tds . 11" Vok;-rf, ayiae,
Cr - Creatinine
ICP intracranlal Pressure S/A • Fractional F102 • Fraction ot inspired 02
KO2 - Pressure of Arterial CO2 SA1 - Saturation HCO3 - Bicarbonate
PEEP - Positive End Expiratory Pressure TRACH lracheostomy
\\ ,2, (Continue on reverse)
le) eio„7-- z DEPARTMENT/SERVICE/CIJNIC DATE
7/54 uA igKwa3
Wen entries give: Name—last, first, dical facility)
HISTORY/PHYSICAL FLOW CHART
•
OTHER EXAMINATION

O OTHER (Specify)OR EVALUATION

•
DIAGN9STIC STUDIES

1111.R:
. TREATMENT
DA I TA% 4700
-
MEDDAC FBg OP 375, 1 Apr 90 (HSXC—NU)
Proponent: Dept of Nurs
MEDCOM - 23854
DOD-037432
DATE
DX PAGE20Fit
HOSPITAL DAY
TIME AL I t 2 .,11/1
BP Arterial Line
&ink &fiiiMaigliklE111=52111611/ELT 90 ANN
BP Cuff
RIM
MI MIE1111111111111111111111111111111
Temperature
MIMI iiiii MU
antrammummarmarmatamen
Pulse
011511=1111111011121611111111M111111111111111111121011111111
Respiratory Rate
MM vo a
Da AORM 20 MEMO Qci) tamann
ITMNIitillIlllf&ZBIMinikiligdIIIIMIWillEilgfillNEGVCTIIEJIIIIII
MIIIIMIN o
0 IMEREllinlemmtli progini
itigma WM RI 3
vallfillIESEIRIEMEMIRE111011111111
L
IMMIIIIMENIZIEUMEHNIMIIIMEIMUIERIMIERMIEMIII

Mr11111111111=11 5 s MI 5
Pi HIMIIIIICIMISIMUIENIEVOIMIN
MICHEIIIKIEMEMIENIUMMEAUMILIMICOMIIII
0/ REIMIMILIIIMIEEMILVIIIMINIMEMEIVAMMIll
NMI
11111 111111.11111111111NINIMINNII

oco INIENNIVINENNIVIL
crammilw ' rilt.,61.ffilftr4millacAm. '*".04,mal
1 P Mairiginti
MEC 'reiniggaiiniiiii
MEM IM
II 11111111M111111111111111111111111111111111
so .111111BIEI 1 EINIMILI c( Illffi 8
FM
IMNIMICINIIMID Iffignagal ID NW= /0 El 0 so
maim=
-
IMINCE11111111111111111111111111
Mil MIME= IIIMIIIIIIIIIIIIIIIIIIIIIII
Mal 11111111111111 11111111F5 P1111111111111 NMI
1111111111111 111111011111.111111g.
111111111111 11111
• 1111
1111MMIMMIN

7°UL Arnanummoratmasto
sP9t
mum. mimmamm
GUIAC

NO arliniernia

MUMS MM MMIIIMMMM
MWMWMWM
MINIM

MINEMUNIMMIll
TOTALS
MEM MEM 6 LA.-f-K:);
MEDCOM - 23855
PAGE 3 OF 4
IMPLIMMEIMirml Ire
finalliMENVEME110111

