Medical Report: Treatment Records on Numerous Detainees, Baghdad, Iraq, May - Sept. 2003

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Medical reports on numerous detainees and their Treatment. There are a variety of ailments and injuries complained of. The ages of the patents ranges from early 20's to late 60's. Most of the records have handwritten notation by the treating doctor, nurse or other medical professional treating the patient. There is no indication of abuse in the records since they address only existing injuries and illnesses.

Doc_type: 
Medical
Doc_date: 
Saturday, September 6, 2003
Doc_rel_date: 
Sunday, April 17, 2005
Doc_text: 

(Sin Instruc'dons on Back of this Sheet/ REATMENT FACI1.1 `I cZtansp) 2 1 -54-CS • - -fr RAMISPORTATION TO HOSPITAL CURRENT M me• .fund, unmans tAteacil'elve 'Hyalite sheath.- - - ' r..zation. and other data) ::.7,-,--ARFUV44,7-:`---,,• gin ffill==g41201=212 61V._ 0 - .0-.•=a61 - -.•.• frte-74-F,;,C--YES.0. .f.W47.4,re.Virradi.:SrGNS :DESCRIBE (11.5iibiective data (Partinaistatatary): (21;0k/ea** data' aisiMinatitas.mufti of tertz A.41.iss#11ag,(1)44047. (4) Flan rZsatmaduprodedures- MeAsedripediaatioredtimpradd'faaaw-up 6 Z- TV: • F Prt-Pt: • fr-.---.,...40,401X14144RetOR Z. TIME OF RFT' 41 cE•a; L PATIENT'S 1-DENTIFICATIONtreaUrs'agFOR-WRITTEN,ENTRIES .SSN; DOB. servierAtatus,iam4Erifirvive r4157 ialtiralrr . :v.., =NT aRCORD).. .!-.- h' • .-CMEROEN ?TS,' •¦••¦ I MEDCOM - 268 DOD 003395 FteArry: EN EMERGENCY CARE.AND TR EATMENT • PotedicatRaco'rdi TRANSPO.RWN7 s Ft ARRIVAL CURR NT M 103.1betanscriMirst42- :attizejt asre' tut:64 .2*N:other data)' DATE . PatyAtiti. -, 4•!' -.'• AMBULANCE.. VE.t71-CSPeeifyti--. - ;Ate it • it PA A00 ESS- OR 0 ATION • _ COMPLAIN h. L SIGNS . 4S.PF013g13:1'5.4bi44#0.V444 .0*Ontrztlgitelry); (21:0W4424iitit ,/* (44sm.indttars-Iiiiis tiMe Beit p.0) Plan ITreatrunt/PrOdeditres • 7... -.-._ EMVAMA-111 PRIMMIE 11111101iMill CATEGORY-Mee EMERGENT NON-URGENT ORDERS .;e44544¦4;terel..er":',) 24 Hrs. igirAeri.e.,,x ?eetice4tr#4,14:0:eer--,elec."sec .s. LiNcHANGthia - • . 425-r oiv Ar elf re tr#4."-e-ete/ .1 4°rIeel""leigUrgni,;1.7, ffr/00.67: MBERAMEN=5.1'0ENTIP.10 es.h.casical. irrikorint0 ''WR17T.EN.ENTRIES. 01 iterm4,144f j7 t. b)(6)-2 ,,syrsiet s." _ wx name and,rstation 0 • s /tsar. or.isext =' ,Rf,px. ANT.' `PACTMT27 SO G-22LEAT- •• •.•.. .•. •• nt and to CV-UP EIVIERSENC.b&OAReaini (km s-az 4.0'w MEDCOM - 269 DOD 003396 T REPtTM ENT :FpiC1L IT . (Eranspy: 'TREATMENT. TRANSPO ATION To HOSPITAL: .- CUR RENT,ME t (Altasalr.aar-e-inninitakeetr .. -a ' — '1 . ----"-- 7-. - --'bizent tind'other:ad:I- ArViiEL:.f.:1 Am-3"--uv----4Nc-e.fo----;/:5;r.e .? . VEHiCLE .-.R.;.:., 6-THER4-(spadr-,-*-4,1-7-# - - - -_ - Ail . RESSOR HO NO..( 114. arEe :CCIdec.), DESCRIBE (1) atblettioe data (PettinentiristorYR: (21 Objectine data IME SEEN •BY, " PROMME.R,Oexandnation • include iustate'aftests. and x...rerysj: (3)...asealnutrat (Dnagno , is): (4) Plan Crreatrnent/.Procedurra-= include medication-given add follow-4P ,740 11t^4i;oe? r: 4744 ; n„.,/ h..d was re4/ G /red s fide,. Aur YPI/, e­ .170/4 (0,14i/ e4'.e).5f•'S, /re x " NVONAJRCIF.N7 •?"1/r14 If/1 /yr 0'7 /Aryl deiew ;At-44 E 14.s. .die./ at,. //,F.d." gel kedir...".=„,-4-r-e$ • 4Xsof 04,...€ 4, Az-4-e 4.4e1. i.tee irrAgt-5ef 1474g421 ESSMENT/DIAGNOSISI.:: .... Pe•tirri. -zite /44-ceic-4r.,49- d -a-e-k¦iiiq,111 pea 4•4••••,. -;ita 7e.it,e7s-s isce.40azir-444.y.. DISPOSITIONL(CherJr.-612-thatapprch&- HOME 9)1-r- OUT!. -C1UA 077 .1..44i-dfr ,v•A - 24 Hrs. • . 1 1.42 Has. J 02 Hrs., 416:4'tz ht*'#7isue'4ea rite-4,;71*' e€ 1-e-dr'"44441-- MODIFIED DUTY UN31,1..: AdOECT1-1---I;Y-EAR . r.-srite--sr drr;sw,e" • zz - • /P-. 6. 1.4-e L"-XA -4,e-elesose - REFERRED407(builcaterelbuck ta,3. /9/ x -if,i4$3 /5Ty 2s ."¦.—`"! -77zTiefLip* OUrNE AomiT,x0 /SERVICE itt-r"-e -54° :,; ;-.....-,--74•014131+1.014+tPOIVRECEASEr-'7*-7 • g.t. AMPROVEO- -.• ... .0 '47ERkaasArtb.., c;25 4 t— TIME OF. REL.EASE: (CONTINUE ON SF 507 IF NEEDED) PATIENTS rOENTIFICA ION J3ifeeitanieed bnprbat): FOR WRITTEN ENTRIES. GIVE: Name -¦ Lae Mg b)(6)-2 - "`"tdrittri."' • ET.A.IIT: tzsr zerctury',16 Dgel'Eejur47144e_ servos - la4.2-INSTRUCTION5• : 0-FOrilrahletadito-rnedications-ordenrci, any Itnntations and follow-up - • • kiRti • 774 P 0.1.94r5 (A-xi 7-404/ _ ek44:02 -5-:/2•/.0-&--tr_c_efre-cd151ST'IcAiVE- Al /7055784,---, - ei?) :;ef..45ilieAy‘i 5 eor:"7' 4c-Ter-r• 'v'f"°5 '3'a "2 1 e 5) - -EPAERGErtiet.:CisfiEvogerrREAcrirAENT trANDARD, foRm 658.,,, ,&423 04 - MEDCOM -270 DOD 003397 _a (Ptii§ackof this Sheet) " TREATM ENT' ' D-TREATMENT 0* 6. TRASNSAD R T I ON T SP ITAL CUTER ENT MEDS_ (tetan M HISTORY OBTAINED FROM (21:ttsevaateattroute. shalt). izaticei and other data)— • " PATIENT E0-6-, ER PRWATEL j AMBULANCE VEHICLE ALLERGIES ER 'LSFd^3J 27.7 • RIPS'Ort DU AT/ON (City, "State HOME T NO. (Inc- area coarir— ac lude-avInIttamtah: 0 IBL HI / YES NO 01/2917AL:SIGNS DESCRIBE (11 S..4Weatiiia M ddta akirtent Bistory); (21 °Neatly" dam TIME SEEN BY PROVI DER (Z.tointrtation - Li:chide results of teats and-x-rays); (3)Asassamant (Diagno- s s); (4):P/an.ri,reatment/Ptbeedures ittelaule r i 7 6. -' dice zon given and follow up 2 4— . C 71-/p C4.+4,4"/"' • S'` I / !GA-A/ -e(6-1 • 5‘ CL, /Lc c-14 c...t A 6'4 strriowchau-thavimitypr­ i, DITTY I I ryy.:. 1.477--47°3 QUARTERS/. HF2-[ -(— .MODIFFIED .QUTY.UNT1L. v.-mot4TH , 1(.YEAR 77:51/14`Ze 6 -Of IA4 a 71.-X (7e /21.-It3jdat: ' IT TO-HASP, UN .T-AsERY .tmomov ,t.2,," Le-1, cserattisaIRA-, TIME Or -RELEASE: frri Arriii ir II re, I,. , • . PATIENT'S I DENTIPI TION 'FO" Warr/ RV WRITTEN ENTR ratt.se C Ikvi. (IMPORTANT: -, ,-. a i¦r r tRwrIzrrsi -, -. . . acruirs, any /Imitations and folio w-up — • • .. • . • •• ,• • • •• • . • • ..... • • •, _ • • .‘-TANDARD-FORM_ 55a (Rev. 6-34 MEDCOM 273 LIMFNT DOD 003398 r)- -. • t NSN 75 40-01-075-3713e 1W TREATMENT s, TREATMENT FACT LIT LOG NUMBER TRANSPO'RTA T ON TO HOSRIMAL..--OVJ R.REN1 MED. tte tana.s,inart on- HISTOR 0 AN (Attack carretrrtiute sheet) _ . ization and Other data) flPATIENT Ti .13141YATEL AMEtU LANCE 0:v ii..,&e:Set 424-64-00 IES ae-/ "4-.4 •01 A ION ICJ*, st.t. ,,,,d Code) HOM L NO. area CD :sec symptolri(5). lout:ion) R? YES P NO DESCRIBE ay LubJectoni da (Pertinesits.gistory); (2108feet-it:Pe data TIME SEEN BY PROVIDER, . incalcle iesuatai teat, and a): (3)S‘cumant (Dino. e../).-/ •-4 Tirrm Nan. (Witabilentaroe - irsc medication jalkan 4%:,(IOW- UP _.,. _ ?Zy #q4r/ 40.77 e5t1 e ' _.'" 041111'N -14ke ‘ '4 A il • 4ce: / i 4 • eCe-1 s-0 i-/-..to Vi--.-A-?'r (:::) 4-91;t41',del r...--/`;‘,.---ct 1/ee .."-e"..-e-e. „. ,,,,...., C-7 5'1-(:..) 4f., 4144 /4=e44 4: ..z., e„,z/f,„,,z; ,),„/ .0g,....„1-1,-ez44:LY.4-4-e.,, 0/ae( deA,-;4i.-7 ..." --ckWOORY .MOtt elei.e_e / ej e1#1,,, 44.05-21 ,...a-r,X.r,./0 4.e. :NON-URDENT ORDERS . ,."111s1 E- ' ¦ Cr ( IT kg. i I fit., 1 4-r. e 15 • V (,--t ii-e._ 5 - ‘' - 7 zio-deti- x I Anti:- i i # -2 , 02.-4d-e11;Igfe t et lie- 9 41f5' ‘4.-3-42ie-5 4f,17t ..., ,,,....efe_ ati),.-416 leo.L.Z - -4- . .7.`',::'.9.--. ' .ASSESSMENT/DIARN4S' ; /4",?o-.: .d.-4-ot 4. --' -al-- /.., i• 4 r• :• ef ? - it,!:.:4741*40/ 4-).P3 -• 314---t.-44g4ft g-'472 r,:e-1.-i- ' ¦ ,. 3--41/ - , --- --;,-i..-, J. -":"-e-Efec""47,,,- d.t, ---- --:.,,.4--.--.,..57ketkve-ort. ..5":1„,..0••'";t4te (.-e` -arit:4C--1.:4 ://"-‘6"e N (chi,* ar-4p.. -- OfstE DUTY dffr;e4-d-5-:. i ei-;,--3 3 ev"..ee,d-Cis41‘,5 e ,e, s-e 6v ; ;/e,iloro-fe.re-iz,) 0..., ...4/5 2- • 0:1:e4105 ear 4.,e-c e ri---*-1 6f) e 42 -"340-;,- 15.115411160 :,....„......74/-d-ti"Zeli^e,e5 _1741.e4e c446614 141r411111414;"4cov.:. 440. • .•—.. ---- --- -.. E'NOURE ROUTINE ADMIT. TD MOSP. UN1 /SERVID -,74)---`-" ` r, 7-t"-- I*PROVED de-1-4‹.-/ -447e e.ie" DETERIORATED rtx--el"---- er-Etd TIME OP RELEASE: C7711777Ntl gF 5174F N FFn n PATIENT'S DENTI FICATIONiNeaheunaal imprint) FOR !MITTEN ENTR_ IES GIVEDNarne, last Mat, musdIer ..4,6SlitUrsendet,_ -e.a.acr.manariantrreiartiOte ofiponwor-oentreorktit. MIRTAAPP:= FACIA= 80.Z.D.UTG_MIZZAT-. • . 1 (I( Ln,..1 1 UrIlb-I U M. r rE141.1` Ur:elude dons o GUI iitriitatione and foitoto-uP'" ­ 'Brar&S) : .j•77;:- , X---/` roe. •_ #... ¦!%f •• 60.,?---t • _• • • • • -nr • .ANDARDIEORIP..55e MEDCOM - 272 • DOD 003399 TA. ION TO HOSPITAL: - f7.14J R ani2r,ppgasjapppy...r7-. HI ORY 0 Mtv frroloiiten PATIENT AMBULANCE Q VEHICLE 4t4t.ell 47, HOM L NO,. ( DESCRIBE..(I) $lituaativa data (Pgednent History);. (21 Ob.Netine data(Examination -(naiad's TrilLaiN of orst2 and x-ray;)::(3)AgassarlunitililagnP` ' /1(4):Plan (Traatnutat/Pioaadunts - inande me given and 4allow-,p •-• — -.7tS1 kliV( 111#14-40011" =-StottiCtia416; 14w, riti,ccer-L ..004).RG.ENT TIME b)(6)-4 tkaaglipI71, FULL. DUTY QUARTERS 24 l-Irs. ROUTINE . TIME OF RELEASE: b)(6)-2 PATlENVE r DENTI MCAT IONNacilanisaLimPrtfla—,...-­ . FOR:WRITTEN ENTRIESA WE: Name mix Mtilale: _.--Sgthenim7 eft.".% nameass nacaaoa-nott k R LIST PA HO a T Xt ....... . • .. ato -4.-.--. --7--- -Ponmarm-rcri.ro-e.przerivwvo.,,..9'iwirrimprr DOD 003400 1`..;_aM.Na•-.,a•s • . s. •.01 dtts.Stmet, NSN 7s40kaziiTs LOG NUMB R TRANSPORTATION TO HOSPITAL (Attack camenroute sheet) M -• • OTHER (spectty) PR rvATEL Li AMBO-LANCE LJ VEHICLE OTHER--(speciryx ------- - --- - HOM LUNO.( rte. arms co-• el I n sJ , Ptons(*), rattan) R YES I B (3.) Agkkie ve (Pertineigt•HistorY); (21 Objective date NI° TIME SEEN BY PROVIDE (Zsamtatation-include of testa and x-joys): (31Assersensent (Dialno- (4) Plan (Treatment/Proeedures •,iisclude medication erki. .tinen andlnlinw-up - rssy 104i er'cle 1-0 ; "A.to 4 f‘ip 5 Mt ;‘..-, e:4 1-3..sy -or 4voat Ivi.47---ev 4 e....,uwici 1-r) AA ' 5 Ai', ek. Cvs -1(- a. ,,-ITI-tid4 l"Jletrun•H• 5 1.4-891" ky0,‘, 5 ? 1,:;1( e.1 Ti....A.e...e etOCT 5" 2e9....a. 14 1,776.4.4A.J, ate. RY (See, seueras Octott-4 SeAr ..t,-i 1r c•;"7 i or 4114.,, e-,.......4 EMERGENT C504 ,...4„,- ..e.„4, g2.4.7:+1.0, 6r et...Au+ 1,.t. .URGENT - NON.URGENT a $tLe-A gairrv.41 ec.-1- =64. 1.( 7'''. 141 C ill 7- ORDERS . INITS. '0")7/0--eGe46/0.-41 "'Cc actc-le.we / EL T/OIAGNOSIS LL . / Ttc-en -(7 or„;.4.e* 7W/4W N.---trxer/47; I:, ire_ 71 ' sr ,ca401.. 4` 44f--a a• .6 oisnernowlay,..1.-.07thatvppto fc.c.,a. NOME ,IerFpu_ DUTY 4/ ; -.‘mtv- G am- QUARTERS ff'6' I.24•Hee.. .72.1ers: MOO PIED; DUTY UNTkL.­ * 13-At -A ' • .:;-;:•-.7.-7.,`MONTN,. I ., A"ERR-' ,., /,-z sror-4,05'1-s -REFirti‘ewrovisdiectr-dim, .5‘ r-r'e -4V.1"-PC•4---;64,46. ie Xriez/ze-a;c:-.-/%44.72"-ec i f:e--t4.­ C7i. Y2 140-1:10.S-77-.. rr.ier.‘,..e.-• -,yr: tis- 4,./.- et-12,4v., .5 ,.., e-t. 5 ! -C,1:4-1-e--Ar, ,---,¦-..• DETERIORATED • s -.. • -• .„ • .. • , , TIME OF RELEASE• /CONTINUE ON SF 5717 IF NEEDED) 'PATIENTS IDENTIFICATION _Olitecharsied ImPrin t): FoNR.TAriki.)SIGNATURE OF PIINOVITIFuedearo tri-n-raeed . rrreg.r4 ENTRIES GIVE: /fame -dart, Mwt, b)(6)-2 ; LAT .F.A.Gtrarr a: hast ‘• /0MS TRACT )WRIT :,., IIVati,alstrisuunts.ct4ciatlarasordere4 any Wrnitatidne and fadou4sup 1-*-7.0•744'70;f44.`41 A. ¦— ete,or­ ere, e R7~ Trrie; a 4. - odo "4-0 f-is'xy.ieezfj.rp-4r,4-- 40 -iii- Frtr, ;t4triii.414,-47:4(4./r6.49, eric 4‘,We.-.4,44/-Y: „ sTAtermo,FoRts sat alev.6-82) MEDCOM - 274 • ,s- •. • DOD 003401 • - -:. • - Inarrycnoort : Backpr., ttts SP _ _ NSN 7540-0 1:a7,5-37 LOG NUMBER .t,etTz" 4TR.APISPORTATION TO HOSPITAL ::(Atibeis C/276 a:Ovate sheet) • . .. PATIENT EADIA.TEL 0 .. VEHICLE. AMBULANCE 1E5 14-IER-Opeci61 4-. • , Code) L.c.. NO. ( nc. area co • el DESCRIBE (1) xubjeetioe data (Pctanent History): (21 Objective data 1ME SEEN BY PROVIDER (.E..raintiriation.- malaria results of tests said x ,roysl: (3)'.­ A7aaseinent.(rdagno­ (4) Ptan.r1"reatment/Niicedared -iisclude medication stow acid foLlow-OP . . erof, Are,e1 4./.4.T.-p/ ' w •-• -"irt_ ?54., ?-;004044 64-4`Arie GORY-P*1re. -Jaaf‘irtf;.-riGeA.-•t.;-,-s _j, 4 ?URGENT' 4...9 ¦c-d-rd 11CitiftSENT' 440 Arc •ORDERS IN ITS. e- -, itt.rste - -72.(;40 - "frsi "16iee".95-.: ,(11Cd4F f°54"4".5 e 1.1,4,4 e;iee 40-7.„64.000 era44•Z•44Ca .1i•V_ -*1z Age­ t‘4•A•1. r€44:4_ ' ..---..-•••;:, 2Pe%/4".1digt•a/ _ Arie44~11:;-lAVI:440444,44e 4tree/P7117004,4'1..gog,..0 Q • RTERSZ:4-..7 .44444,1Pe•Vole 41,01 44410 e MODIFIED•DLITY " 144 "044/0--eaelee7 "412 14S 0 ',47°?‘4 --S erovotfAlr-er,e4 24/ a" 7 de44¦14 4g49--/ eiO444.44j" "afire. 4 e-F/1+ r. c„eireiftte 041-41Ce-1. .440 -16-ear-46,, --4 • bar-INV .44,603" 4.41.4. "P.-or--­-.. e4---, Awf.;4 Ale; 14-,440- ia‘ziaive _ /44- .174¦114.. Ro.)4F-0-:••••• 44)(7. 1 ,,,--,.--fir v_ „:.,‘,,, V-0 (CONTINUE Ofit'SSC7, IF NEEDEat "4'—'4*.. -47 . •,.:,.,,,,"le.44t_ PATHENT ENTIFICATIONAlechanIca(:inipiint) • • pro R WRI...14 ENTRIES b)( )-2 WE:• Name,v1ise4' 'Mat middle. 33.1V• DOB. service *lofty none end cmat ponatiebi= elekliaPOErdENTI tIrrlrA HOZ,liala *f" statiorunand foliate-up ,:e..-.4:0*¦9e0Z2ve../ .0 ;V. :447_,:i4/4014 7 1.1L4 ' • ...":57/veo 447 ft," '3.• i-76.71,--0107" 4L.3". R-ErAN -• STANDARD FORM 55II "km 6-84 MEDCOM -275 DOD 003402 liceInstiiietions_orfBack of_rhis_Sheeti - NSN 7540-01.475,-3784 T FACILITY LOGS NUM = ER bX3)-1 TRANS T TION TO HOSPITAL CURRENT MEDS.Iteexuais arensun-HISTORY OSTAINED FROM (Attach curs Meat) -tration and-other data/ 0-PATIENT [1°7'4ER (SP‘cip4) PRIVATES EFHCLE El AMBULANCE ALLERGIES HOME TELE. NO. (Inc. aura code) (Sr:( rc rxrapto , gurzazory YES I NO • &RIBE(1).gabxerive data (Pertinent Elstory); (21 °billet= data- TIME. SEEN BY PROVIDER inatioas &rebut. results of tub and x-rays); (3)Salessment (Margo-nit; (4), Plan (Treabwent/Provedures include. ntedicailon given arid fallow-up 0 s - raCC . Ti'seee^.7-1 42 ; 05, 24:.ViAt .4+0' etleat14,01,-••— At#0,144-6-..44-5 #4.4,-04.7" '-":;;;13,-,-CATE33FLY; (Seg. /Imam) ."-PIERGErfr • crozpi... ,4410C ed oetealel -44-cat.* 1.f7ic4.444.44; 4444 /Pr, ItiX .aglAfteirer""e14 I .f.-002-3,4 '111-12 'TY viee-ec tAA-s,----01SPOSITIONIEhicirait aurraPPb.P' ."..rote-sd 'MOMS 1 . 1FULL DUTY QUARTERS •464-4e4='-'7 ' 48 Kid 172 1-irs. 'AFF,keriti3e2044-1 4:14041%.4— di-7,017S•e;orie .P 4 0A/CeS i7"•"/ 25--oe:Ac .i."24_ • . • .ROUTINE 7 , 1.7:,.­ cpriOrrrOliTOPM3r-RELEASE ONc4,4Argescr, . Tar-eciF,fRELEAsai ....„...m.RwRyrr-(coArrinwE ON SF 507; IF NEEDED) i..-7...3mTreN rrrwAENTIEs rCISNYI PIROATG, IO:rd:• ciart ottrIkulirail i.e emlelLita --,; . • • otsTR uOTLONSTP_PA7TIEKtiv aheitsdernuicifeatIona.ordirred, :inty Itnrttaieons and,f4ilinarla- ti ;ACV-. 4 CIW.,31¢4,, V:11 4eANDARD• • MEDCOM - 276 . • DOD 003403 s r. 410g05.144* 7 !Sue lustructions on sae* or this iheeri ... 1-EMERGENCY-CARE. AND TREATMENT TREATMENT FActi,_Fry ristumg, NSN 7540-0i-07S.3786 'i,..t..f. 4;:jimigik:pr#0.ercri.-• 2t 'MVSj4 Ire/ TRANSPORTATION 0 HOSPITAL !Colttaaii•care anrauta sheep: PRIVAT-Ek 'ABU LANCE litoariaV •:+`;'•, • • ipre y OtHERZspi! -VS. NOM A. OR OR DUTY ttY, State and Code) L. •:.;,-:•••••.' CHI • •-•. 0 YESDESCRIBE ) gybjectsug "data (Panne:eft RistorY); Mob/active data VITAL SIGNS (Examination - 4911§16-include resaiis of as& and x-rays): . (37 --aannant Ssa L4LEAiirt • .„ liposipneatatoceduriii.rirs.plude-ntedicatiorrgivarcuidloilow.uR :BP • 3,1 10-4 re,tiaf, rrial..L.E1;W t-teciv1411; MosioL. AULSE 4;i1--;---i n ba ck Was • tAff-A*I't:I:CCig•V2. L_A! , n.‘ -11`tiViornt'5/04.10 (1.1 , ovrrr: pan .cfrilp64 -4%101:0—.fiLW - Itizohrs - -CATL=CipRy..(Sat ritsg!..e) 'EMERGENT- .: URGENT ,. CLL, A :..4.- .',/lOMPRGErsr• : iLt pROERS .WITS. TINE IAL 1,4,14,• tsfaik4z. ".•• 1 7 7' •. - -As_sigss ENT/DIAGNOSIS : • . • 1 4; r e , A*4a- 6's-z1Z ?t&-p-u-:;.:: -0.4 r- e d i S — (f) cis.e5 ea vv.* true -A cch-d_ dr-4-c) - Cc IG ­ L"‘" • (•-•' -r C;21 S eve s •• ( 4,-v3, A L., (.7 C „. • + c 7•• r.04044Nciets icrN-42_ glv S 4- trr ME t:IF.RELEA,SE- 4,,TATIENT'S IDENTIFICATItItra iq0R, WRITTEN ENTEs.atvratet-s thin,* uttcr;re oh -Sponsor or nowtht. PORTANT: EFITATTNOLDING TREAT. .:..... IP* "Picuttl SI b)(6)-2 (CONTINUE ON SF 501, IF NREOED) ....cow meraradaraa, an Plot A- r Vt4 ilmitatkms and foSout-up . - „ —L4e •••-/ c MEDCOM - 277 STANDARD-FORK 558 (Rev. &-821 DOD 003404 -aL,i;ffik )5, Instructionson-Bactotthis Sheet.r: NSN TREATMENT FACILIT (.s .LOG NUMB ENTERGENCASCARSA1SO: TREATMENT • . - . TRANSPORTATION- TO. HOSPITAL : UR R N- - - Ir- . Aletanas mm un-1..i)RY 0 N. NA isa......a.arc.,7•Aggrir fAttacita.iFee elr.01/1g siiesitk -.ii1itiaa. tairt Other data) a m_C_L____,..... ATI ENT El °TmER (SPectry) "..^i 177:PRIVATE C" 1: AMBULANCE • !"...-.-1,-. • ivax-,z4=bitim L-IVEHCLE _. ..., ; -A4LERGIES i.l. ..All ' . ..40 THEFI4ST/i#frii)-tK. fiT----7 21/011116=11 .. OiiCtO =r, .7S. 1-1011 A • EIREWOR DUTY STATION (City. State anti .Zn'' gado- Home TEI_E.. NO. aaa_ area code) • " rrirr':. Ito ) :1 .E YES NO VITAL SI NS DESCRIBE (l.) atim data. (Perth:silt Hister7):: (21 Objective data TIME SEEN BY PRON.'? C3ER 74'4 7 (gssniina#on - include . resiate 1014- and x.rays);::(3),91sasament (D 11911310-);.( 4.):Plan.r.Triabnent/Pkiaedialts - thetzulc enadrimition riven arid follow-up \i/c, 1 e/d .os 0.% 56-r Per¦ H; ORDERS 7tME .AAsessmstrtriosa!,tos QUARTERS: 174:144ThE ON•UPON; RELEASE . . • . _ -(CONTIN(JE ON SF 507 IF NEEDED) TZ-10ENTIFICATtOttLedisiiiiisima rirst1-: 1gxN1 A:" 1:17.EZ Namt• 116)-2 nu' • ^rcr G 7-E14-7-17fihr 4r PACILIVZO enriTirr9 f115-TR11.1',T1ON.S..70:PAInewr medico-Bona -ordered, anx-limitations and- follow-up •';^•;• •••,•••• •••774._:"' - STANDR1ER:EfORSL MEDCOM - 278 . • DOD 003405 • •. . •-• ' (See 7151,S,04 • )?USN- 7540-2-075-3786 LO NUMB R i:::;--1--4EMERGENCY CARE-AND4BEATM ENT • • ARRIVAL ,___.._:.rARttacNSPjrca7e0R-T'7'A'rrieni.o;tte OS TAL 7izatiClURanEN,aterzaay/ISIZI unmein- 1-11STPR OBTAINED FROM anerEDS sheet) .... _. _ . OPATIF.NT CTI-IER TE— 71 PRIVATE . AMBULANCE . L_I VEI-11CLE .ALLERGI ES .....—_-.--......tow.,===rorimorpgi A • - rl.1151FWE • sr 0DRE53 • R DUTY STATION (City. State and ZZP -Coda) HOME "TZ. NO. (Inc. arm innieJ DESCRIBE (I).41ableative :data (Pardnent/RatarY); (21.2 lectialminta tAxaminatient - indkide moats of tests and x-rays).;.(3).nFenament(Diagne-- TIME SEEN BY PROVIDERas); 4 Plan frntabnenta, iia:miants -inctude_TvgmtlimelEspLit kagow.cip 7 0 cir S ... d " -;74i • : Le.x.4„... fi1W- DUTY st. eitmrzprotirtrUNTIL.:- e4-42.4t ' 0 e PNCHAMGEM: 0 .1a4e-ti . CA:4-4-21 .04 l7 /.0 -4 DEMTIFICATION.aftacinusiankiMprintr.EtWTRIESZIVEs • bramg,jaltfir#,F.2.iddl*;..r• sponsor-or nazifPACITATI--.1301.DING-ThEAT- (CONTINUE ON:0167, IF NEFDEDI •. STANDARD' DOD 003406 (qSN 7540-01-C75--3786 (See lestruerio . . _ . A. lLITY fabszrzfri_ ERG ENCY CARE AND TREATM ENT TME C• -ktIV , ") '1" Wei:tics/ Rican.. _ HISTORY OBTAINE-15 FROM " -CU R RENT MEDS...tte Lanus immun- TRANSPORTATION TO' H"OSP ITAL. isation and other data/ OTH ER fiSPeciftl (Aatach.eare enrm‘te sheet) ATI ENT PR -VATEL -AtirApu LAN et- A/it OTHER (Swell") /14 ; /5 • 0.2] -• HOME TELE.. NO. '(Yric: area-code)• 4 VS NOME A6DRESS-OFICUTY STATION (City, State and zip Code), sYmPtOm (s), • Watson) , . 3 /, 4 ar", eCi&A. Of;, -- TIME SEEN BY PROVIDER DESCRIBE (1.) §pbjeetive'date (Pertinent IlistorY): (210biectioccieug vITAL,MGNS f samiThation—inetudi-eeesate.24.61etKandeave.);:61Legoresernent (Dievie, res.; include talon riVelr aiuTfeakitilit,te); (4) Kan (Treatment/ , •••‘• K(f _ :• /44 FT 4.4" t-rt, A 1.4 ' frtfts e/o 41 'Or -‘?1 Ge-4 oforvt.24 w,5 AZ-vs p O37 "t.rieete- /14c..-4 z/42.:(1/ de5 irruAle, ert-3,c1 /27A-,f-•11-4-r f crole-5 1)1---b•.,/:1;°-, PT- e • es-IA 43pti ,44.A. • 52:( 50' - LA/jt 4i ; 141;4"/eP4) /A 0(41/ f 0.-7,14;`/ ="1/4-4 01-44."7-2-5 et • 012.4e 5•14-,49-e- , 4 0- •fii/-11-•,-. ‘A..- d 5.1"e4/,‘ //ze 470At-,;es fit:5 eGe-e-T- 7.420-}1,4"; /17•00 4".°5005' 0-'77/cc/ "toir`ZX1,; : , )/4 f/42,1t 04.42 te. 3 r C /6 //o /"C, ( 520 h dat.4s "Z" /-57-?0, 3-7/ 9';7 .1E-1 -Aar-pc-ed, -!"--294 P="I'!rcp r GE"--?4, 4-4' ?icose G/ •'s ^^e( : .RELEASE::.. e.idc.,/ a-5 Az iljVGtIdNGFcY (CONTINUE ON SF 507, IF NEEbEDI 47201)-- •¦•••••• •r1 aiirtaarbeiRrint) ..021ra-' 1.7. zacrnies.ate4 Ntzret mst. Mid e; relation ricinktricdrz././7 Fot SlaseiR.§.4un INSTRUCTIONS T PATIgiWiTnelude medications ordered, ars," amitationsrled­„ Awes) Ai -,407X1.40V : ‘1%.e2•Ic.,y lte /7-C-larlif LA...-.. / 7 -a**- di a f i,eAle rc0 % 11‘.e/fh:r;, 3440 "e'llee..4¦Ce‹., , re,4 ,j41b./4 ..een/ -e....,../a---e b1,-Lf 7-e ley.' / ,-,---,IF / i4.5 f,-,,,e,/,‘.........r /4-7 ,e-r A.-1.---- MEDCOM - 280 REATMENT STANDARD- DOD 003407 . •. • LABORATORY RESULTS -FORM — 21st COMBAT SUPPORT HOSPITAL (subject to Privacy Act of 1974) RANK •SSN-4* RESULT REF. RANGE REF. RANGE iy I 128-145 mmol/L, 3.3-5.5-g/dL 4.8-10_8 x10(3)/uL t6-11-77fi1r. Ute-" Uft /10 I 95-108 twat_ ALT 10-4T U/L _ I • 7.35-7.45 AMY 14-97 UA. AST 11-38 U/L 80-90: mmHg mij/dL :3545 mmHg, -1633 mmol/L BUN 7-22zmgraL 22-28 mmoa Ca 80-10:3 mgidt 95-99% LY% 11.1 I 15.0-55.0% (-2) - (+3) CK [LY# I / 17 0.7-43 xi 0(3)/uL 8-18 mmoUL CL Differential 0.11-123 mmol/L Seas Ciiat Bands . 11.77.1.73:1 5X35 Ulf= Lymph 0.6-12 • _ 73-118 mg/dL Atyp Ly -. 3.3-42 mmoWL 'REC. Morph: 0_,g/d1_ _ _ VOA Na Z'Tf-T.sr Tt"MrqlIllMIE MPAMPaPKOPIRN. .2;s1". OBISPA 1.010-1.025 -NO FOO gal Etemerits .•- Nitrite itne-icroscopic • • Epi AWL Mono RPR I-Yeast — Meningitis MEDCOM - 281 DOD 003408 7540-.01-a75,37 1..0G NUM TRANSPORT:Aida To. HOS ARPIN/ ( SIR% -er,VIVtearseetr.„ R. . ---DATE .) PRIVATE,-1415F-t ?^IR CSIrtt 0 AMBUL5sNCE • EitCE: :,* -r _ .4 -6-1E-BISPecifs9 - - PATIENTS 0 pg.sc E. (1 anblectioe data. Reetinent'His torY); 421 0 bia aline dataalaamtilaittlis -Include results °Pints amis.-m. "4;13T ­ ..erisessment (Diagn°- Treatment/Procedures - include menicatton Oven and tql*Ittl);141 Plan./P IMINE11/11,1111111 04.4" t rplq et, _gecc.. f: _ i, t-_ -11) 7 At._ Puutiti..,:sc PS f-t a.",..4.4.•kei L4- -T68 ppc EMERGENT UR ENT .:7N0N;URGENT • Li ‘,5.,e(r,p4e- & 1 2:44 4 2"?4:14 ,fes r4. dArlw«-14., ,4 tv. a-7-c a r`4/-`' 4.2 TO /4 .6-4kob -ORDERS 8toti LiiN, tt"A4?,17 41-4' 4'13 L i't cr.P. ACic ie: f.6149,S1471.0r0ohecis GOissit'4434- ,CLUARTERB Ortt.: 1-1a• 1 481 I L 132 k4L: iy. • -;,z4=4' ,., • ROUTINE hh .-.0 UNCHANGED- •• S.° • MiatEtt" RELEASE: •(oirrniqiE.ON SF 50,, IF NEEDED) I OENT1P1CATIONAGIreaheunaal SIGMA", I RF 0F44/FtvIDER AND VrEN ENTRIES GIVE N jas b)(6)-2 b)(6)-2re dear sponsor or meal (mot= LIST FACILITY HOLDING TREAT-NSTRI.a._ rurea: I,.p rw I T ENT fhialudirmenieaatorm.errdansel, any Ifraltations:an4fallOrAn " X0-4 MEDCOM -282 • . • .'