MOM OEM

IMWMIZIMME
FaIMIERIMELMIRE
MEM!
MitalaiffiEtranientia
moms mins

MEM MIME

own MEM

MaimlaimmonmIN
FAIEUIREMEIREMIDTBIll

ramvisnonimmulim

111111111111111111111111 MIN
ESIMENNIMIMPLEM
11111111111112 1111111111MMUM
1111111111111
MIME
MIME
MEN

MIR
111111110

rob
ertinramormarana

measimmegleamr

IPPAPIMEAMEM
Prd P2I1

MILFAIMIPIMP2
1111
2—J2-re'cA' MEDCOM - 23856 t 1Mr.67 I
PAGE 4 OF a
. ,
PAPWGicilik.A.55..ESME.N.i,.:4;N:::Ve2:•?:iii:•i::.!::Ni::R.:;:0::;:::::::limi:pgi•:::;.:::::i.:K::Ipsi,s.:-;:.:p:..-
.. :
::',i'?„';':...:. „'I';'.;:i :',., t'. ' --"d',A :'' :::::: ,.,..
LEGEND
zing
HOURS
le
C Closed by SWelling
spon1ANEDuSLY 4 II
10 SPEECH 3
10 PAiN 2 1111
I
NOETEOPENIND IMA 111
T TrachiEntio
ORIENIED
S Slurring
cow USE D 4
I' D Dysphasia
witsimias 3
R Receptive
vocAsIZES 2
W ' IE Expressive
piovocAtimmg,
MME
plays
COMMANDS 6 I ()GAUZES PAIN S . 14 EXiON
WITHDRAWAL 4 ABNORMAL FI EXION
3
k x TENSION
10 PAiN
2EM
NOMOTOR KISPONSE 1
EM
.

1-1WIFET
,73--
N3H-70-5 3lvii/1 IS 8 kiRralsiVA8
I;
NORMAL POWER 110101:z R Right MILO WEAKNESS
0wig .
L Left
SEVERE WEAKNESS MUM ABNORMAL FLEXION Mit Record ABNORMAL EXTE NSiON
di separately if
there is a
NO RESPONSE
I \ difference between the
1
NORMAL POWER
two sides. Niltomilloass
IN
SEVERE WEAKNESS
U
ABNORMAL FLEXION ABNORMAL ExTENSiON OM
M NO RESPONSE
II II
-.

+ + Brisk
SIZE
SF M
RIGHT . - --, . ,
.1-.T"
REACTION
slow.,
A....
, .
T).. ri

No
SIZE ' .)-
Response
LEFT
itexatom Ell Ai II
'
. • 2 • 3. • 4 • 41115 • 6. •7mm
PUPIL SCALE
.
+ Intact
ICP - -. 111
-Abnormal
111'Z ..¦..,
M:

' :.:::,'

:k,:*:w:::
::' 6:::
. ""..-

i::
g:,*:

:::)i.

CEREBRAL PERFUSION PRESSURE
.

WW1:70: ;:40:RIU:::4-:::::::,:::-': .:' :..:

..;`,,,.::...,7
,,:.:._..
.. •
.
:

4;:p
:::...;::.M.WAROMON::.i:::MORM: Mt.. VAR
Zgl rarE3
v_i ____
iv,:
,,,.

.

LEGEND
'
.
_
INION5155//511/NNIONNONN"1"--1

111111115111115111111111 Weak
1111111/111111155/4157:411.5 ¦1/11111111111. Doppier

HOURS
­
"

LA, E---
L iT,

CC J CC CC ce
Absent
,

I CC...I

Right
NIP/OPINSIPINEVAr/§/1111/1/111/11.1/i/15
NONONNIONONNO Let•

OMNI/.

MEDCOM - 23857
.

PAGE 1 OF 4
ME AL RECORD-SUPPLEMENTAL MEDICAL DATA For use of this form see, AR 40-66; the proponent agency is The Office of The Surgeon General REPORT TITLE
INTENSIVE CARE NURSING FLOW SHEET INI I IAL SHIF ' SSESSMENT:
TIME
igartimer a
PUPLIS E SENSORIUM
u
RESPIRATION PATTERN BREATH SOUNDS
SECRETIONS
COLOR
INTEGRITY
reWcOM —XI—OXi
LOCATION 4 a 111:
-A„.....„.,
CONDITION k
‘1111 i Ci
Si
I
T

E -G ABDOMEN
A
s BOVVEL SOUNDS
T
R
0
COLOR/CLARITY
U
C CARDIACRHYTHM
A
R
' 1
0 V' A-
S C
U.
L -
A
R i
PA
•IMILIPiONVMeergi-11
EnTatarglii
fINIMESEMEMI lidEMIIIIMININ
Aar— ail,
il...._.
— • .
,,,„,,,,_.....
05
ler01. i,,j. it
---TiMiila.
Lii vo-tst iniraliMMIllin
A • h
C-sA 1
rfAti l
VI

I
¦ A.
/1 I 4A a ...:•
NW...! . • -, L nVIIMPIIIVIUMMI
¦•¦ • A • . . •I'A-1 ' ' 1 A ,VIRMINI1111111.1111111 IMIESIMM111111111
60' .
_.„ II
, ......ir