. . DOD 003409 75441414715,37fie: - LOG NUMB .LEPAgEl.GENCX-CAREAND_TREATMENI_ . adeditil fittemtg •PANSPORT • T ON TO 0 Pt AL (Ap2sois agicenimatte ikeit) . . . . PREV TEL • AMBULANCE ; PATTEN ATtoN: (alt', State DESCRIBE (1) ambieative data (Pettbuirst.HistorY)V (210biectioe data IME.sgEN-BY pRovt•EFL(Examination - include results of testa and r...rays):. (3).iisoessmastt (Diary!(4)• Plan (Treabizeol./.PrOceclurer - include 011oar4diOn iiltied arilirfPFOW-917 •12 ,41 14. kki *fro t'002; :6i:. 1-1 tn 1-wItr" Ai: t„249• '.•1• • IrCk0V. 14.6-• ear a 4e •(-• .• • ; ORDERS rAt*--,:q _. e44, - kr. •••• t.': • • r -7-7- -.-•-t;,-:-7,--,--,------ ¦554,44, .._ .714-‘,1 t.:4; • a: 4r-i-e K. •-• r Y4ik 4.-e-t ::ii„..4„.:z.: Tv., -,,,,;.„.1,-1. i.„....62 "..,:...A.1...1{- IfTaSMEN:1701AGPtOSIS as t7J.;•' ;.s/-4,4 : Pe6griifft gME FILL cur* ,.-74;211ARTERS: rtiFIECYDOrr UNTIL: • . •-• . "`"'ifcv'e, -*-,(4--2?-4cY, , r.,..,-.4;3" • xseii"• itIVA+fe `.72 1-10tiTtS;.: • / • • • • • ••.., • " • '15 • ..7f2r4ort-'::5 7.Ve7A,77 %-t•­ 4/Ciie *t"'S . "te e CHANGED1-• . *:ge-j'i4. 1.. • .7 . . • .74* • " f•41 . CDNTIAME ON -SF 5071F NEEDED) umers I DENTTFICATIONiatoehookol On rintr ' . WRITTEN ENTRIES G IvF,4 Name -lot -; welooTaiisi-caidielatiais orsRonsor or nest RTAArr: LIST JFACTIZIrPHOLDDIG-TREAT- MEDCOM - 283 DOD 003410 14.514 75.40-02+0t54i786 EMERGENCY CARE AND TREATMENT , TRS' 1,)(3). (e-Erief FteCOnir TRANSPO ARRIVAL TION 7470,.,1-1012 : L .CUR-REN 114 -4.7,"* ttstratoz, own TIME ization,crad other dataj PRIVATEt • 1/.4/10'At • . (AttACii•*irt p0miti.skeit) • • ' .DATE AMBULANPEL-J VEHICLE Itegxe PAT! Mom DRESS UTY. A lo r tty, State 40.4' • COM , • NT(51 tamer), dura ..n) -", 0% -6' li,' • 4/475/1.--4'7./. fr.7: VITA,L.SIGNS • Dimzu..).No.i.o:ft.tegiior..-vg!,g f....t74,:cifIP14 •' :. ?eNo `Tim;saiiq,B,/ ,PROVI-DER 1 (4) ken (Trearrai„......; , wbiteist/Prcici -include nueileation.cfruenteitTrei • ,/ 1 • ZI.Aiwt..4.... 4....,,,,*.k....,.. _ ._, ,,,p li,Ki e•• & .': - ^ e,..4.,...e,. -.--..- fik– ,4:io. ;',.. 14.)-77 Ai I.TGORVISite reinseel ..:4-,..,-.... i.,4p114gipF1GENTr . DME; . Routi NE F 504 .1F ¦YEEbEin . DENTIfiVATIONAltretuirtical buRrinn . Mint)' RITTEN'ENTRIEWGIVE6 Name - !art, 1:1)(6)-2, :14uMf--.Inckceee naCkae; 01.- —ar*lud-relitlorr oe RTANT; low7 B:ACI•ITTHOL.DING TREAT­ -SPX- •:' • MEDCOM - 284 • DOD 003411 • 556403 • 544. of U^is-Sherd -.EMERGENCY-CARE . . GENCY -CARE AND TREATMENT• • • ..• • • • • • TRANSPORTATION.. TO. I4OSP I ­(AttacJ cart anroute ihtitt) . • 177112,191VATEL . rr-i • •qmp3 0*eiof TREATMENT. FACILITY : Matasity . ti_RL'7540,01.13/5.4*86. CM ER (3Pfelf71 oEscniElg-m:pWeettoe data Aretildnant EffitotY):.intal lispeirsawnination -, Anchipie.iesUltr.of ticsi* aftd e(3) ­jgadatr4ant:40, (4). phm. oieude .#ted!,,,,tiongton add•faatoto4P• • the COC44 e .-"eitt-rf c.• 7. • fr -. . ••-: • " • • SEEN BY PRay I DER . -( L/ . 7771:4Ze : • ex.111.1 - •• -T4A4'.!"' rlESSMENT,713IAG140.51S: 1.47"AbO:Fis •014640iitti.ki'-• b)(8)-2 -PA-TIENTISIDENTIFICATI.ON Dfachandad. t gpru a:: ydIRLTXEPV,ENTRIES.Giyas Mama-484. 'In • -airiddraWat; nonta-taid:taksffort otaPaltddr'ornex o kir= RTAIVr LIST. pAc r J30Ln.u4ra.TRE:4.7- -p . • , "t",-..Saq srAiiwatrFollikssivO.i.s.44. MEDCOM - 285 DOD 003412 • : (See instryceoni on Back of thi Sifted. • NSN 7540.01-075-Z74-TREATMENT FACILITY (Sitimpi LOG NUMBER -EMERGENCY CARE AND TREATMENT • ANSPOR A ION.TO HOSPITAL (Attack [We gamuts sheet) . PRIVATE` 0 AMBULANCE VEHICLE 2_5 I=1. OTHER (Spataityl• : : DORESS OR -DUTY STA anaindesymptontlat. duration) SEX POSSISII.ETNI RD PART7y. PAYER? A.A DESCRIBE (1) pablactive data (Pertinent. History); (a Objective data ilmE SEEN BY PRctyi DER (Ecanzination inched*, result/ of teas mid #..tays):(3)4Pasfeinewt ITheinv- . TIME sii); (4) Plan (Treannentanaaations -friend. niedinatiori X.tdit)4.4( t$"O ei-AleS. aeS aft- COH /161-ktee /7 .eier' 5c..e 53'r s4, gssmEtcr/DIAGNcrsts .$4,0Me. 119)ufmtofe ZitilOORS ROUTINE. MIT..T0.HOSP. UN • /SERVIC K,:cotgorRoN, ur014' RELEASE •!Z:e •ROV . :'''.1'176L.;0011101471.** i.CON77ff 11E aArsFSU lENEVIED1; rlENTIO_EN-TIFic•AT..CONfiliieehignigni AlTiprif_iii :: gc(6): --7,,IFORL.. : iVit.ENTRIES,GIVEtbpsinit. biet,.imim:middlirt "S.S. SAVQ14 settataa statai: 4 name .;,.,f,-..telk -reiation-arapottrar-or nectd :s panwrs .usT PACILTry ii0.E.QING 74z4.27.-,• - . . . ipg., f1.111.:J{:: 1-1411VS- ..I U. PerT1 bACTIMCILdit-rtgltdfiCaStlanitTreiglik , :. ill 4ZZIMIACItranaa!Ut. ?'011.?"?' ,?...,:ev% - -•.-. .14 r, ':N.(..-51 , EA.. - : ;1,:‘ / --.,-7. -- ....,. MEDCOM - 286 tti4NOARDCPORM:560141i...le-tiOf .17 • , •-• • Q.• : • , • DOD 003413 (See Instructions on Back ofthis Sheet) NSN 7549,c1„p75.1786iv:::' REATMENT FAC (Stamp). LOG NUMBER - ENIEReENCY' CARE AND TREATMENT , • (Media/ !Record • 24 t .640444-i TRANSPORTATION.TO• HOSPITAL CUR REN mEDS. the tanus gnuntot- H • - 0 AIN MAlsfch cardertroute• amity ization and other data) DATE . . • TIME LNP4-4ATI ENT CMIER {71 PRIVATEL 0 AMBU LANCE -1/6'5` 1=3 VEHICLE OTHER (speirifyj er.v/Aife-44. 1.4' / ,E.dirf T'S..HOM Coder 'HO COM' an P .R V•TAL.SIGNS DESCRIBE Cl) Lab/active data (Pertbuint Ifirtta7); (21 Otdectipe' data ." -inehodb.auautte Of Oita-and,n-retza): . (3) .8izzinlIP‘Ple -r adagn°-. 3: (4) PIwi (TrzabIleIFtterccedurzi -glum aidlog4WitIO "-Zee. cer %9.4, ¦Ajfal 4?? 4/7A.4*eZ- 64/7 Ze Wit, • • //LdJ 5... 4eoei3 Ala de erg &;07a.2. , /mg,' e;rt /C4; Roerrr. : 4.t #004-1.‘ ittaOtt,: • „op 124.„; e"'" .71f."4"f -- /¦-sof.".i14/1".(;.-.•Sai.....4e/....4...:. • e.,;,/4-1' 7011....-t "18110"X -0'* )‘ Al-"K W.dfeLt.." I Q ‘..011-dr e'411,r idc/)61.1 _P.t.f et, 1V4e4 . ,151ogeor . isouire",a/ fro try.f.441,4144.x. P9LL 010,­ /IY do4.4/ef • .444Y fe—ah Avoc;444 7t 44-0*1.4/44" iZter4 • ita:tytes­ friede.( - 4':,41; 4'4=1 AlditgAGEN&A- - 7.21;..101.1 ROUTINE. . _ •EX Ti0e)e,e : 0 ezeor-142/4P004%er iawm.4 :2:SbiPec Pef. VZCONDIrOKIJPORREgEASE • 00-7441ea och-kv: r 41.57 ' ,;....,!':.., OF 4-ANE ., - :, (62ArrliVil: E70.: 4(-F50.7-„1601EE tD1.:, ,:9•41.:4•PIENT'S-.V.DENTIPTCATION COfechantaid'imtnattr ' 42^”' 114 ng'ctr"ir "'""'"...."'-'"'"""” ' i,7,gKantrga-. • ;,....: 20.11ttneroicrstanwmarnti-ane relation- ottoma= or meal ,..Art.ErcrRieszPvE. Arame,Lait; 67E4 middle ;:' -b)(6)-2 47....-'‘,74-• ¦4('‘e.:..... ::: , .:,;: IMPOISTAXT.: I..' .. , .r.AF.11:1727:HOLDING TILEAT- '1,4:1„P-faifarr7tr#C13"1 lidos&• &ur t) oSo 1...., arlt1/4440,...:::,-,-,' e:41;r1".",?k'**P' : 'et?‘ gr • • . : ..' ..' - -.. .:. , • .: -,:,.. . ,., :.. • • . *; . /4:6*: -1-4,.*;14'ffer.:+f--.)2--- ..e:44 ;."'Fi4¦•-,i.d.,. 4.4. ity".:Ar., lf& ...„:„...., .,-,......:. )-:..„-ir,i1;,,,-,..i---..,...- MEDCOM - 287 DOD 003414 -• -• — nstractsanront-fiacfrrt • . . . ' • - • . • NSN7540-01-0759713S •3 t ..;T7I;;MIN., T11ryr(Stansit,: "—f-fr.:7:•=?. .4:EMERGENCYCAREAND-.TREATIMENT --':: • Rant)-• -• • • • s)•sL•r • • • • . ''" • '." • TRANSPORT.ATION TO. HOSPITAL . . . Ps1,7.--• -(Attaaltaae• ertrdata zhotOt) • , cup par.+T MEDS. ttetrause:annzen= , .14:STORY OBTAINED. F ROM . • is.ation and or data) •t EIGTHESU --;,".•••-• • PATIENT (aPeefts] AMBULANCE, • Er'ZIMEEL ' 2FEMIEF4D014159-'-' : EPa`t.)- DDRESS OR DUTY STATION (City, Stage and ZIP Dodgy; . . _ HOME TELE. ND, (Inc:, area opde). • • plitTe (4: Ytt 1:3ESC RI EtE .(3.) • ELM/active data (Pertinent Eistor7/;:(21-2bieetinegintaL, ' TIMEEEEN-ay PROVI l'Examtnattale include result:Fat Oftz tolds-rayog(3)Assetairtersil pigigire;A (4) Van fritattnantiPtcia0datek=' biehieeiiisdiaatoitliven' guidisdrop-up . -'0?.g4): AI. I \ ' t • :4-A- 4-t • • . . -0..,e)'^:"A37,.¦1 I ' • ITIOrilareaFeW11.. in,11.7,!.d. TIFICATPDISILate--changes, firap.ript). -•••ENTR-1:65 GIVE: Nama..: las nreteeniddliti-• •tor-• oftwarlirltair. ' .-FACILPT , M : 0­0 ,‘"16 1,12= ••••¦•... MEDCOM — 288 ,4 • DOD 003415 553-1(73 ass Instrundons on Boot of this Sheet) REATM AciLi se: altaaspi • , , -EMERGENCY CARE AND TREATMENT NUMBER;.-• "t•ii 24. 5: tC AO. 1;414'¦ • :AKIWA.L. . TAL CU R REN M erratum iMM R • IA TRANSPO TATION 'TO- HOS • - • • N.A.(Attach cam ersroute sheiti Lradois and other dptal • TIME 1:10*14ER (Specii'irY DATE Ctke..1/4.44:{i4- I 0PRTHALLERGIES, a : NEARTveroincifpw uzAMB LALies. NCE Imo- 11/4.1Te-X 3 -4-o,t (Q vuo rcf .A.T1 S HOM ADDRESS OR DUTY STATION (City, State and ZIP Code) HOME. TELE. NO. anc: area cads) J. HI COM eymatone(s), ura .03.GE SEX, .._POSSIBLE T' - • fk(La :S1)13 YES• E] NO DESCRIBE (1) VITAL. SIGNS tive de.ognatt krut./).-(21 2bmatim data •I'IME SEEN- EY PROVIDER mbustion - 'waft and. ;a ..r.n. R nt IDE'esw' TIM !-•Plat a z:ileekitres -tnelude:medn giani:"caid failoar-aa 2 6 • BP. Ps.. /Walatit22ifErAt • iO, p • . o I K., I SS pm 4 a PULSE y pi , si qtfg r' 444-i loi)44 09rkev-_,:ii,d41,"faAlgtill to RESP. IPSIM951111211111 •„ ncek Pr\i' S'14'43. loctm: Pt NoX) PAslAir5 / MAD LIflitate:21PM1 • PS - AINCy1.0 ZERIZ 3. y C.-11-A• 0 -71-¦ 7 4: 4. 15 /1, rc4 TEGORY (Sei alma) r zac,,t ''EMERGENT • FT / ¦1417.1)• . Z.1 ov.-4-i-L.v•-e-C) RCENT. . A :• • • • • • • 4‘,....• 7/"..":""..7” • . • •:* 1 hi5; c .t • , .7, „ RD—r ROES rE. , • ...Pt" C A MP' • ) 14 rt• •••;..W-iatf,,.'" k•i . 1414g1 ESSMENT/CUAGNOSIS'• •- • 7). -.Cf. •9 • JOISPOSIT1ON Vhaelt that atag7) :.4EPLL birry • rejAcf.--. r ex2i TODAY" r-ktuatiestachan,­cat.hnps*a: gistwRies Marna -ioak mat, ikterdiect fttue;-nose end relation' orator or next RTANT: rFACILITY G TREAT- • MEDCOM -289 Al mENT DOD 003416 RA ATION TO HO5 ITAL(Attach_ ems ererazite sheirq PRlVATE^ •V• AM SU LAZ.q CEVEHICLE-- • 0 OTHER yspsgtfy) neixal-tymiltanrfrk duns Z 8117,-DESCRIBE. (1) wafeetibe'llata (Pertirseitt irutor7):fnerelite-sentit* . iii.a*staltOwtlx-rays/i(3 - 7Lasiessonnitinrditiaciv:-Tar t ion irie.144 ine.ditirtion ­gfitirimidlcireniA4P .4. --pvtitntV 6avi A . 14. gaG414Z • -L-;z7 : gmERGENT. 1•5 . • C.: 71)^g" "Cr". L:virt• • 1",. j-- • e ' ..t )4" - ttv-417F--- attak$21 DOD 003417 Z7i."%.751i6-103: -- (Sae inscractions on Back ofillia Sheet) EMERGENCY 12ARfAAND) TREATMENT rSTM C • (Etinnp) TRANSPORTATION TO HOSPITAL CUR RENT MODS. tattanas aeon = ISTORY AIN (dt-tnah ears enroute sheit) izadan and other data/ gPATIENT • El°ThER (SP•ethd rl RIVATE' • 1:1 AMESUINCE L-1 VEHICLE t "laCTIER-(5`paedi;) Wt/C1 DRESS OR DUTY. STATION (City, State and ZIP coda) \\L H • -vr N • .. no. =CV -• • Zb.1.0-‘• PLAIN. -) sYmPluet(s . • • • •rt) E YES ES. . VITAL SIGNS DESCRIBE C3J'gbJective data (Pertinent HistatY)r (21,0-ttiactioa data TIME-sgE•.Ery PRQVIDER(ExoninitIon -include results of Lab god• x-nry±gPV.Assaalmant. (Marto.; •• nist)114) Plan C.4u trnant/ptovide t c ...megaigogArbot Aim fesow...up 2i up C a Ilb !c•¦•oel'"ct1 it) 105:. -ii; ¦i)C-vracj, ed \aceTK-eciet(i ve-7 0-'t . x-K6y.1c‘i r :;?¦ .¦ cln Y.Nett (czyyxi..644.0 5yrov.e- Li5 . tRY1314 Tanana • py PU.:111 SF57J7i:IF NEkbEfl-1 .' siov bX6)-4 . ._Fmti*Arei424- MEDCOM - 291 DOD 003418 (4.5N 754o-oa4m,476G, 'T-FiEA NI TENT FACILITY (Rtant./0 EM ERGENCY CARE AND..TREATMENT. ' • '. flifeen*Recard)' • RANSP. CON TO 1-10SPITAL CU R T MEDS:ttatantar aizatun- attach cart anroute sheet) . . _ PRIVATEL 0 AMBULANCE . L.J VEMCLE, _ ..... . ,....OTHEW(Sosect,)• OM ADDRESS OR O -STA ON (Cstzt, ;State an „.. . • ¦•¦¦ CHI .X.ONI .55 DESCRIBE (1 4uairattas data (Pertittaitt Illstdry f: Objectlpe dabs - • Macartnattaia -include results of testi and.straysg:(3)AsessoriOrte (DliePre-4 :,,P,101,..(TMAttRatttigSaapdtpstitipalts4testltatithardimenyatia.tairota,a0 Oiciketniatici.0 MEDCOM - 292 CrIVIENT7 -77.**7 tbiainARD;FoRia ::-7, , DOD 003419 S _ fIERGENCY, SE .AND TREATMENT FisbE;/540431-0M378t_ ieiiR : " TRANSPORTATION 0 HOSPITAL (Attach care enroategheitl AIN PRIVATE;- MONTI4 YR. thiOr.' 1 09.711gR-034i2ift.r.: t;" VEH1C‘E -• 4*413ULACE:Orge07hiXtettii T7S HONIEA DRESS OR CU --""'-.VITAL SIGNS DESCRIBE (2) 41thtectiat data (Pertinent Histet39:- is OttkrOtibikleitcr(Examination ,: incwEe remit: of testa.and-x-me_k 131 etaimagnmitadaenoi — t04-9-lan•to mmaneatvPmmedoter=rriude medication gams and Mr.:P104P 5”. c - tteG. a x 9 cts n p4 h, 1n.q s giles.3 P4 .4 aytd -64(14 'Fdkr`A 3.‘"1 • „M7:371MORE S4 !1.-1401..7v- Siew.otarrr MEDCOM - 293 DOD 003420 - • - -- ($re- lortructions orr Back of thir Sheet) • ---3786-• TREATMENT FACILLITY -cEtansnf - i1. EMERG.ENEY CARE AND TREATMENT 1.0G NUMBER a Ricanfj 19.4 "tfac4 Cam enrolitr sheet) isation and °thy-data): -IsRREVAL - :4' - -A011.54,1 rAT Ioni Toi p ITAL. CURREN r mepts...ftstansis tmanun- TIME EIPATIENT' 97.11 WP,Pec!fzei --, PRIATE,-• AMBULANCE 1.--i VEHICLE ALLERGI .16%A er- -OTHERt(Sp¦ci(y9 S.HOM A. REES OR DUTY STA 10 State • N I ..Oucle:PMPIPPI; •t„.7k-• •: YES ,. E. NO' ' • VITAL SIGNS 1210 141 it5/.43 172.- VP-4-Antr-s - MEDCOM - 294 DOD 003421 LABORATORY RESULTSFOSIALti 21st-COMBAT SUPPORT HOSPITAL (Sub'ect to Priva Act of 1974) SO-90 mmHg- —7 t4110:0440Regi;FM. Straw/Yellow siai, M••,;.-•• riiTi MAI _ Negative At-4 - b.-1:1 talm t10.) Negative ffi Blee;.. ' L"",:r7.1r071 -Negative -5.0-8:0 • 4.1 Negative-Tiede -.7 77,11:4 „:=DEM21111 Negative opic Spelinatozoa ___,_. ....azasimeemesimmonesemmimmoomm.„. ALB' AMY. _ _ AST iihono Tiopotiiii `r. ¦Source: Gram Stain WetPrep IgKer mum Otaild - • O&P • ;‘, Sneckiren.DatOand Time: Date -and Time: 111.3s'. izta 4.8-10.8 x10(3)/uL ! , Ly_ _ Be Morph: Negative " Negative No Plasmodium Seen Negative Negative Negative • • cuancjimi. Sed? Rate 1.07 man 10-13 seconds- APTT 22. 1-33.7:Seconds Negative Negative Negative 200-400 mgldL No Fungal Elements Negative • No Ova/Pat­ ails • 11162M111111= MEDCOM - 295 DOD 003422 • • •-• -••, • • At • • • .• • • ¦ • •• ¦ • _ • . . • •..• • • ¦ • • • • •.. ¦ • • • -• . . • • • • • -• • • , . . MEDCOM - 296 DOD 003423 NSN 7540-01-075-3786 TREATMENT FACII-I --EMERGENCY CARE AND TREATMENT LOG NUMBER. , modicar ',Word TRANSPORTATION TO HOSPITAL ARRIV .L CURR NT M S. Jletanos orunun-ORY 013 AiN.R. (Attach cats enraute shirk) ization and other data) TIME • PATI ENT OTHER (3PeattY1 PRizvATE‘ • pvvi - RFs 4. AMBU LANCE V.E1-dCLE. Lam _„.. 7 CTTHER -(Etiecity11 -ya-v1 n IC ! ATI rS.HOMEADIGR OR DUTY STA ON-(City. State and L. NO, ( area co tzda eYMPtoinfe). Gan) I = H - • PA lActAtiig& //IA-4 0 YES Ei NO VITAL. SIG NS DESCRIBE (1) SobJee ve data (Petonent History); (21 CM/flatter data TIME SEEN BY PROVIDER (Examination - include mazats of testi artcrx-nnra): - --• TIME- (3).Assesalnetir rptcgno- - staN.1.41Piatt Meabnantarocedufer—inalude-msdication-given,ancl foGaw-up GO Ce.ylo kvi-,14 ActAu.g., spa. -4e 4:-Ic trait, j14 L. Lt 4-qikav-e Ge4.4fa* ayt SG CA,S.A.4.4.: ETA) • c :77 1-11 cv •sai. • 7_7 6/ ps ­ -7.4' .. 7 -4. L,;‘,. .• -. . 4.-C1,_ udays• EMERGENT cftx /ff: ...• • • s • cl•-¦49 ••• s 7 . -• • r C •. .:•.1DISPOSITION •--: ichaeleatilhataanttil • C.. , _ 1-tomg: a- 7-T.-A--s- ClUARTEn. ,z naruru. ROUTINE . /74 MIT TO HOSF.....IJ IT VI 5, &LA.., C k ? re IL.; c4 T it v s etre. !ORATED (1717N77Mttr nm or rn7 ir nrrn, i b)(6)-2 IDENTIFICATION e altanical imprint) SIGP,ENT 6...torat, middle: • name and relation o sr r...02: nitPACW27-14C/ $1.14 1/14 C •IN .p-ma ;. I • 'ENT (Include tnecattorM'ordeted, any- Llinttatioru and follow-up,.. - en' "7-r- 7 • ?'• 1 MEDCOM - 297 STANDARD FORM 558 (Rev. 6-824 MP 1,W= DOD 003424 . (See hstrruczions rut Back of this Shear) NSN 7540-01-A75-3786 M t FACIL LOG NLIMB RANSPO TA 0 HOS IITAL CURR TM •-. 'tetanus anmun-B IN cAliatm'e*reikriraiists,trwatj-Isation and other date) DATE t . 4 CA) 0 PAT I ENT .CrrilER (SPecirN)ri PRIVATE;-'0 AmEtuLAN -.1VSDN'TH-7; E -7 ALLERGI ES 1.:J.'VEKI- • ....SLAN't ¦ ••• *I 01- fL ya Hp*4- MOTHER: (Simet59, --' Cg J i\j tr &R r1 PA T " H Ohl A•0 OR 0 S A -ION (C , tate and . Cbde) ( area co CHIEF COMpLAINT(S) (Include sorripirmatel, duo:Aston) SEX AGE POSSIBLE THIRD PARTY PAYER? oke-.4 5 4. CI YES j NO VITAL IGNS LIOESPRIEtEAll•itAiealipa.,dota./Partinant klistOrY); (2104M:tip, data TIME SEEZ4 BY PROVIDER iEsamEreditterr-inctoide,reatau-or bests ants-rayl): (3) Arseasment (Nairrezr "TIME );14) Pion: erreabssiost/Proesdurez -istaiside medicadan lawn acid (oiloiv-4) .7-SP a ICA PAP[Cuniv1) \6\.,EP.,2 cand --frkpaLA.)( 1 ) _ CATEGORY Mrs bens) '1‘,60%;:f „ f ( EMEAGEALT . EPr4r, O ACiENT 1 7 47 C c ty .11 A.--1-4 NOPAUASEN'T ORDERS -,, IRFccika,,itt:, ,p,"6 6 i- '4,t/. Yz -4 4---.---i •1., J(c/o ipic al.,'I lq,m, 4 g,_ 0:r -w.i.:„,..-47,‘.y 4 It.s.,..di) --"L-4-0-(i 1.)- 41., o.—th.A's.,44.-AL, I.Fil: ta riiiiA. s"....... I' n 1,%•'-‘ -c-rx , ift i- f -4tex.j -„....... (44.....4,14....t.A.y;.: —.----C-61-4---—. C A¦¦•¦ -to4- 'HI €AA't - t4A.I.A. 46.4.: La.. t is/ F,t, ..t u_J.,. 1-4,...0,,,,j cut sl e DISPOSITION;1C/teek eq.. that aPPII) err-7.-tp MOME ruLr.;-.0trry MA-a c . `1c-IE rt‘c-k-i vbc, 4- 4.3 Hy% iJ f frc- 11111111111•1111 LW-44.44';"-/ rt 0, i-,;„4(,,;) 1,64. r M=Z7ZE AAA V`e-(4) Pc-4 1.4'35 -PtA^^". ‘ 01-4-410.e-A4-k—gPVCI—fre L 1.42r UPON RELEASE z Co. late d h, -,-r friF1\ 31-.; miocrsurren Awl av-----nmeOF RELEASE: (CUNTINUE ON SF 507: fir NEarlial AMLEMVS-1-IDENTIFICATION jAreakankatinekrerttP" FOR*WRI-TTEN -ENTFUESAWEi Noma - Ask rereit nataaW PtiVieg nuns. end-elen-er-sponsawa.-mact- antopr:---PAC -ruze... I lurch, I L./ PATTe NT (rnelochr inadicadona ordered, anr. amitatenns and 4,2.A.AA-E 64 - irfer4‘',•4.4"vra„1„4/„. MEDCOM - 298 DOD 003425 f. 558-1cs: . - ATI f.s-Host PI.214We 'UMG.F.Nr- :405pre: - rie;eirottAikt ''ke.7, f!.; 46e 5 -• ¦ • 4*r•/”. DiSPOS71.00 Vakei'la0h# oPtejl iaLL, OtrrY -777.77:7;t1YARtERSi-13.4.kit. IM Hrs. unai CONDITION UPON RELEASE IMPROVED . : UNCHANGED. s -riktE OF RELEASE: 4Ses Instructions on Back of this-Shoed N_SN '7540-01-075-37E16 LO CV R T M OS. itetanas P7Litt • N PA -kation ' and: other data) %Er179';19f17"cL. 7PATIENT ricniEF' r3Picit7) - -10 AMBULANCE ALLEZ -;:rAlt (sp;cirzl.,Late Vi•'03-1-) Cada) HO 127138 Co aratuiny A "s -1. — • -A E YES NO DESCRIBE (1) Libilta dad data (Pin-Pasant Hitter7); (21.0-biettive 4ster._ TIME SEEN BY PROVIDER (Eaititisation • include meats of tastdand -x-rays); . (3)-Atatamdat OD*7000.-eft,/ Kin (Treabrient/Procedurrs -inalricre inidicatton given cinit -66.5do rPb./ Pmtntr EAT v c/o fiA ()Davit: _ sola Air A Ai I ' Pi-/Vox3, 4 z; 44,80,.‘ r -0700.6er,tr iter. 07' 7 31:44, Airord, Aez : ' 77, 0fZ- 4-(-4-44-r--e/ as-Ai ye, P-e.-cd -T=Per-A1.1.q:;icA;::Virg Ckc f r t,(w corm clv LI„....6P A*. €'4-141-eta"---611 .74 /e/t4A-k._ /-gittl-et e3 4o 14.1. Acta4ic r p_It -" 4/1 iso." d,14,‘ t -1434gC 1('Zfr-A 1401490/-as4.4 A-4.7 •cr yI ca -A.-f..‹.4.44-,--(/fri ?-tAt ro /54 if•-41 $,2Crat, o efh.t.i.Accy /ftle-ty "(-5 : hare ' e:us J/I eds ,(/2 s = .12e/Lawc. Zrze-w 4-4-c_ • ikef ,.4 ie._ • 07-';‘,E, "um)" wry 50114-74122.tles-S-e 4- f.t4-911XA1-1.. /r,---e-e-f /t 4-1141,0-?1 c'/s 0.6-;‘,) ,e6c .rWirKS--ie.c.e-eS C57 1)-Li-vA6---11.0E.e.zw_ 741-4. ti Coat w^ S, ( 14y hit- z Gie = 1. 2 z_ ,;_itaffC7F.547;_lE_WDE:t) S .7elves - 666 l retired, any a7nitatfons and follow-up fier/401 e?4, - Mi/2; At 6er/idiom-,e 77-ereree-X- 6­ Co-; ALS/4 .7P 'go Is b)(13)-2 MEDCOM - 299 DOD 003426 • NSN 7 540-06-634---1 12 7 •MEDICALRECORD -CONSULTATION SHEET - REQUEST DATE OF REQUEST Z-4/ Sai-p 0 REAsONFOR'REQUEST.(POIoplaints and-fincongs. • • ¦ A,- b)( APPROVED PLACE OF CONSULTATION R; 2 O0 UHTI Nu ER s AKODAY lb)(6)-2 ' 1:2 BEDSIDE 7 ON CALL CONSULTATION REPORT PATIENT EXAMINEDYES 0 NO -2 °- cr--e,be 7/41/7, A--- 1/7- .4z 6(3 fect/4-•$-,-. 'Flue on reverse 'side) SIGNATURE AND TITLE ZAT,E . RT boo-2 IDENTIFICATION NO. Lieutenant Colene ed aidiXtge4 WA RD NO b)(3)-1 -47ENTS ZENTOCArON .Forl,wea or werren eves gwe: -­Po-sSows CONS4iLTAT!ON Medical ecora MEDCOM - 300 C I DOD 003427 DOD 003428 5513.104 (See Inakructions cm Back of frits Sheet) NSI`,1 7540-01-075-3786 TREATMEN F'ACJ G;1 " (Slump/ G NUMB 7:EMERGENCY CARE AND TREATMENT : ---04wocad-pecoidi RANSPORTATION,TO.HOSPITAL CUR R M .,(ienZmts IMMCM -HISTORY OBTAINED FRO M" (Attch awe enronit,sheet) La:4Jan and other datal , E°T14 ER (SPecitylPRIVATE L .L.11;4•;;;. PAT I ENT . VEHICLE AM. SU LANCE 0. ALLE-RGI r..)1 l• b.- c, aOTHER (Specify) / 17-- TIENT MOM A DR OR DUTY (City, State and 7 Ca e) Hi COM T(S) ne tide symptom(s) ; aumtuanA DESCRIBE (1) Ititjective Vfl1AL SIGNS data (Pertinent filitor7): (2-10b/sctiPeAita. TIME SEEN BY PROVIDER (4-12,1"TiPati!?It -anIts or taste and x4sue); (3) Aesesertient (Molina- . 'i=t1Pitt-I r ian (i), Near Mee bnertt/Noteitunes -include medication giusn arierfOlow-uP -TEMP Ur. 4*aEtTra 1111M rf FBF; ,„„a,,. vi4 40 r-C it x OA-7 It) r*4/. ()RIDERS' :' .INITS: TIME t-Ne— 40g ,c,-•‘,/.-.444:,_ 6:-r up,;,,,,--4,-7 4 ti . •,.,1-1) Liito.d...4...., p— ••41-.L. f „...„ , -.1.-'" P" :I • •••r 11±^.. V4:40,i . i+4. + .4•-...i.... ; ..L. ' , Lc--, 'L 14. ' . --ifi.,.. .. .,...t ' ---- -1" Lc. -1 L:....iew :W.VA., • -, -.• I _ KJ ft, 3'1 fp it' 11.4i.t.y •DISPOSITION- (cfrir..agidimatiwpix;g; 11PROW 0,44 r3T. "Cr‘t-sim.. CONDITION UPON. RELEAS .UNCHANGED:. _PATIENT'S. NZ r • * *, ...Italtewat=t4LEIseca1E.I.GAI .3.424; DC(8. 'anger stood n ' • - --FFV,WFIADN.. 5r414:311iiMPle:Yrinteinde Trigaitaa017.‘,0 y and follad-up• ;-.,F17F.,7;r4. Ikei% Lo1/4/7,e-111‘J'Ce441.4. ' 7-MEDCOM - 302 - • • ^, .1 • • DOD 003429 — LABORATORY RESULTS FORM •21st COMBAT SUPPORT HOSPITAL - (Subject to Privacy Act of 1974) ef) -if ....-_ LAST,­.FIRST; MI::0)(13)-4 - - - -- UNIT RANK Sim, t5') Physician: Ward: .. STAT Date and.Time: Reported by: Date and Time: 1,)(8)-4 - H14) Routine-:',•&'..-4: (53 lb 0 1 0- - - ,,,,;,,t-44: ---,, .zs .. .,-iek4,4. ,.:.: 5..I.:ga,.....4* 7. -....-.4,g;-,--,, :::: ... ,:‘,4,12.,E, ,,,. :,_,E „ .)444irzi. avt ...".";.;1"" .. ggaidot4:-.44T-:Z:ri} ek-agfig. ..i.k..--'.41111.,i8,1,4A.0'"". ,i-M z", !r.zmx,svg,"---%\kw4 1 - . H . : 2 g Ax4,-,...:, X-.• TEST RESULT REF.: RANGE 1 k , JEST RESULT REF RANGE X TEST RESULT REF. RANGE Na-117 --i28-714,in3nTall:7 AFIF: 33-5:5 gicIL WBC g, 2 4.810.8 x10(3)/uL K ' . 7-1347 mmoUL 26-8411/1 3,99 -X-ALF,.. . RBC 4.2-6.1 x10(6)/ul .' Id 9a-108:mrddl/L ::ALT -•- -10-47 LK. Hgtl /0--, i 12.0-18.0 g/dL 1p171 7ryiz 7.3-7.45 IAMY 14-97 UlL. Hct 12• 9 35.0-60:096 pcQ2 -f,.:0 . *454.'11.04 AST 11-38 L1/1 MCV W • 0 80.0-99.0 fl . . Ipo2 /-2:. . 8&911mtniig. ' Toil-._ . 02-1.6:mg/dL MCI-I oq 4 , 2.-27.0-31-.0 pg ITCO2 2..7. ,... 1 kiL., Mriidii: :: ' tCM -1 7-22 mg/dL MCHC 3 i 7 33.0-37.0 g/d1.- l HCO3 2,:s7.: : , -2228 !ninon , ca I I 8.010..3 mg/dL Pit 51) 130-400 x10(3)/uL !s02 .1 95-ge,6-IChOt 1bo,2oo rrigiciL I LY% -/I: 6 15.0-55.0% I Lytti ' ..iBEecf .. . / . (.2)-•:,(t3).---.-- .,-.- 1M- , . , 30;1.71 i irt. . / 3 . 0.7-4.3 x10(3)!uL ,,- IAGap 8-16 nirrioUL ICL-I 98-108 mmoUL Differeatial I iCa /, /2 I 0.11.-1.23"nvntik .7 ' ' CQ2 . 1Er-33 mmoUL. Sep' Mono ;BUN ; 7-22ing/UL • ICreat 0.6-1.2 nigrut. Bands Eos iGiu 102_ 73-iiii:m4-1,:i 7. 