LEGEND

Cr - CreatinIne F, 0 -Fraction of inspired 02 F., 0,- Bicarbonate
i ,
.....
OTSG APPROVED (Date)ce) Appr 8Mar 89
,
INTILAS
111=11111111r"
N./,.'
.....„,n,;,...„1
I IvngfeiiMIMIBRIM
IIIMMI ll 111123ifflfflISIIIMM
II -t a
4
IMPESMARIZMIRIMIMEE-. . -'-I ii
I El II I P /A.-
wr wringimml„,, 1,1
,
wili,ILI.,_,44,131
l1MIMIFM141AVM .-I / . s s ‘ _ ,1 . a. . a ir:111 /Mr¦ 41,
. t!!'
. . ,•_,.
r! ' ..
A1114 1M
pw.m
-.4.a.-. i PEOW,firaWar
f.
4 /: Ykei/i/i. .0. 91.11fet 0 s cv4.-e ta ¦
„ .14 a ' 0. . Lk . I IN
A f ta
EfirSEEMINIffil
Miroli gniel hieba•le)
ill . 13 4 a _ • ,
IMPIMMIIIM
.-‘414,AL'11'411
MIIIMIPM111111
MMIMMIMMEN
.
,i3i PI, IMM , _--..,Iiii
!ITTTrTIVI„A ,. /A, „,.. . ,")& I # .00./) -4--e0/0 leP 114-stiy.41.A ,
ICP - Intracranial Pressure
S/A -Fractional
PCO2- PRESSURE OF ARTRIAL CO,
SAI -Saturation
PEEP - Positive end Expiratory Pressure
TRAC H -Iracheostomy
(Continue on reverse)
„ pt a or me 'cal facility)
HISTORY/PHYSICAL 0 FLOW CHART
CI OTHER EXAMINATION Ej
OTHER (SpecifY)
OR EVALUATION
DIGNOSTIC STUDIES
(g
El TRETMENT
el, T---Ain, 0, -t„. I DEPARTMENT/SERVICE/CINC
i DATE
I MU*" I
ritten entries give: Name —Last. FirAt 1 /"Unt iM
MAY78
Proponent Dept of Nurs

DA F°RM 4700 WAMC OP 375 (Redesignated)
1 APR
MEDCOM -23858 90 (HSXC - NU)
-.4.01.1.11.1=11•111¦1.1¢-
3
j73V's(Cr
VI;CA19
7-;(-AG516
E 20:
DAT DX
SPITAL
T ME 0.2 03 04 05. 06 07 1111
08 09 10 11 12 13 14
r
BP A linie t(5-
e;
elk/J:1cl "It ADREIRIV-.111111F1124.9611.
111
BP Cuff nxi
i; A7-amul.
Temperature
Pulse

EMIR
t
Respiratory Rate

.,.• a6
ft 0 METENESION 50/1211111
Mob e
5
j51ir
at
I 151'
et•to IrliNg too (60 1111111160 caraikamsainl
virpt r jar
of-P qt1),34). ELIME111111
TIME
02 03 04 05 06 07
/0 11.15
tAc •
v e
61.•

t‘,7{vem,lt -4--3--;
VISO 4
( ,L4
(0 , 011211,11ff
\I R., anon 2-- 2
,c)12.15C

.0 150
cAt
TO
uNRTG
,NAE:HouRiv
t* 111))11
sp grTOTAL
S/A
IF; Ail
OUTPUT
6/4 II
MK PAW
PH
GUIAC WAIN MI 1111111%
EMESIS
STOOL

11111 Fi
DRAINSrI y I I111111111111EIRMINIMIkM111101.-Ji
I 1111111111111
1111=11111121
121111111111
IIIM!
TOTALS
°AO
a MEDCOM - 23859 MIN=
PAGE 3 OF 4
POST-OP DAY ACUITY LEVEL CLASSIFICATION
ese--
itt*-1,P4v tut
/ 6 17 18 19 20 21 22 23 TIME t5,45
41 WO ttt-4
V
w MEM IWO
Fi0 2
MODE trs-50/Ernorion
0 -rv
10 r Mffirinall11111111!1
RATE
0- I I A DxI) MEW]
PEEP
9.0 DA) al )0, NISI MINER
pH
45-'is-45 tio___03C0 1-15 CET 1-3 MINI=
5 5 3 • PCO2
licin 3)-1311111111111111E
s 5 n ,r) G 6 1111111=7111111111111
HCO,
-2- iv PO 2 raw n-1111111111111
SAT
•• C P -
BASE
3 '51 1/ CO 8121111101:111111115/1
TIME MOD cfro CLUCOSE
11111
16 17 18 19 20 21 22 23 8°T Na/K rdilIMPAIIIMAMI
\-45— 11-Y nS Cl/CO 2
'PIC n5 r,5 5 MITIPAGINIMIEV
BUN/Cr
5-0 t2c0 EPAPMEIIINIPMEI
IM3C/PLATELET
EINFIMPAIPIMISI/
Hct/Hgb
1
105 ;Pr-11yr.- Pv/Pr-rvr"
I ,) a a 5 .21
3 3 3 ,3 3 3 41