'IGGI -5-65 UIL [Baso. 141P0h- " , ::.. :;Creat 0.6-t:2: mg/dl - I Glu 73-118 mciLgi Atyp-Ly Imm _AG :, I___________ ___.1.-34.z.cornou.L___ *a:awn:. .,.., !Hgb 42.-:071.8:0-gidL ... --PRrOtein- --604-8.49/dL ---. - , 128-145 inmol/l. Pit yerify: • • : __ ,, 441011111111,411: I",•,,74 Spun-Crit 35-60% 'Color. Straw/Yellow ' 3 :,,tiF'37r 41.21.11:23,1K4.117.7.".7--'"1.14•91 4....iTiirrl.;t3",'“"721 . r„,.$11.„,.,.. rClarify Clear : Source: ¦Thin No Plasmodium Seen . 'Glucose Neiitkie FecLeuk Neg-ative -1811irubin Ni3gative -GrarifSt Thick I I No Plasmodium Seen 4. l'Ke une.. NtigatiVe _.-'WetPrep Negative I SG 1.61a-1.025 KOH . Ne Fungai Elements . ',i: ittiteiter' 160111170181 I lood---- Nagativi;7 --pccBld-' " Negative Sad Rate . 1hr . 0-2o mm ., '-toi=r :, . 5.643.6" KAP' No Ova/ParaSite ''.. L:itiitiLlt;77'.0"1:!4: •::-Protein Negativo-Trace PT . 10-13 seconds 1..trObili . •Negative ' APTI 221-33.7 seconds Nitrite Negative 7--_. ;: A Z.; fl: .4. e' ,;t: -.... -mmL.-...A.,54 Negative "-,,..,rm:FDP -- teuico • -eiR • - - Urine Microscopic Tatc. ii airiHMARTTt''' "k: :-:c,;ISSIM WBC • Epi.: T&S .. .. _. Mono Negative , --. . _ -_.:IgaC Mucus RPR Negative ,. lBaCteria ;Yeast -;..t"SW-1 671:;:ii 1 : M:7... ":;7:::;:-._:,....7 -WittrAli Negative .—: .... - ..: l Casts - — - — - .." — . :: NegPtiY, Meningitis Negative i--itiijst—alS: Senirri . Necjalive NNE MEDCOM - 303 .. . Hie ...... ..¦-r-1 ." . _ . ¦ _..-. ..... DOD 003430 LABORATORY RESULTS FORM 21st COMBAT SUPPORT HOSPITAL (S.ubject to Privacy Act of 1974) 13 UNIT 4 /RANK S 05-7 ciarr Ward: STAT. Date and Time: Reported by: Date and r.1 RoOtine: 75-03 4.00 60 'i-4Zk.tqrX-se-rN*IeX",At'"4. :.• t 1k Ili 3.3-4.7 rarrpt/I• ALP : .( 96108 TiriailL ALT 10-47 U/L 1 : 7:38-7.45 AMY 19-97 UIL 7.02 15f, O 7-35-45 mmHg AST 11-38 UIL . 72: 84etramti9.,_ - !TGO2 ; 217 1 aL-.33-Ininafk f^G03: i 428tisnnEUi 1 s02 Apap 3.40:p3.1914. BUN 7-22.ingid. !d61:".72-L i. ;''' ;351Y400:016, .citt-ViK,kaW 414arat-Twamer 7tiregative-Race . . . Bacter7a; : MEDCOM - 304 DOD 003431 !See Iftstrictions uo Sack ofd* Shen} N.B.N 7540-01-075-3786 EMERGENCY CARE AND TREATMENT TREATMENT FAC1LJTY (Efazapi LOB NUMBER ": 7ArtENAL TRANSPORTATLON TO HOSPITAL MQ-iterosnuc mumina- TIME (Atbsch cam enrbutr shelf/ E-RSTO-RY OSTAme.0 skom DATE DPATIENT ErTHIEFI atimtaff7) PRIVATE. Yav Imcwerm. _YR-Gto . vaitTE AMBULANCE ;Zs ALLERGIES :0)3 1-1 2 5 p64-1 E..ommi ospicit,, 'ATIENWN0841 AODRESS OR oury sTA-rtor4 rob', & zit. and fir-, TELE. NO, (lag. sista code) • eem em. yarn ,Com•Ptia.MONA , • ri -"st-s-_ r..110-• . ET A .1-kgiit 011ie' AtIV liw.J24.1 54. • D yEs_ . VITAL SIGNS DESCRIBE (I). 2igZuleadue . data (Pertineatliistoryg (2):.0.bidtative date:. frIME SEEN BY PROVEDER (5,000frusifoii.- bleigdar reix*r.rit tests .put x-rsciatA3rAtorgartailit (Diaga°••via); (41-Ptan 4TPROLInelltaITOCtatt7et -include mediestion• gimes mid follow-up 0 ca..tv... rtd tESP: • MAR:- VT..00123 s 4"-^-" URGENT .!-114) iscvatutly jic fjA,G, ' , IM0.4.4 %-IC:4; ORDERS . INPM. ;,:r-the I. fe4Aolf: 141 j 11-4". 44111 4441 4 dr, or 1+4• to 5:"."‘"" " ." t•-‘1 41'45 A -10( CRAlik.s.414•"--4441 tr04.5- 414 CI 411,-t t '......SSESSitE0CE,GuAG01460-II 0 t 'A .T.4-If .3 , •- S'A-4"."-6 1 C..v • K.1 ft SZ i/ DISPOSITION (0h4eleaS Host 41,031 14-11; got.i,„tr HOME I 1:f.PLI-Dtire 74: cuARTERs- h tiE Fr - - •mt- ot La. 4..9 LeiLa.s „ CONDITION UPON: RELEASE IMPROVED UNCHANGED Co, A44,j. 441;71‘ ---DE,FERtORAVE0—•-¦—• .044 exrc­ b tc'4' lvka c4--- LIE Off-SF NEEDED3: aTt UR:=tahtES 0P-PRAIDEct 0. trjElICC ZNIMPW-"eit.Nielli 61=41 ' b)(6)-2 b)(8)-2 21V; DOES service sta zilatlestaott .mas or next. -Roz0 mar erlastoNsitTce naksede raecheagont. orsterad, wary -Assitalicusswed PA° . _ . MEDCOM - 305 DOD 003432 -1) ...-:asidli4o4fols41707; • • AUTHORIZED FOR LOCAL REPRODUCTION --MEDICAtr-RECORD eHRONOLOGICAL-RECORD-OF MEDICAL CARE SYMPTOMS;--TREATMENT - TRFATI NG -ORGAN IZAT1O.N ,DIAGN SI$; .gneac entry 44 (Jo kik,/ 7resemf-5- r it-4/1 T cinHeigdocile oihvy Thirict-, "crA 1-1/Z al Yercri foot f*, 11(rs-1W.0F.4-74--eter---7-. 51-4 - - .vrafccF/ -9 k't Ertgi-10 1-'17vm an.0641,i eiry,t..)Z(-. ((Wily Weg k LrAll te, cial pulses- /71 10-n o 1-ed Pi 5.)-'_\):11;1 i A _TV -hp wort ifriii4; e .-L-196-4-,--cir4wpr • 4-t) L 6 vniateted. 1440,7 ffirj 441EP' 03- /73o takeil I‘5o rid-tivnp (1 /701­ , Eel% tee-e.ur Noo--ityirt-id° V:itr4 4.1.14r. S ectim BVI se141-1--o MIA Afetn 116 At 44tcx 4 Cso r b (6)-2 4'2(.1 ' 19.° HOSIKTALOMMEDICA‘FACILITY• STATUS DEPART./SERVICE RECORDS MAINTAINED AT. SSN/1D NO. RELATIONSHIRTO SPONSOR PATIENT'S,1013,MEICATIONFffi.-tirp— ed.iiiiintteriititifes, give: Name - last; first. middle: ID No or SSW; Sex; IREGISTER NO. WARD NO. '0(8)-4 CHRZIRIO LOGICAL.RECORD:OF MEDICAL CARE Medical:Record STANDARD FORM 600 (REV. 6-97) Prescapc1 GSA/ICMR DOD 003433 .. :;;;. • - • ••"'" ,f.:3!•••• • , Nt .i4211.0hili '30 DOD 003434 .4.,q1r477.0r7"-, ....... -7 S:". " = • A IN EM f . 1=1 . -OF--• Fgr . .. • •a. 2.Sigt/s . . . n13in' . • . 4 . - . - A 7-0 •: '4, AAR 2Sim/s ADULT xa 4:'"R a 77. C: 0:12 _ s yes=INC.. SFS rE.,6C-F; LAW- • tett.,;. Alj°7•41:)19 ti de . ¦¦=.14.,; -T MEDCOM - 308 DOD 003435 (Sea Inttrzicrions on . Elei orpyai-Srmert) NSN 75 40-01-075-37B 6 LOG NUMB R TREATMENT. b)(3)-1 -• RANR N HOS ITAL Y AIN CAttgehtiiisiOn*route..-016it)- Theft- (Spaeth) PATIENT 71-PAiVATEL 0 AMBULANCE L-1 VER1CLE OTHER (Sped • ¦ L YES NO D-.71. RISE (1) 516 data,iPertinciat History , (21.370,ktiiii0e Antra . 'TIME SEEN BY PR VI DER (Exarritnation .- iischicle_resultziaf tub. frilarne- M. (4) Nan erissanentiProaedurrt -:inetiade. medication ghat arid follpui-up i¦tergemaiENT._ :04:msT*Enoit: . e4.44.4.‘ istairation ,,,vr.TEN,-FmActEbromcsmot._ele,....haftiata st. warETErst , WE. ca vas thgetw• bX13)-2 +bctix iNtrinraii naddik; nome-anc.nstattoit oracion.earar mare *.rrriSerat-,"apay. arena( follow•up MEDCOM - 309 DOD 003436 • !SOW In:merlons on Back of this Sheet) NSN 754076 1. TIFtE.A rFeilEPUPACILITY (Stamp) -47:116 E.AID:MEAT:MEW LOG NUMBER RANSPO -TATION TO NOSPI_ AL CU ..R. N. M "tetanus mantas-M AIN aY !salmon. and other data) DATE • PATI ENT OTHER (MpeOffy) PRI VATE L ON . VEKICL E 3 AMBULANCE ALL... aOTT-1ER /specify)! . : A .l Hom A OR OR DUTY STATION r ay. State and tr. code/Ir Home TELL. NO, anc. area code) 47mPI:Otn(d). ;Lunation) •• • • Six POSSIBLE THI AO PARTY PAYER/0 YES NO V-IITAL SIGNS DESCRIBE (1) Ian/endue data (Pal-ciao' t Histcy7); (21.0 bias due data TIPAWSIE5'8Y PROVIDER ); (4) 11 (Examination - Module result: of teatt:ancts-Mat): .(3) coon tar -(Tivatment/Procadthita OalatidTalaina­ *.c.€P) ., I J ;A y -• - be 1....crs ,,,Lec r v,•¦ f. if x-g a. s z 2 ‘,1 41/ ' CATEGORY.Usa reverse .(2.-e•W 5; /rye-10154,4 /c.c./ EMPLO.ENT (12.2- t.J RGEMT 2 3 - z V 4-'1'7 Iib (.7". ----ORDERS IN ITS. TIME c44 e I 6. el• ) -/1_,/ .-"e =-5 pis .- 4_ v ? 5%.t. .• ." —7 /,77 -41/ 4:Z5' ee''S 5 7 - - z C.!./; 2 — 5' VS2_ -*.?3 s 5 -N t. '/ /c - CA, f NTI-PICATR:IN alifeojtanieta ' print/ trilDtal•CFMES GIVE: Name - fast, /Vint. nagidle; - Wars& aa and mlation_otsponsor arm:act - pians) ncruds ins oat.-ons ordered, any imitations and folk, w-wr . X6)-4 •. / • (-4-e72-5. 5' ) e-- _ _ _ r e-‘ ‘-61-7 MEDCOM 310 DOD 003437 DOD 003438 .2i,;55E1-103 4.-- • •L . • (See lnarucdons on Back of rhis Sheet) N5N 754G-01 -075 -1786 TREATMENT FACILITY (Stump) MERGENICY CARE AND TREATMENT LOG NUMBER - • (Mediiii Record) RAN.SPORTATIONEXD 1405P / EDS; .14:inat HISTORY OBTAINED PROM TIME -• action-and other data) (Attach can eYvroute sheit) P .T1ENT ErTHER (4501c-ifYi PRIVATE"-LI VEHICLE L'ERGI ES AMBULANCE /5C0 ER (Specify) STATION (City. State and Co 1-40M aria co ,r• RD PARTY PAYER:) 7-1 I YES NC r VITAL SIGNS DESCRIBE (1) Lubiectina data. Martine:at Mister/ 1; (21 p bjeetiee data " TIME SEEN BY PROVIDER (Examination -iisciyde­ rensligof teat.-and' x.rayr) Ass-ofilmignt (Dieltrac); (4) Nan (negoltent/Proccaum • iiactude medication eV= and follow-4w rf...;7u.s--T ft.," 74 9 A-Er4 c , r:. 1. ¢ ri 0A-L L s 33 4• . (-1-x rfir;14,, , t w-14. 117 -¦••••••••... A+itir,44re-2. . r ' tit ,:fc7,271fri.ofek. , • affcrt ct So a c 1'5'1 fi „ 14 V. c-D. FVL.L.:Ottrit 24_014.4-7P..1.46•Hlt."[.:1:771iit , 7M001FitUterf:UNT1 Cllki%Fl-TEES. 14;7,1 t A IV'• e , • 1.4 cI s L 4 - v- e ,_.... . . “.„,( rc • 1,2 - L • _ . 11 15.1.t1 it • k . 1¦1:11..120,, 1:1(.7CATI NE !MOM `'°111111allitiagriaallign L'Itrtrviy. .0" c ; 0041C .1/1=1.111140¦111! ; ti cONDITIONAJPON RELEASE - 4 , 4 „ f .7 ImPRovED • RP.Ii:VOkematir 4 r 1 ( 5 ---tstremvaarrol, A -r • 1..3 C !CONTINUE ON SF 07, IF NEED T 1. 3 px-ntr4.:ms4zepermicAlrior;rsreit*,:ereprint. fqN A F r-fc oorivtr,c-. c-.,..4. . FacrwarrrErtiamtrararagnyanio -.....16,4 !b)(13)-2 • . • Fraildre; • b)(61-4 1444.a R OCT( 0115 TO PATIENT (Maude meditations ordered, any ;imitations and folio anup Plans) . _ • CV' • MEDCOM - 312 DOD 003439 (See Instructions on Back of Oda Sherd • NSN 7540•01-075-3786 TREATM NT FACI-1-1 EFicttNcy_qma AND TREATMENT ' Y (StteriPt LOG NUMBE • ....11,04fieskifeect6:0--, TARRIVAL TRANSPORTATION "I 0 HOSPITAL CURRENT MEDS. Itetantts unman- HISTORY 0- .TIME . igatien alPd other Paa) ,— (Atrial: care ersrolits sheet; PTAINED PROM DATE-_ . PATIENT1: elIp .eVP CE Ve-V40i I f'N '14'41 ! LAN' '41vit3t­ 1711 ALLERGIES Es 5(Q . p OTHER. (Speat,39 tc`-'" `Pi-Istru PA-•I] M • DDRESS'OR DU STAT State and Code) HOM L NO. rec. area co —C HIE C *PA A T( e ta symp(s airs t...) torit * 'et -1- I H RD PARTY PAYER/ -• ' . . .,..c.p•Ii.1 YES NC rY) DESCRIBE (1) &abjertive data (Pertinent Hitbor:i ); (21 Objective data TIME SEEN BY PROVIDER (Essuninatims • lisciodasressats of tests assti" '1616 ! Cm (4) flan( (31.111selmnent (rifeig"' Treabnent/Nocedure;- include medication given arid foliorv;up ofseteal/.41L-Virr 05',/ze-q. 6 a-e- .PULSE- . • ql ceyt_ "KW-C/1/y Y-sti ,RESP:' - ceed404-4-x-e-e 12001-€ Zr;c*-3 as-s-Z7v.Z7•Pc-s.....c( et-eac-c-ce-afe/X-eza/7 Ae-e-ez-gra‘ Wtiaiddi:153Agg Tr% soteze,e 4 /-14,--ssztries'icad-01- CATEGORY Mew reversal • èt' ' .007-4,.. /4, 414-6 EMERGENT r-re-ofidz URGENT 0t.t.e07 dt•e4 di-t ..Stotd,upt.GENT ol-e / 2 ORDERS IN ITS. CSC ) LYT MU-L xce.ds-7-Xl,Serb., -CALR. EXC., • V Xi% ...c) ite..ext.e Sees.rgaseedfLi-- And4e..5--z—e UFTWIPANO cis6c‘-e-- dori744,--'17.72 aregalll /tidc4i .4 •ace^ CLOP Tin nWee,1 teg 4 4F.ee----tvtr,,teek,4o..„:„44fze__.ey,47-Fy7, 37v.zdt-e,-f A. -2-.5- 7 .62(44.4,92d4v?-eAl epri4-64€ S.e..-0‘444.4ze--s :=e•Ac---c INSPOSmoN.foseciesa:tbarappo) 1it I-tOME pt-trer-0' 79::Frre;t4; 77-'0VA-R--TERSZ',"' 12: 4Hrs. 1142 Hes: 172 HI.: -MODYRIEDF.D_teriftINT.11.-2:. r. ecee, -&e;4,/721. r... - • ZA:-/-ferezeL 4:e ,F-22ERGEN. ­ • -• •-/),4t/e..7r- -7 72,Frottm- - ere- - 42.-e/.2 -4i /P4:444-4 e CONDITION UPON RELEASE ,r-yece it2 7'. V3 4./.4.0641, .0v-e-AS IMP R9VED - UNCHANGED-. . - DETZ,R,I4DRA-Tt0' , afr00-14K .4y, 0-0/(e.,e 0 5764!..5. TI41E. RIELEASE:. • 1 - ^ 7rezeNtik­ ilitsF sog:..IFNEEDED; ,MttrizVerMay...g.m.p. tatesainaxs (bp-2 , .SS1Vt P013. service statue. matte cal is atailla --ottddc-.M175113or Fr' ' ablfitiveZ. r.£67r-MiedfirEadz.DPArgrwrrsfrt-- • • p fan cf,,Frlarbcabvikcordirsci. arty aimita4faactart follass,-; 41;7: 411j'e' '7! MED - 313 DOD 003440 DOD 003441 , -- • LABORATORY RESULTS FORM ........ 21st COMBAT SUPPORT HOSPITAL (SObject to Privacy Act of 1974) /3 4 . - 7t--7-ItOkS7;7FIRST7M1:— -- • • ,,, , A UNIT RANK SSN ?•(.1,7. /5 0 -7-Epc,., -TAEL-C - PhySiciarr. Ward: AISTAT Date and Time: _13.e_kgPriltol hv • ue)-2 0.6,2 Date a Routine Vit Selo 03 Q . ( & [P t... o11- ••• ...... • -., ''',,,...tr 1•0_,•,•,,,g4a-,,•••,.4.... ••••4 "4,,,,;:1y,i ' . •••••,Q. ..P.:, 74*%1...- MORta..1)*W.S24W-VIiNV"A,i9..":"'' ''". :::i':',:i*' . 5.a.**1."."7:;".: ': .." . ''''''' :6 ' 'IVAIV'''' ' W. ..,....--..,...4,1, -, P -'.e."'"k ---"wt 05 -f--i$M.g.',.-.§.tt-el-,-.x.-6.:' ,, :-,...,_,::: ...3:::,::::::::-::"iiiMS ,:,..- -Ita,., 'A. nb,„ . z.:..1$ ... ' ..iRii... vs .g..:st4-,:i.:Tre,AW-4.3;i:-.,-„zw:3:i , ,i:; . -• . :?.: . , • ,,,,,, , ' — -Sr --RESULT -7 REF. RANGE X-TEST RESULT 7,i. • r ,:e' s i?4ww gig.-.0::::-=--, ,, M eg I: a 4, REF. RANGE TEST X RESULT REF RANGE 128445 Mmdi/L -ALB - 4,4 3.35.5 Olt_ WBC 5c1 4 8- , 0 8 x10(3)iuL 3.3-4.7 mmoUL ALP Rcl 26-84 U/L RBC 5 , f,‘ 42-6.1 xl 0(6)/Ot -98•198 mmoi/L ALT ac' 10-47 U/L Hgb , CH 12.0-,aa pa 7.35-7,45 01 -AMY a3 14-97 U/L Hct l-tir.0 35:0-60.0% ' IPCO2 35.45 mmHg AST I WI 11 -381.11L _Hi MCV -80.0-99 0 fl _1E02: .. 8040 inniNg 1114--- Tbil . lx(, 0.2-1.6 mg/dL i MCH I 2082 1 27 0,-31 0 og .: . ( TCO • '-" 18733 mrrroUL 1 BUN fp 7-22 mg/d L MCHC 1 sthif 33.0-37 0 gicIL . • 'i HCO3 22-26 mmoliL Ca 8.0-10.3 mg/di. Pit I 130-400 xl 0(3)/uL s02. 95.99% t.41-) Chol 10O 200 1 LY% „3t,5-15.055.0% 1.BEecf. • . I (2) - (1:3) 1 ILY# 5 \ 3.7-4 3 x-1 0(3)/uL iAGap 8-16 mmoUL CL b) 98-106 mmoUL 1 Differential . 1-iCa I 0.11-1.23 mmoi/L TCO2 I at. 18-33 mrnoVL Segs (Mono !BUN" 7-22 mg/dL Creat I oiq 0.6-1.2 mg/dL Bands Eos (Gilt ' -73-118 mg/dl --- GG-1.7 5-65 U/L Lymph 4 :Base 0.542incj/di_ GILL 1 .i( T3-118 mg/dL Atyp Ly limm -•-•-'4Hiat-H . :: •• ' 35.0-60.0% K j_34:.___ [ 3.3-4:7 rnmoUL RBC Morph: T . ...;i , ...:„,_ ._, .„.„.120-18.0/cIL . -Tprot ' CI I NaAt 128-145 mmoUL Ptt Verify: 1.0...eltirti/Wie.t44:014 • Spun C rit 35-60% .410:1'..:..... Straw/Mow • ;11/. traillianr":0111-1,14.:":41*-'; -'''' ---!1",0001114.0n ; 406lift --"":: '•':-..' Clear ": Source: Thin 1 No PFasmodium Seen GlifraSti.... Negative, . .K1441( Negative -..:s• -r'77.--.=i---L: . ,: -LT: • zWegative.7. -.'7= .,..-._ FIT-St Ames our irfar..:s-1.-iv.loo Thick L I No Plasmodium Seen .- _-_-_i4eRratit,43.._.1-„,.;:...1iArefprd-15: NegatiVe- MI I111111/ . • 1.010-1.025 KOH •,:;,.. ::.14-M-.:.-.,::k.•k• No Fungal Elements ..?,::: ?::P::::.:ia::•;;M::t. ,:::, ...M1 I E :MI, ME 0oslain--Negative-Sed Rate 1 hr = 0-20mm WITIoni 4 . , ..O&P ..,..v. ..,ii: :..o.ovaiTit.,-...ta. w ,,,,,i ­ ,4,$).,,r,.:....,,..,w4.21.imre:--,z.-TA ,::, -,,„.,,,4,6tAt , :',,,tx;OP: ,:.,.. . . : , .. .f=: I_.•._. -poTelE13,:. -'''''-----1. '2. Negative-Trace PT . 10-13 seconds -Crilkiitr Negative APTT 221-33 7 seconds : Nitrite..._ v iieiei midtose:),pcNegative fe 1 ' . '... 1.4Aai,-4-Jag.MMO .2e,:.1:::„::::rs-A .:*4-i FD,,.,,P,.,,.. .„,..,.,_,,,,,,,w,,,I._ ,, vvist.,.• ------71----ABO/Rh ,,,,,,, . -ukeL:,______. tor. . egalive T&C T&S Mono ,, Negative •-EICiig------- -I I RPR [ , Negativeiikferii.., ---._.--,..,-.7.,-., -ast MO ::64:.:..• g•N:MOK,i,,•*aan'•,,,' V:ku-:c,::41:::':'?' -:•:•fA3k: -t--- -4da,1 —,:•:-mm Atmas• ,,MM„ MET HIV ' Negative _4444.4 0 11INRIMII - awe inimimmtmil .. Urine Negative Meningitis Negative _ , I .. mykatas SertIM NegatiVe -T let Al -a.1.4 - litIMMERIMN iZ21121.2tuf-takaiya., A In MEDCOM -315 DOD 003442 (Sea InsinXtioris an Back of this Shard " NSN 7540-01-075-3786 EMERGENCY,CARE AND TREATMENT TREATMENT FACILI (SIvmpi, LOG NUMB R • 4Adadicat RastadJ- ARRIVAL RANSPOR AT N 0 KOSPITAL CURR . M DS. Vero:rum 1h V -.m Aira4• TIME CrIttcch•eare euroutt sheet) • Leaden and. Qatar data) PATIENT ErTHER (SPEP*1 PRIVATEu lexx.sli In4erpreter DAL*1011r1)4 By LANCE \ft-riLs ALLERGIES 29 t co 01-11-104(Spec) IA P 1010A. 4,Prt,(1:7N-vt-• ' ATI =iTS OME ADORESS'OR ON WAY, State Code) SOME TEL.E. NO.• (Inc. alma coda) • YES NO 7 Ill ESCRIBE (1) pitdectiDe datei,(Pertinent Histor7); (21 Objective data TIME SEEN BY PROVIDER azaznination -ateattle results of testa and zany( R . (3) Afocion"Filt Mkt"' OW (4) Plan (ranlekt/Pi!ocaairMs.• , -incittideinidiacitibn,rtiata.antrforkP) : • PULSE '41e/9S' z.cir;-.. -- RESP. .IfirelAs•ig-ex. Cc:%,,c_de 4._ _ -d 74v 74:AY' wr.ichics . ak, ;re--4-07,4,15:.rceyir, -f...c • !:-..4,'.s.il;¦ ld". -0,i.....1 the; •ei, 0•1-'.,./. URGENT e — 47 ;cle .-f•r.*4-,-. .«.e.-:folfele----42:ror 0*. z..e..,4,-7.--1...e..474.6.1 --4. "C.44.4e; ;0.,--:;.,:e4Oe S ..4".4:, it A,5'eeteir-ii-44..e, e.-/ ..i%.-41, re;',7*-4.e474 . 0.-4°P.747-er .'--4¦:C:::74:7: 2. 1: ..---,•:.:::.: _ ,.._ __ -, ' . ,!:--:-: 4:4,,:-..., 7 I*4-/ ..4.-ft-".. -- - 4-e.-,-;-eaiz-. --)---,,.--.-- ,e,___ __ ,-...---s-----4,i,"..--eivieiL steer "fee-' 04' 't ', '••• , 1 ... -3., , ' -•blt.5 4.4 _,--4,r. _ --.- .,-, . .e„..g...1.d -id.e...'d,i-f-..;Irk:i.rijit-cev• •-•.: ---;—r Sf.:. . 1 ..7 1erre.. ;.ce,Ce:S4,;eit**¦_4-_::::,,-7. • . :- ' Ar",/wi;4••••,. .•( 04,:efof g:!4e2:-.41 . -' 6446164:40— FfEtrelEr7r, e.fedess ad, : er-e7041744, • et, oc.:4 A¦edc:40-07-r -• • - I.,,-,1.40(4441f, frroa A•47or., 4‘,:f 1 7 Asle • -1 -/.2"v442-A4ir'.:.eGi• • -.7„ • •I iMPRovED -,e;4,!42fit.e • " -. .424‹' --t. ; • aw-; iaco# REEAs (CV • SIR;10077&0)'' • • - bX6)4 MEDCOM - 316 DOD 003443 1See hisrrtedcits an'Becktf This Sherd Nspi 7540,02=075.‘37136= 'EMERGENCY CARE AND TREATMENT TMENT FA it. pliampi G NUMBER (Madkaf ARRIVAL TRA,NspoRTATION TO 05PITAI-CURRENT meDs.-1/....0. TIME . isathan and otter daft, • ' ' DATE PATIENT (OTHER MAteitif (Atmeis:cart inn-ante MEW TORY OBTAINED FROM PRIVATE' c3AMBULANCt-"ik ALL ERGI es a3(o OTHER4S1Mair30 NT'S HOM ADOR OR DO A N NKA D fate a HOME TELE. NO (inc.• aree'coctek•• CHI comPLA, (riTsymptons(s). duration) SEX AGE POSSIBLE THIRD op,RTY-PAYER1 YES 0No VITAL. SIGNS. DESCRIBE (11. TIME SEEN BY PROVIDER &atriaannedacaaPnrctnaist itstor4;42.1 0alidtive de( et:',;' 1 Micandnatian.--asehicicraairita-attestrand;x-nrsagtatAisenimmt Wiaawr-OW Mi ran (Treablent/Prefulunis;MItufle ai " re ran a dd foliotok , /a f".* * j" 5 Z.7 CATEGORY (Gm 16-tracco- EMERGENT Pfttlf e (URGENT., em5 ORDERS , INITS. TIME -fv,..ko,_ CONDITION UPON RELEASE IMPROVED • I 1 UNCHANGED 2 DT' j'.'""TIME OF REL:EASE: '4•AA,T4ENt4S4DENT1FICATION atasticat BSBt112gat.. f4,477se effier2Wanisr- 8; Ha rrraUm e E PORTA.111 zarraor-ar-ivact--- -.P4e1P-IrrigOat G7-2 ' RD): INSTRUCTIONS TO PATIMNT:ftnalintelkaitgaancltkordarad, any . mitadorMand foiknaH9 J4-0_ go-11' " S'• -IbX0-4 MEDCOM - 317 DOD 003444 lftstrYcci0fWgn 40c.of OisShecti 1114N1549-.917074.47,06 EMERGENCY AND -TREATMENT . (3)-1 Im••¦•¦•¦•••¦01.... Ofesfical Reciirrk. RANSPO R N 0 1-tps TAi- -CUR R N m lte gs: walnut, 11444clitaConcligitt Asir) . i;rtton ani other r0o7 AIN • • T.iM E DATE ,PATIENT OPAFIN PREIXActTEELjtj • BuJANCE 13 1 a 49-1....eRsted CeY, :•NTS HOME ADDRESS OR. DUTY sT.o . . nci:::: -. ;. .cocie • HOME nifc‘..) I YES . NO UkAITt L SIGNS DESCRIBE (1) acteigatiue data frierthrost Iiistorl):421 ObiegtiPe 4ato 111110E;pgENO3YDiticivf ape (EXaminstEar :inefudirmaisaorlit -TibtE eriragno­ _, "04,1DtelitartqrVittrli BR 0931terie PULSE .044,¦eCtr-.:• . d,• 4.z /,-5 e-e4.4 r __red-cc ' / Ca s-e (p•3 aa, CATEGORY (SU nevem 544,- s. e%""Yr..-ere .: RDERS ladtli.141 „.„ /a 7 eiGt ci.t.c.?4!‘„,a,i,,,,e Lir 67 ,o1/ Ey dr?1-4; di 4-4:a e s" 4- ettreze-e-/-cci. 4"--fiAre--/z.elc IPA/ A_ efi.-/id', S .7777, ` 017 • + DISPOSVI4D1*(g 4 I. e 7-41-e s 1--ere x' e ery s z 12=1,22 , iretjULI;lakiaLanAtEltatia Zr F;T7,;"171=1a"V-.= !•, ;=n117-xifietthi&MA ;;E:1tc. .„1.4es (2) -etiez•—•01.." I 4t.'"40e " inTI:11.474.e*r'1,-"? -_ . . . art.eae_it r 59 ¦44,,,, 14 4 W14 AO 1 -f-J (K2-tom 9-41 AAA-M.1./i; 'if.. nu w r e.Rr1rA.04Elciainc.4.1-1b14-4riseisineeethain Em-Fffilgi-04V Name+ loo4. :SS2.4, DOE: araiaill ¦WIRA.-..14.1.....9¦10. • .1, ••¦ ••.• • " .idol: .1,1 a - FENT'firreitscIr madicaEonforditrod; ,91.4?"0 sar/11,i3-i 7-0 72,,e21 4) cc MEDCOM - 318 DOD 003445 5513.103 (See lasTarerlons on Back of rhis Shestibx3m PISN, 1540-01-4543186 EMERGENC REAz:L-17r% Y CA AND TREATMENT 'If LOG NUMB flifoglical Micah" 'ST • k,J.,•) TRANSPORTATION TO HOSPITAL CUR RENT ME05..ostanua inunun. r....... T.Attach HISTORY OBTAINED FROM 4. wout. shalt - . . ' - iaadan and etanr &gar) P OPATIENT ErTHER (SP°11iV4 EHicLE 0-•AMBULANCE -• :OTHER (SpecifY) Ter PATIE T's OM DESCRIBE Cl) aater4Percinagt Hirtari-);.(21.0terectincdata_ . ariirmariation meactisirititzBa anoints inu*zircreg.(3rAisserisient TIME. SEEN. BY PROVIDER - ( iatige7r..till:AWIPOe inatt4r4ca 9Cettc7 rTgreafr firebi' TA61,- 74tei ttik 1'464. %tt40$ . 1:0; ; b)(13)-2 Pf-7 if...!;Y%,..4 • 4,,e. 1-.1N1'. . ' 444112: 4---"""j 4T5 4: 6 47,4*.,r4 "-4"r , j, )., 14 IL *IA f°44./X.r.-Artea. 4-L 41.044 , . I.ibto ifj. ng . •:21±.440.1?::F. 17z LkottfiFiittetiort. - CON OITI ON:UPoN RatusE.: aim:(Qw= • f I iriir,44ANGEn • • DIYEATO RATED - • -7-7777. 7. TIME OFSEi '• • • (CDNT/N ..,---ikerfilENT'S.PDETCRIFICATIOWNideellimprint)' • b)(8)-2 rrrTTEN-Si --LrFOrrviBprrRigs as vet an& naiad* nanarmat _lation ofaavvoyiTY -112:710111Ura PORT --nror !moo . INS • piano 'Declared, any Unisitzifoin 'and :foliago;up: • Pi X8).4 66, 4 MEDCOM - 319 ..„ DOD 003446 (Sea Instructions on Back of this Shand ER NricZARE-AND-TR EATM ENT (akeenl Ractirrfi Ita.t4SPOR: .PCE t..1_ TO. HOSPITAL (Attath care dprrortte sheet) • PRIVATES,. • t_.:1 VEHICLE AMBULANCE­. . —E7 OTHER -(Specify) '11Sk 754041-075-3786 symptom to. • uratzonl DESCRIBE (I) Etakaava data (Partadatt History): (21 Objectipe-ct (Examination -btebutirreaultaratiesis-arartx-nwilet3higigallion -(4) Katt (Treatment/Procedures -irschide ~din Winn /fumed& foilig-up 4,Cf.;71.ct --/A--de dt.1 4- eir .71Wit42Cel- -764-er / " 4(3-- -";/-127-11We-/-*-Ge•freAG--21e I ,mac 7.414 0-e ce-r.er-,K ' • • " : " • • -• . • • • ePr-; /4 j ¦ -.PON .FIEL.F.As E and MONT/Nue ON SF 577,1E K DOD 003447 Mt-COMBAT SUPPORT HOSPITAL REF. RANGE TEST ALB 3.3-4.7 rnmoUL ALP 98-108 aunoUL ALT H. 7.35-7.45 AMY P02 • ,. 80790. mmHg TCO2 BUN, 22-213:MMOUL BEecf (-2) -4+3) AGa 4-1644‘101/1- iCa TProtei Mr4KAA's1- •.7 SitavitYeikev--Source _.,7.__: Iesellielmtase7. _Jo 19M6110115WIMAMIN t itco(olraelleeeedellen =tel c Negative ABO7RbT ''S'Frerrfne-Miciosco is LABORATORY RESULTS (Subject to PrivaAct of RANK c2-. 0 Reported TEST. WBC . Figb Hot may 8.0-10,3 mg/OL 100-200 mg/di. LY% . . 30-170 U/L FORM 1974) •66 — SSN CXX) Date and Tirrte: 22 REF. RANGE • • 4.8-10.8 x10(3yuL 4.2-8.1 x10(6)luL 12.0-18.0•g/dL 35.0-60.0% 80.0-99.0 if 0.7-4.3 x10(3yuL .98-108 mmoUL Differential 18-33 mmoUL Mono Eos _ Baso -:, ROG, Orp 6.4-8.1 g/dL 128-145 rtirnot/L .R.WfAWPIpgMM 22.1-33.7 seceixii; DOD 003448 5513-103 Mee instructions on Beck of this Sheet) . NSN 7540.01-075-3736 TREATMENT FACILITY (Etaarispi ' EMERGENCY -CARE 'AND-TR-EAT.MENT • LOG NUMBER •• bx3)-I S 1-1 .TRAINSPO --ARRIVAL. -T HOSPITAL CUR RE OS.,(trasmis unatun-. ._, TimE isation and °giber data) (Attach care enra sheet) , _ DATE rl. . „, 1,, r, [:]PATIENT:LI iSPeaW -1: PRIVATEL -7-7-o"--, MONTH YR. LJ V EI-ItCLE 0 AMBULANCE -. -c**3 ALLERGIES ' .2 --. 