1.1.5
tax)
TIME
MOUTFI CARE
BATIIH
SKIN CARE
FOLEY CARE
Y/707‘67)vi7ttsi
WM-CARE ROM EXERCISES
•
180JOTALS,
NPF3g's;g1PRIA
WT Yesterday wt Today Cer
sr
WAKE
OUTPUT IV Urine:
OA)
Po
TOTAL TOTAL BALANCE
PAGE 4 OF 4
NEUROLOGICAL ASSESSMENT
NNW
HOURS
sP126 LEGEND
SPONTANEOUSLY 4
C Closed
TO SPEECH 3
by swelling
^•^
TO PAIN 2
NO EYE OPENING 1

CEREBRAL PERFUSION
•
ORIENTED T Trach/EndoCONFUSED 4 S Sluning
0
VERBALIZES
I— (0
D Dysphasia w
rf3 w
VOCALIZES
co 2 R Receptive NO VOCALIZATION 1 E Expressive
OBEYS
COMMANDS
LOCALIZESPAIN

FLEXION
oz WITHDRAWAL

ta
20
u) ABNORMAL

a.
FLEXION
co

lux
EXTENSION
TO PAIN
NO RESPONSE

NORMAL POVVER
MILD WEAKNESS

R Right SEVERE WEAKNESS L Left rC ABNORMAL FLEXION
ABNORMAL EXTENSION
Record NO RESPONSE Separately if there is a
1 1 1 1
Difference
NORMAL POVVER
1 1 I
between the
MILD WEAKNESS tow sides
SEVEREVVEAKNESS
—3
ABNORMAL FLEXION
ABNORMAL EXTENSION
NO RESPONSE
I 1
SIZE
a 2
RIGHT
+ + Brisk 13' REACTION
+ Slow
SIZE
LEFT A' No
REACTION 4-
— Response
PUPIL SCALE • 2 • 3 4 0'5
.6 07 min

ICP.PRESSURE
+ Intact
— Abnormal
I I 11, till I 1.1 I I I I I I I I I I

.V.A:401(0k;14.-000-00t
HOURS ro, 6
+ + Norrnal

FAMFAMENNINWAHMEN
Weak

WAVAMENNEWATAWARE
&bsent goppler Right
INWAVAINEWINANNEV4
/VI
Left
AVM AVAWAVAVAN
MEDCOM - 23861
DOD-037439

i , ';,,,, -}(4*.tea ET 1. ''''''''7 0 Oral 1-.=:!:-'W,11, -P.; ,'' l' ' 17 " '7, 0 ETCO2 Change ',7:-CT Scan: . 9. i-Jr , 0 Contrast . ' '''':'' ''''' 4.40iiis*P:1#,,y '
Intubation 0 Nasal Teeth 0 BBS Post Int 0 Post CXR CI Head 1S0bd kelvis v efj,AL—
Gastric CI Oral 0 Air 0 Contents CI C-Spine 0 Til Spine 0 Chest
Tube 0 Nasal 0 Verified Suction: Y N 0
r 14. Urinary DPL k‘, 0 Meatus 0 Supra-Public CI Opened 0 Closed 0 Return cc CI Home Dip: + -0 Secured CI Grossly: + -Cell count A-Gram Site: IV ACCESS & FLUIDS -4 ,. i.i.,.