52 7.2 "0:-1 ./',..:-°,:) 0 OTHER (Specify), 5 PATIENT'S HOME AOORESS OR Mr( STATION (CI*. State and ZIP Code) A . TEr ci-icos,ceetIne(s).cteretoin nj 11 3 i r,TAL SIGNS (33 4.y.weetint ding mere:tent Hittor2);:(21:Gbjettite_ ,data _ , , (Examination' -TIME SEEN BY PROYF:PER (tlation 7 rested* nuults4st tests inscre--rakt:"C31-23csecumlogrillialtwo' TIME . 00 jai; (4) an (Treatrtumt/Procedssme -t-A : , ::"44;"1' Insassde medication giant end foam -C7 1 •iie W) /4 EP .7--PULSE 6c, ,Fte•rck / .-7 5 14 et" s c*-"41' -7-7 WTNCNII4. CATEGORY-(see resew' EMERGENT URGENT NON•URGENT • t.d...y.)e--riotsz-zed ,".71 ORDERS — : !NITS. 'TIME ,.-1 /SOT -// /A. g5i ASSESSMENT/GIAGNOWS . C. • . S%25• 24' °C"'41. /Cie W-41:7 ; 4 DISPOSITI00.1O1410 ail. *0 'Mtn ; T nu Own /.5' . -Mnplr-IPMNIN UNIT- -e /%0 55 • OONG/TION UPON-RELEASE : /-°S. IMPROVED•' • TIME OF RELEASE: /"' (CONTINUE ON'S F .977-if N'FFITP17) PATIENT'S IDENTI-PTCATION-Gaehilateal Jai (b)(6)-2 rffit) FHTs/Irc GIALEL.htaesw-lae A-Mtddle;- .--31N,"-DOE.-asealos-m,mtsge:nosamPasrid94dattoor . ierW4ter invoRTAAvv -t ---..ccrrarrfforx G-razoor thin. ecOnD).. 1 ,Y -ri", klk,¦.‘r-gremluffikpiedscat,censsonisred.:arsx.iOnizatittssanceltd4Ru"W -. . ° •rbX6).4 5ro MEDCOM - 322 DOD 003449 :r 558-105 pee Instructions an Back of this Sherd NSM 7540.04-075-37136 TRBATMEN FAd -LI EMERGENCY CARE AND TREATMENT (stamp) LOG NUMB R Mom° - - ARRIVAL NSP OR ATION TO-HOS AL CUR R NT .M DS; venous - DATE (Attach cale:caroutr chcitt) .4sta:ion. and• other data). • AIN IME PATIENT CYTHER (SPecifYi PRIVATE L_1 VEHtCLE Li AMBULANCE ALLERGIES 0 OTHER (specilw PATIENT'S-HOME ADDRESS oft curry STATION Way, styer and z Cade HOME TcLe- NO. (In= arsa code) L--CH4E wad gym/Itoin(s) cissration :• • !RD PARTY PAY.ER/!... _ YES UNO •vITAL.SIGNS DESCRIBE Uaidetzve- data (Pertisic.nt History): (nobjeg#e.4ata TIME SEydrIbbiaapVIDER.(Emnninatiow• FiseSaida)einsits'at testi anit,*-miyile(.3rA sseaiiiteriefDraiiii); • TIME MW 141 Van- (TrecthrieertiProeedirier,.ftseinde-thedreationvosirituicrtratene4a, moi.^ (7 4.--e--.-4..., e -2., ec fr"" 47 G ..." . ' /a.? .., ' ‘i• zri.d.‘:-W "e7c.: CATEGORY -Mee mums : . EMERGENT URGENT--e-te -e if-4.....*: ,-.­ .).' ' :--..' ORDERS . ME ..f. ,,, ‘---77-77-----e 7 , --1---- -,­ C.7174-/' -- . :••• .7-// ?I r. a /t/I-r----ru-et,:, ,*(•."'"'" e--11- F. Ae t;der#1"1111A1^Nrtete • , • . ••OISPOSIITION4OPow"thataPPO1 Nom .1c.t.1[4-or.crv--- 2.4• . `72. HA. sete477,1 -' .*. CONDITION UP -RELEASE:, IMPROVED UNCHANGEM Tima.or RELEAEi.• .1-0:A4r _ (CONTINUE ON SE'SDIANEEDEDI •PATIENT'S iogNiripl b)(13)-2 ,77 7FOR'WRCITEN-ENt ••••• FUESIGI-vwefato,r4orkmm; Mange: service :mime and rotation Z/3 3214; nooror mixt .vo•ar.,41, or - i NS-R- (hnciude meireaftintordsred, any ;imitations wad. follow-up _ plans) • ol 3 bX11)-4 • MEDCOM - 323 DOD 003450 5 8:109 ISM instructions an Back of rhit Shoed risrf 75404)1-475-;3786 --LemERGEN.C;CARERAI:s9 TREATMENT LOG NUMB R AMP° R AT ION TO HOSPITAL _ARRIVAL CUR M OS. „penman annum- TIME (Attach eare-enroute sheet) f/tattion• and other data DATE-PATIENT PR IVA L • .„7) ON vE1-11 0E [3,Amau LA.%IC-2 :.4 etido -ere ' OTHER. (Specif39 . C'/'nof[/c/^ -r NOM A R OR UTY /1142‘ S , naiads mp / fe'pe, h'"S 44-t o !glee C17 scaisatiOe data. rdneat Ifistor50;.(21 0 blitelive' 441tPIESonnnotIon- --taciusis:3708ssitrotteStraSelz-ntN11:(3)..,fisseumient- 4457 tif rl 1: (4) Plan (Treabncrst/ProcaduNi- inclisda mediaadon /hem add fair•4P 47," /a & / ate s LI; - 4e7¦e'ed-e.-re" 7 4 dfc:‘ 42. %,-, 44-4- e-."- If e'/ if re 5 ; • /---42. Oz 'eff c /-4.41Z49,6-c 4-t- J• • 1 . EMERGENT., a. 2 SG r«e -6-e 5 475/ 4ety/La.-4:44-.S" URGENT 0,44, - ("A i= 1)I • ? C rc:Jut-t "I th„efos;;:;-'F.Ai • x7;--6-7-...-r/e• /*or . /e7)2---71/7: e.-/,,"1,6 71,/... 4 fZ- 5- C4/ ; '`­ „elt 4'1) z.); -7.e a- 5•s" _ 72 HOURS r :ROUTINE Z 422 - \./5-.6 /zz 7 1 YO ImPROYAD 4,(44 - 46- v c/ 5"— 2 I -. t10-14-1-44.. z IV p 61..thoct eir5/z-e-0 to- (CONTINUE ON 924 iF.NEEDEil bX13)-2 4 )? rardicazong ordered; any dilatations and' ifolIookgo - A 7r- Al ArTir --7E,TrA4414 7- -0"11-.7 . re . .... ... 7? AZiOf/41' 2 Nr-.:70"-...._ -(--t'lL.. .. 12-' al-V. _';i-_4-`_ -v`f 11f7 r. ore,ip/2/aer. 5;24,... -ekt;i .'e e.5-ef/toit , .," . 4Gfeeerae­_a- "'" MEDCOM - 324 41970-JMealr; DOD 003451 Ess--iO3 (Sea Ifxstrvcrioas,tur Back of this Slxet N.SN: 7540,01,075,32 86 TREATMEN t FACIL1 EMERGENCY CARE AND .TREATMENT LOG NUMB b)(3)- (Areercirmaairo - - -- ARA IVAL TRANsPoIRTA TI ON TO HOSPITAL CURRENT MEDS -(Attach can enroute shalt) !lemmas mon un-HISTORY ST A NED; FR OM ME. Izattan and other data) . • . GATE PATI ENT }OTH ER! (Specify) PRIVATE, A RI' -• , . AMBULANCE -T VEHICLE . • ALLERGI Es -Ne-,1----C1-•••••1•Irt• OTHER (Specify) C L 1-3 - \A/c, I nKit ATIENTSMOM A OR STATION fCtty, State and Code) N areG 'CO Leda smatontao, -auranon 4 garP-A-A-TY PAYER . tr\ I L.07 E YES NO DESCRIBE (1) Eta bjactive data (Pertinent lfistor7);-(210,biettiue etas_ TIME SEEN BY PROVIDER -rayst; .(3):14,8Feslittest aneerao­ (Examination • include resat .of tests art‘x n (4) Plan frriabizent/Pr-oeedurer -include medication, i2(td 1Pllod-up, A ie4 se 4, PULSE Ace..5-5-*,=-4 -Pay.';; f;fiR,/ -7 AA 2 . , . /U. , •S.. • _4_4._ 5 .74; CA.4_„,./rof,t r ••••¦1-?.../V•t=4-tx., s IMPROVED :-' 4", 44/1=1 #1.1 -• • cse 7.-11114E-OF^RELEASE:` (CONTINUE: OltiF -,PArriEbt=540EN:111 NEEDEO) ----FOR wRil"anfeal'hs Girard an, ins na - -TEN-IEFrri*t AP OP(rwilrarni= teetolret. middle; b)(6)-2 2 • No and-estation-oFsponser-of next , ZDEVG-PRZA-2'. -yelareir ordered; any aitittations and , ftilioca-ga 1­ 21ans) re ‹ii-v-V1•••`*. ') MEDCOM - 325 fia- DOD 003452 (See )nsintconi-em Back of Mis Shedd NSN 540-01-075-3786 -4-ElfEFiCTENCY-CARE-AND 'TREATMENT TRa.Allb)(3)--11.;;TY LOG NUMB 2/5 cs72/ ;Mr'"—t-...!..=_°:=1•_. ,:rFLANSPqR,TAT I . ‘"'"-tITY- ON 0 HCEP , 2-,,. It-JR RENT NI ECS. lte=nu awn (4n-Hts-rcove oirrAiNeo FROM Piannen:atre:anranin Maize) untion and other data) A I ENT 0 OTHER (specify) LJ Cl VEHiCLB [-_] AMBULANCE ALLERGIES OTHER (specow N (City, Stare and • 7 Cadel HO M NO. ( nc. area oaat) C_77/.." t? COMPLAIN nclude amptom(s), anal:non) ISEX AGE .FOSS i E.-= ,1-11145grAWN PAYE R? - • - • .... • _ r--, YES fl NC I DESCRIBE (2):&utyjectite ctifra (Perdriant History): (21 ONectiVe aceta TIME SEEN 3Y PROv I DER -1--11 4. Cr 7 ,___, (Examination • Include restalti of hash, and x-raysj: MIS'ses/merit alrfagrao- , • j: (4)aPian (Treabnene/Procedwra ::„ ,,3 ,--L-E.-cY - 1"nelkier:sediceation given mid follow-up)c . gb--1- -- 4,-‘1,,,,rt-e-.1- -5-43?, c14' r",zelia, is err-4 .....4,--c= %%ow*. SATMO.Py Man renew A4/4 ‘444 "1"2.•--C 4 ., -9.1.."-0..2-2/7.1-44-, 1 . - ^ r- t.d...-1,--C-c EMERGENT _ AGENT i-t ,,--A..e /-e-e--1..-.1 ---e--t-c-) 6C-.6 Ge et 4-e-, droe d 5 . er­ er_2,2,,,c, ORDERS. I ITS. ,TIME 7)17-2/1-4-54c. 4. 7„,„1(-4-4/2.--e-.4.._ ....C.,e,pe" a ..c" `"4"--44-1— _ _ ...,:.- Wre-14-4--4.444'.c'11-".'L7'.f 4---i‘P-- :i:_ 0.--Le., e--,...iz ...•._ _e_.,,-..--1, .47-e. e-e- ..." 44.9 s-r-ei- 4,-,---- #79-tr....b.E.04--S Arn.d/44;47­ nt,-(7-7,r1c, ruLL cone --. QUARTERS . 7t 01,27 f:11- 124 Hrs. 41 Mrs. -€_ 4.4e/dee,res-sca4vc4-a-,-_s_ic,feee:( a-5- 6, 4,1.-14,0/3 1/--41Ye-^") PA 5, ,rds-s freer-P-L:ie-e— upicmAr4sEb .....nixanm I.e.N EZ 4 2 ferg-Ntillet CM SF IFNEED --NTIFICATIONpfeehanical imprint b)(6)­ ENTRIES ; Noma • iiiist. t. on-of 4P0a.01.08,Aext jr-AGINTF-Ar0. Le- d//er 41,‘C.LIL 11: 2"-= — • — canarana murcuermarts ctraerecg. any anuninain anckfoilizarAtp; eci),P- .11111112 eAd'e r2 (d. 4447 rat 1-10 Sc MEDCOM - 326 DOD 003453 - (Sea Instructions no Bact of this Sheer) USN 7540-01-075-3786 Re.ATIvVEN-T Y :EftOgNCY' AND TREATMENT b)(3)-1 LOG NUMB R-CAREL flifeclical-Recried) _ TRANSPORTATION TO HOSP I AL C:.) . (tetanus -artaerctinreitroutr sheet) izatiew and-after- *Oat OTHER (3paait-/)71 P R I VATE' 0 E PAT! ENT AM B U LANCE ED OTHER VEHICLE (Specify) too oe..- 1G,04E ADDRESS OR-DUTY STATION May. Jtatir and Zp C.7de f tymatorri(s/. duranon) PA YES NC DESCRIBE (I) Agbdcctive data (Pertinent History(Exandna don - ); (21 Objective data TIME SEEN BY PROVIDERinclude' restate of tecte ancfrx-nuale(3)IcisestaneattfThagno- .1.444) Plan (Triabnent/Procedurce-idetudie medication ittarnatid raiirate-up, efr-A-L__ „a htla +:1-4111' /a) LSZAXA.... ‘-fSt-LI,C4/ 3 ›. t qi 04--ap-fect7 reeAe cjo ew ArAr j psi S ,---,,E.X:FEGOITY (Sea muesli 'EN4ERGENT GENT - ,075-0 6Wifigta -----ORt)ERS . IN ITS. TIME .,-tA/ CL 0-4 PI-AA JICit.s = ,c 1X-? / .0/ t ke.e..4e-5 D1SPCSITI ON (Check GU dud' „et-i-ezzZ. /,e) ; I 24 Hrs. 48 _ETD.11 _ e-e./3gScj-dc-c.# Imes tetzmeiligpsrffr ef.ranaitationa and follow-up W-e_er e-ed /ter...5 /o// DOD 003454 • LABORATORY RESULTS. FORM. ‘,,-..-------.;.2.17sECOMBAT SUPPORT 'HOSPITAL (Subject to Privacy Act of 1974) - Date and Time: and Time: oW dt3 3 )5-)3". 3.3-4.7 mmoUL 98-108 mmotii 35.0-60.0% 80.0-99.0 fl AGap iCa BUN Glu Great " 12:17P11: 0Vide77's corer saRai.t:45iN :11 117:1 ;11711WilAtiaiii 1.010-1.025 KOH- ---- • No Fungal.Elemenis -" NO Ora/Parasite Urine Microscopic MEDCOM - 328 ) DOD 003455 :::arrieR:itiffe,413441rr -. - • SYMPTOMS, DIAGNOSIS, TREATMENT TREATING ORGANIZATI N gr=7§Tre .".. , AUTHORIZED FOR LOCAL REPRODUCTION CHRONOLOGICAL RECORD OF MEDICAL CARE at¦ 4..44.1 -a 5 cr E --31,..4; c?.2 -c2RJ-4 (ah? c( 111,11 Loa) ear c 41 z.) 4-14. 4-. 1-`41, 5 eily72Xf % ( e C e74X-Zr; da 1-2,Gar.,e z .4.34e 4:ze e .12./ 1-1., //‘ a, ,rte • (6)-2 b)(8)-2 A TY, STATUS- . OEPARTJSERVICE SSNAO NO. RELATIONSHIP-TO SPONSOR 4410•8 giro: Nemo - loot flag middle; ID No or SSN; ISTER NO. Otio of-grele Rarstalido-1 -CFIRCINDLIIGICALIIECO X6)-4 MEDCOM - 329 IL. DOD 003456 TRANSPORTA ION 0 !-I0 il'Ai. . U R . _ _M CS -/tatanas UnlIZILR- itic-b ai&info:4 te serif; izaticuLand.otiser daft) . , pRIVATE, D 0 AMEOLANCE t__I VEHICLE 0OTHER Opreith CEscRIBE (37 414uective data (Perenant Ifittpri);,(2100katitie data i ESE (Examination • inatude results or testi:eiurk,"nrek 7 M P412 Phassessusset CDie4Fso• M() eat ,-29". frrment/Pl'actditnts - Inaba& 11111111111111.1 wr/fAll, P le , irrylevilr ;-184rdiealiOn tarn eliiCrigagrUP 131w r ly 1'1/ y.:/ •l/f • AI' 0 0- -fit J.waipvVredilovJ e. ,N.ot I ./ Vrtll I. 311"(W IIi,1 -(-61. WC-T. nor rfijr•ovr, nett j.","Titi %',--11MM'ardi ^ ' 7-- • 4C7 11 (C.UNTiNF,1711 c.c 077 te A 1 Cart'a f DOD 003457 fSes Instructions nn Back of this Shoed NSN 7 540-,d 1=075 -37 It 6 1(3)- 7:2, I 4.7-1a71E LO NUMBER TRANSPORTATION TO HOSPITAL CUR R NT M DS. dte tangs tram un- M (Artuth care enroute sheit) tostion4and, other data) OTHER (Speettyj rl PRIVATE, 0 AMBULANCE L_J VEHICLE fl OTHER (Speettr) 1-10M N . ( C) ucHaymqtbm(• duration) RO PAR 1-1 isiE/Ys/er TEYES L j NO DrExamina% ESCRl Bic ) ineh Jruubitiortesta andisto(2.1.owectiveraww. its); (4) Kan rrmatment/Procedoms -include medication giurn gait: fakna-IIP SIGNS (1 .Sititiceticecizaeninent Fix.ra77431wangradatg0B Y PR 0 VI DER c //L/c..1 /cr.." 4-^ 7/die a-- 6 f(") 4e1 t te • 5" IL 7 a- et. e./y 44. -" Q if‘4' ""( /re-1/ o- • ••••., c_./ • 5, ice 42.‘? it-1 •r-s • rd,e / / ... /14.•¦ 41 7 /Li itue r•-‘ 1,7.e... • •-•s-? ( ,t/Le. ,) ,‘") 1-j/2-"1 szi :era, 3 724472 14 iter7re.