Sentl___ am is
Chest 0 Air od a ME Vtleuravaclacm
L R MIRti4e. a Liivimmi
Tube #1 0 Autotransfuser
111.11

0 Air 0 Blood0 Pleuravac _____cm MEDICATIONSCheat
.
Tube #2
0 Autotransfuser
L R 0.' .=,
Rhythm: Comments12 Lead
ERI MigriNFAMIME riii
.e..",2, NM_iliirtrAiriiini
, OA 'd -' _ ' P, eq,-‘- tkor
-..-px—
F2IMINICEMEE1111111

I ii I
1) 42/2.9.--%-lt
2) .
LABS X-RAYS
Iry
,,,.. .
0 D-stick 0 SHct ItCChest Initial 0 D-stick 0 SHct 0 Chest Post ET BC - 0 Chem "Br-RT/PTT 0 Chest Post CT
BLOOD PRODUCTS
...e,
o ETOH liir.Z&S CI T&C x 0 C-Spine
42 S'k A 4 , r I CI Tox Screen 0 Pelvis A 0 HCG 0
. .
'
la OTHER
. ,
LAB RESULTS
IVF Urine NGT NGT Blood EEtL Other Other TOTAL T T
TRAUMA TEAM ARRIVAL
VALUABLES & CLOTHING
.-R-w,,-.77,
, , 1, -WaTMZE.VjEf ; ' f'l ¦ P: .. '
V . - 1-W '
D Phys
None Found

urgeon
Given to Patient a:test-Fr— Given to Family .. Inventoried and Released to Patient Trust Fund/NCOD See DA Form 3696
Other: See Nursing Notes X-Ray RT
' 0 Home . 0 Ortho Admitted to Neuro Report Called to Chaplain Time ransferred
"'"" —^'CI By
MEDCOM -23862
I I !Ocher fa Wheelchair n i
DOD-037440

MEDICAL REC LEMENTAL MEDICAL DATA
FM' use of this forrn, see AR 40-643; the proponent agency is the Office of The Surgeon General. OTSG APPROVED (Date)REPORT TITLE
TRAUMA FLOWSHEET
QI Appr 11 Jun 97
The proponent is Dept of Surgery
EMS REPORT ARRIVAL STATUS at? ETA: r_ UNIT: TIME 0% o x o 02 1 /min 0 C-Spine Immob
TIME: 0
MED COM:

Meds: 0 UKN None zf2-Yes:___,L sthas_e__
Allergies: PET-UK N CI None 0 Yes:
Tetanus: "Erttl(N 0 Current Last Meal/Fluid Intake hrs
LMP:

A
PRIMARv SURVEY 1
41, pvtioN
.
0 Natural Patient 0 Labored El Unlabo Absen PULSE: Present 0 Absent SKIN: Cool 0 Hot
TRACHEA:YMi ne Deviated BLEEDING: „Ii(Pink 0 Pale 0 Cyanotic O
CI ETT
13
CHEST SYMMETRY: HEART TONES: ear 0 Muffled ry CI Moist 0 Diaphoretic0 Secretions
El
SECONDARY SURVEY
ifsD'af
GCS: PUPILS: knqual 0 Fixed o RHYTHM: gular 90 El Soft El Rigid Non-Tender
TM: 4-Clear 0 Blood PULSES: 0 Central „TEC.Peripheral 0 Tender:
\L} V 13 GI
Z\13 :nBLyi til)r C-Spine Tenderness: BREATH SOUNDSXBilat 0 Equal U Clear Cpltable El Unstable 0
4
SPHINCTER TONE:
WNL Pain @ / Decreased ISO Alassa4g.g1,_ alzsitte/vegine:

plif-None JVD: 4411venes—RE Crac .Giumrao. Heme +I -Prostate: WNL Abnl
13 13
USE DIAGRAM TO DOCUMENT INJURIES AND PAIN VASCULAR ASSESSMENT
(AB)rasion
(AMP)utation
1AV)ulsion

.2?
Battle's Signs
(BLleeding
(B)urn
(D)eformity
(E)cchymosis
(F)oreign Body
(H)ematoma
(LAC)eration
(P)uncture (W)ound
(Pain)
ISleatbelt (S)ign
(S)tab (W)ound
(GSW) Gun Shot Wound

D Dopler
RN
f/3 7
ue on reve
PREPARED B ure & Title) DEPARTMENT/SERVIC DATE

t 0"),
PATIENTS IDENTIFICATION (For typed or written entries give: Name—last, first,
n middle; grade; date; hospital or medical facility)

O HISTORY/PHYSICAL FLOW CHART
.
OTHER EXAMINATION OTHER (Specify) OR EVALUATION

.
DIAGNOSTIC STUDIES

11M
D TREATMENT
10((_')
tED BY DD FORM 2035.
DA 1 FaM78 4700 MEDCOM - 23863 EAMC OP 503, ec
1/62

Rectal Temp: TI MigialWA egiok-kilt9N. GL SGOIN COMA SCALE
ogrg tri/G_agi2A /21/71 0 1 2'8 l'ZS /77 t404'3c- VeA 2 Ansra tie,OL 92(6 'V' 1'3 4 Spontaneous 3 - To Voice 2 - To Pain 1 - None 5 - Oriented 4 - Confused 5 - Localizes Pain 3 - Inapp Words 4 - Withdraws to Pain 2 - Incomp Speech 3 - Flexion to Pain 6 - Obeys Commands
1 - None 2 - Extension to Pain
1 - None
REp
Backboard Removed BY:
0 Downgraded BY:
NOTES

MEDCOM - 23864
S.(1C11/FliMucarr Dos.ersa...
DOD-037442

1. rceporting rvi t-2. fr.777 , ,
Admission ar.- _;oding Information
b(1)4-7-2, For use of this form, see AR 40-400; the proponent agency is OTSG
3. Register Number Name (Last, First, MI) 4. Pay Grade 5. Sex
____ .,_, -_ „ FGN
1 6. DoB (YYYYMMDD) . 7. Age at Admission 8. Race 9. Ethnicity Religion
X 9
10. Length of Service ETS 11. FMP 12. Social Security Number
; Organization (Active Duty Only) 20 13. Marital Status MIS Hour of Admis-sion Branch / Corps:
09:20
. 14. Flying Status 15. Beneficiary Category 16. Zip Code of Residence:
NO K78-PRISONER OF WAR/INTERNEES
17. Unit Location 18. MOS 19. Trauma Prey. Admission
DIS NO
20. Source of Admission Ward: Name / Relationship of Emergency Addressee
Direct from ER ICU1 Address of Emergency Addressee

Name and Location of Medical Treatment Facility: Telephone Number of Emergency Addressee
_
b( 2-) "- 2-
21. Type of Disposition
22. MTF Transferred To 23. Date of Disposition (YYYYMMDD) E
2003-11-23
24. Clinic Svc -Admitting
25. MTF Transferred From 26. Date this Admission (YYYYMMDD)
ABA -GENERAL SURGERY 2003-11-11
27. Location of Occurrence 28. MTF of Initial Admission
29. Date of Initial Admission 2--­
/
2003-11-11
(....--FOR LOCAL USE Type Patient (Inpatient / Outpatient): Inpatient ( Admission Diagnosis Narrative: GSW R CHEST/ ABDOM
Procedure Narrative(s):
Cause of Injury Narrative:
Admitting Officer (Signature, as requ"
Automated Facsimile - DA FORM 2985, MAR 2000
MEDCOM - 23865
2. MTF Locatiori- Admission anu k,oding Information
1. Reportin MTF I For use of this form, see AR 40-400; the proponent agency is OTSG
IZ
5. Sex
4. Pay Grade
Name (Last, First, MI)
, 3. Register Number
FGN
_
Rogion
. E hnicity
9 ti
8. Race7. Age at Admission
6. DoB (YYYYMMDD) 1.
9
X 1
12. Social Security Number i11. FMP
ETS 20 =Ill
10. Length of Service Branch / Corps:Hour of Admission13. Marital StatusOrganization (Active Duty Only) 09:20
16. Zip Code of Residence:15. Beneficiary Category
14. Flying Status
K78-PRISONER OF WARIINTERNEES

NO
I-Prey. Admission

19. Trauma
18. MOS
DIS

17. Unit Location NO
Name / Relationship of Emergency Addressee
.Ward:
20. Source of Admission
Address of Emergency Addressee
ICUl
Direct from ER
Telephone Number of Emergency Addressee

lity:
( ) -
23. Date of Disposition (YYYYMMDD)22. MTF Transferred To
21. Type of Disposition
2003-11-23

HOME 26. Date this Admission (YYYYMMDD)
25. MTF Transferred From
24. Clinic Svc -Admitting
I
2003-11-11
I ABA -GENERAL SURGERY
l-

29. Date of Initial Admission28. MTF of Initial Admission
27. Location of Occurrence
2003-11-11

FOR LOCAL USE
Type Patient (Inpatient / Outpatient): Inpatient
Admission Diagnosis Narrative: GSW R CHEST/ ABDOMEN RENAL FAILURE

Procedure Narrative(s):
Cause of Injury Narrative:
• Admitting Officer (Signature, as requi
DOD-037444