- : 14/ Ar ø 7-I' Al-era•r-/IJ r: Aef C 7 ,— ,f72 6 : r //5, z1/4,/ zc•A e e AT /44.4 /7,6•••3" — e• 4.1- 43-4 4,1/6 e.44-6/11“-(- / Pc,/ .0=-Eic.../4-AZ/ A • s te, r • (CONTINUE 0,M SF 507, IF NEEDED; b)(8)-2 I DENT1 FI CATIONffiladhalliaa filiprtnt) awRITTEN ENTRIES GIVE: Name last, Mat. ntiadi 4, • • ,7.41,4.P; nentriranto nitration orzgarutor or ,t' • INSTRUCTIONS TO PATIENT (Includa medic:ado:ea ordering, any Limitations and foiknote7 plane) .r" Al /9 0 X6).3 ByLl "LIZ 7"4G.;•-e.-4/e.`" 7/26 424-EC.-7/ r c/ MEDCOM -331 DOD 003458 fSer Instructions an Back of this Sheer) N.SN 7540-C1-075-3,86 Tr-A lENCMI T Orprvi LOG NUMB ErifERGENCY CARE AND TREATMENT :"= '-' Memel Reetirtf) TRANS ORTArION TO HOSPITAL CUR R NT M (Attach care enroute sheet) iikvicr, 7andt other data) DATE PATIENT ARRIVAL D$ (tetanus onnwa• Y 0 AIN • R•M . OTHER CSD‘PttY) PR I VATE'. ri DAY MONTH AMBULANCE VEHICLE 6/ 7 OTHER (Speci (39 AT !VS HOM ION (C State and OR 0 Code) HOME TILE. NO. (Inc. area ¦:.roae/ .tk:F C.DMPLAINT(S) amities amptom(s). duration) -eta-1 a HI RO PARTY PAYER? Sitre,E YES 7 NC DESCRIBE (1) W VITAL SI GNS data (Pertinent Histor7); (21 Otveslive ata TIME ELY ,11EI, nEtg OVI DER (Esambustiots • theism:le results of tests and X-•) (3)..igcessma'" 117628vw. (4) Plan (Treotment/Procedirms • inetude medication chap and toaow-up y/5 4'1, L-PIA,, pre.) oils 1-0 EST z-=,/o Woody 51 u„ls- f Y 3 (7Q2/....;-. vi y (RA RESP. TEMP. lte d s ( s • 1-) e s Wt¦CM CATEGORY (Sei reverse A d EMERGENT NON-URGENT 6 — i 5, - ORDERS IN ITS. TIME C 6,1 • A— 6.1--1---1 • •OPI 5 ;DENT' FiCAT1 ONefechankal imprint)etwRITTEN ENTRIaS GIVEs Name lint, ANC middle;DO seraitie.etar”• manse and relation of Wormer orltext . LIST fe4OTLITIr .8101.13.046 TREAT bX8)-4 b)16)-2 SIG -1.t-/ L -1-4, MEDCOM - 332 DOD 003459 • 56)21:ics Instrverforn "on Bac* of Viis Shard '''It:-E*EWEISCY..CAFIE AND TREATMENT TREA fM.dical Recirdi TRANSPORTA ION TO 1-105PITAL ?Attach mar enrosser sh DATE -TIME PRIVATEZ • AMBULANCE VEHICLE OTHER (Sped/3') 1 3 T*514 •M AOCIR STA ON State and 1220 Mkentriaptom ..r.1,0 SIGNS TIME PULSE RESP. TEMP. CATEGORY (Ses nevem) JUROENT NONA.IRGENT ORD S INITS. TIME Emsiteargry R01:1 NE Nsw ­isokki-o75-37116 ii6-fetome 5 ¦-f c. 4 7' 5 5 c J • I? $ tr. 6-s - I e F . 4. . P 7'5 F t '77 ..„ 4."(CA-41f, • C-r„ S ,;. 1 . "--se 411?; ItYZjr ."1 4 , • , tic HI Aiwa. -•poi PATIENT ErThER (313‘cifs) ,•••••••¦•¦¦ ALLERGIES 7 z 111 - • - TIME $E Y PROVIDER r.' • 1 • • • ' 64,4 5' ../.+L 7' r--V bX8)-2 •.f•••••• (b)(8)-2 TEEDEM MP: , 0.1 e/7 (V(' „...----. rot t- , IP licaCons ordered, etti cktfr 14.., 744......... T r / ,. n and a W-uP • 4, /.....L.4..4.... ,, e .4,1) / - --- 11.4 F-tar 5 . 04' €: MEDCOM - 333 DOD 003460 II$N TI4O44434.4174 AUTHORIZED FOR LOCAL REPRODUCTION MEDICAL .RECORD CHRONOLOGICAL RECORD OF MEDICAL CARE . SYMPTOMS„ DIAGNOSIS, TREATMENT TREATING ORGAN IZATI • N ign eac entry Cc 03 E3 M 4P r 9 Efri • 65 w 9,A,30 yu Liner f ce R liolleieur few or/pelvis gyms. rt. ch etY /Y1,t,c) • 1! ak' PAAVOY d /100d dr d atov a r1yG , fv-s foce e Lir / Reciq/ , etv4) RE Cvcr fit; recieveti --TV a( 017ker,i b)( 13) 2 JO/Ar 4100d cirgivy, cev,f o Afh ordpreol 3 /0 h krY1 et, g.1 )10 -gy 4Y) tg -f.,(6,2 3-1/PR fvi @ rihi ctTh4, . Z3 Pt, VoNyvieJ -fr,wt re, d ip9 •. • a. .,• HOSPITAL OR MEDICAL FACILITY ATUS •••"'"1-410.-•,'T DEPARTJSERVICE " • • -- SPONSOR'S NAME SSNIID NO. RELATIONSHIP TO SPONSOR =STMEMIMEEEEEIISCILIION: 'Th: • • -+---For typedar wean soffits. give: Aram - apt. I lack* ID No °r SSN; Soo; REGISTER NO. '- Date at Binh; Rasbeisda) =-7tRatTuS 8C T:5 I CHRONOLOGI • presrabuf 1: 71 • ,...*1••¦ • ' I MEDCOM - 334 •- DOD 003461 A6 -a fV.-1 LABORATORY• RESULTS FORM 21st COMBAT SUP OSPITAL •. - (Subject to Privacy Act of 1974) Physic:I n: b)(13)-2 INa K IGI I pH I PCO2 IP02 ITCO2 HCO3 iso2 I BEecf IAGap liCa .4. • IBUN Glu ICreat I Hgb Clarity Glucose IBiFirubin • Ketom r SG Blood Protein Nitrite Leuko WBC Bacteria Casts: (Crystals: UNIT a STAT Date and Time: RESULT REF RANGE X. TEST RESULT. REF. RANGE pto 128-145 mmo1/1. ALB 32-5.5 g/d1.. ifo 32-4.7 minoUL ALF' 26-84 WI 98-108 mmoUL ALT 10-47 U/L 7.35-7.45 AMY 14-97 U/L 35-45 mmHg AST 11-38 U/L 80-90 mmHg mil 02-1.8 mcgkiL 18-33 mmoUL BUN 7,22 mg/dL 22-28 mmot/L 8.0-10.3 mg/dL 95-99% Choi 10C1-200 rrigidL (-2) - (+3) CK 30-170 U/L 8-16 =Id& CL 98-108 nanoUL 0.11-123 mmoUL TCO2 18-33 mmoUL 7-22 mg/dL Creat 0.6-12 mg/dL taco 73-118 mg/dL GGT 5-65 U/I. 0.6-1.2 mg/dL GIU 73-118 mg/dL 14 -7 mmol/L 1Z0-18.0 g/dL TProtein 6.4-8.1 g/dL 128-145 mrnol/L Source: FecLeult Gram St- Negative WetPrep 1.0104.025 KOH No Fungal Elements -Negative OccBld Negative 5.0-8.0 O&P No Ova/Parasrie Negative-Trace Negative ABO/Rh Urine Microscopic T&C Epi T&S Mitcus Yeast Urine Serum N I ce MEDCOM - 335 orgerlfte• 13)(6)-2 X TEST WBC RBC Hgb Hct MCV MCH MCHC 'Pit LY% LY# Segs Bands Lymph Atyp Ly RBC Morph: Pit verify: Spun Crit Thin I Thick I '"NP4440,4Y ISed Rate PT APTT FDP Mono - RPR HIV. Meningitis RANK SSN Date and Time: - 6403 P 1 '24 •i-c.:ditStZg, RESULT REF. RANGE I 4.8-10.8 x10(3)/ut. LItS, 4.2-6.1 x10(6)/uL Pia 12.0-18.0 g/dL 43.4 I 35.0-60.096 CI.C4 80.0-99.0 fl 27.0-31.0 pg 334 33.0-37.04dL 30, I 130-400 xi opyuL 310I 411 I 15.0-55.0% la I 0.7-4.3 x10(3)/uL Differential !Mono I Ems I Baso I Imm 35-60%- No Plasmodium Seen • I No Plasmodium Seen 11u* = 0-20 mm 10-13 seconds 22.1-33.7 seconds Negative Negative Negative Negative Negative DOD 003462 • seo-ictl (See Instructions IM deck of this Sheet) NsN.754o-cl1-o75-3786 TREATMENT F -(Stonsw EMERGENCY CARE AND TR EATIVIENT (Medics/ Recoicli .7 • C bX3)-I TRANSPORTATION 0 1-19SPITAL • ''' -ARRIVAL-EN-r wroon...ToSTAiNeD. FROM-(Attack raroutt Owen • 44tiO4 and other dattlg/Mglag Uning6n. OPTNER:i(Splatti):PF1 IvATEL • CATE AMB U LANCE L.-1 VEHICLE ALL.. 1:11 OTHER (Spicit") COM LAN nclude symptom(,/ Maa VITAL. SIGNS DESCRIBE (1) ad:dachas data (Pertinent IfIttari 1: (210W:titre d (Easmination -include results of tests mid x-r/r/s): .(3).Amemment CM'S"' TIME Z .5" , • • ); (4) Plan (Treafinent/Procedif7t/ -include medication )bon and logaza-up BP ..7:; 37 y iv PULSE Cr GiElMigiorria 436•64) e Gi 0,14 SINOmc.)CA I/ • RESP. Illintit•-411111P211111 TEMP. oi/DINEOUNIMIN 3 7 v. 1.4., S JF C.5 U.,) c vIn - • • EitilEINEMIMPS o•-• CATEGORY Ike maim EMERGENT ,,_, 4.-T NON-URGENT ORDERS !NITS. TIME ,r4• • • 1„.• 4.--3 4.; fs +ad C • 5_5" / /V 8 ( • ie C ? Ze b- C S.) i" ya /4 %I. 4. 7 - -r r 7 .LA, C—S(...4-, el 4E-• ,A0 -tr., a..- aid.e est,. r 1 •••• S - "4.,!4•;;N: re.% ?-• e -420 & vv.- 1101,11.1. Mine „,„ QUARTERS Itki me. I jut*: - 5 24 ¦••-.S yu LA't 6-/5--t: , z4- -EMERGENCY Tow/ 72 HOURS ROV7114 n c UNC,MANGED (CONTINUE ON SF 507, IF NEEDED,/ ISIGNATURE OF ARON/1=R AND ID STAMP . 'b)(13)-2 ?rn EN' MEDCOM - 336 DOD 003463 t:- 558-103 :See Inetrucrions aseA- of this Sheer) EMERGENCY CARE A EATM 'any) a7= 4u1,4"air"."--- • (114edieel Recdrd): " b)13)-1 ARRIVAL TRANSPOR,TA. ¦ LON. vc AL CLI R R M .4tWek-adra.Wawaktie-ahae0 . arid. other dotal . 'tetanus OrarstAn-HISTORY OBTAINED FROM TIME • DATE DPATIENT ,E1 C7114011312044i D PRIVATE' 1.--i--VE14,1"CLE - -Rta!k4. B Y LA199E AI LE-RqlEs 1 DAYjvioNni wt. /..e. I t_261- 7 ‘ 1 2 0oThiEtk. is,*if, pATienrrs I-10M ADDRESS OR Carel; STATION (airy, state ornd .2:0! Code} HOME TELE,. NO. (Inc. ArAla .00cle) • rimP•onyftie zoto YES VITAL SIGNS RI = E ( &at/votive data (Pertinent Histarl); (21 Obis:gibe data of.tc,ifruatim. ii,17,44rrimattraif iss(rarsd's-raYak:.43):CsFenn!gnt Wialia°' TImE 'SEEN BY PROVIDER sial (4) Val* erriabaiiii:Miimadarrei -iifollide Omni's:mit:ken slum mid follow-up7 p • „,..., I' 4-c . ;4.4-, S.:6,-j-A .......4., CA...., e....--t_ , 5: ,, t=e-ATEGORY-ISeer (EMERGENT /6 s.-. :--- URGENT A/it r _ ' . -,c....1..,......_. ORDERS IN ITS. 1 c17"1: 47...5 • . . _ . _ C • ( DISECISIT-ION_MiverJr: all that. amPbq 4/94LLAStrtY 11? 73.(3.h C' C.i.f. - 148 172:1,1% G_ a c uftrriu Lbi:YEAR_ A: p . , h•• • iePROVL•O UNCHANGrirr --;,,:CONDITION-UPON -RELEASE .re? — =ffiketirlilatiart _num. se -- -rosco a ftapriatk: , b)(8)-2 Driono..itookArocourdakie-ne_orlitivc_tilorspottoor or 'text • CCOT7NUE-121417 SF 507..1F NEEDEDI ordered, soy dmitaefoist and-rollaakid:$ _ 7- • MEDCOM -337 DOD 003464 (Sea hittiiri.ari-Osick -Ofthis.Sheed __PSN 7S40,01:475-3296' TRIX1) ,..IAgr4 FA 0L. Wrap OG NUMB EMERGENCY CARE AND TREATMENT iMadkal.ltaatit -dI _ _ • ARRIVAL RAN - •R N TO HOSPITAL CUR M itensruss unansn --- --- • --- -¦-(Attaeli ­ eare:eitrouta -shectim---.7-.----..tzeRamend'ethgr data) 0TMER Opectivi PRIVA-TE, DAY MON YIL VEHICLE AsmsuLA,a , Alc-g 03: 130. -• • D OTHER tspootry) --- • TM-HOME ADDRESS OR DUTY STAtICIN Mar. Bhp; atatTae=j7- HOME TELE. 140..(Inc.araa coda) . CHIEF COMPLAINT(S) (Include symptont(al, duration) • e-,&.• I (15 M D YES VITAL SIGNS DESCRIBE (1) &takatiat data (Partinaitt Histar.): (z Objective data TIME SEEN BY PROVI DER (Exatatitatt - induct* reatatoof testa and - 3a):.(3) ge z rs actiqstA illikdar-iagarCliP A .7 10 &LW (41. flut! CtrijiarsatiPt• ot • SP . trrism-„, tali PULSE • bae 24? aso ,e-!) Q_2-) PA Who h ; Si , Ps vefi_ • f; tag Lib: 61Aleis1ft1 ,orr.11:11131 I GO 66. PATE-GDR Y, .iSse ievartai /42 44,-6,,,e• .5-'7 e-/....cfro--6 .--..i."7"1-41 EMERGENT URGENT fs 4 4-7 . • NOPWRGENT !=k,-- • : fre-i/7 ORDERS TIME er..14 e.4.4- 6;61-v._ S. c.,!',7 ih/e. 4z p -44i724 /a-24-A- A./ e .e..;•./ 61-‘:17-7..- .. -.ASSESSMENT/DIAGNOSIS V , . • . - .• • '' ,v, - f &-evit.,;4/0-77,9t2Q /11/ ..,:-.7;a4et-."1.4.6,..9..17ge • DI POSITION (Chk ad, *Pt4PPI7) -/-40 5 Z-1-to IF-VP-OWN. _ )4- e'f /270 vo,""apleal e+ (At rrI, I. s• . pc,/ 440D.W.1-EIEKILITY7'. 7­ 42. d-f) , I ri-eri :4•*0:0.? oce, -0...*:.••- ICY—L ¦MERE.WI err _•, agog 5-dtecet„,_ CONDMON UROAI RELEASE /64./e Aer--,1 tre.Rovw RioR tic-Al/we OF-RELEASE: (CONTINUE ON SF .507,-IF NEEDED) . • . . .x.::, PATIENT'S IDENTIFICATION"toot tanicai imprint)ga•e• FOR wlirrrei+ENTRiES GIVE; mune , las; wt.:at, r''''.102,1:IJOB:laritlita statsitiwtontrzaia riliatt.trolfmaingius Ifft -'"-'•7 ''' si.rand~rw' (el't4--- LIA—;;11 • 3A/Z7 Ate:ie.-Lee 77-90-44A MEDCOM - 338 Dna --co- DOD 003465 . . (;g4 Barik of dairSieerj NSN.7540 01-075-3786- EMERGENCY CARE AND TREATMENT TREATM a FACILI-(Stamp? NUMBE •" (Mei** flecorill - 2tespv- RAIN4P 1.1R.13 lattastas unman­ AIN-4• M TIME Liaticia. and'. data):DATE PRIVATE . 3A-riENT oCi, "fim (SP•cifY) DAY MONTH rYR.; 0 AMBULANCE • ALLERGIES OTHER [ca. 70*.Olefir¦C:4i-ee. -A I -Nr'S m A.OR 3 OR A FicA , N Stare-de) NOME TELE ((nc. area coda) CHIEF COPAPLAiN1(5) (tnciacie evninnna(s). duranan) AqS. 1 rossiBLE TN aD12-ARTY1IIAYER1 41a-. -114-" 0 'er-s VITAL SIGNS DESCRIBE El:"Yo EIE a). 4igkieedie. data (Pertinent Iiittort) .: (210 knettive data , TIME SEEN BY PROVIDER. TIME --k-(EtimMetrati. - LneMaiereielta air MEG and x-raie): (31..aammmn_1441214/42- (41 Pia* :(7tiiiiliMeitritProemlaima "Me l'eali 7aseirmation, inilate•ap OrIeL rew mA.. PULSE. etso:to 0 Pi tvl . .h sl Phtl4S; $cureies.. kar ps r ogIVAFolDay lea (,-o: "SFYIEIStPia CATEGORY-Wee arm) ewite-/-0-1.404ci EMERGENT URGENT / fs oc-f 2eorts, 47 ._NowuRszENT. eere•go-i maz.-,..-----A..ANe....mum...---OW. (5 ORDERS 11417M: TIME /14.,eg.e ‘44-ea-44; a-0-4ae, Sewnveze,f4c- ezt ./ 0/t, pry ix a seveiTtA;,-e-c.1 - ACVECC: Wid171.11 At2PdetC IC .41e,49/06 eed&r:€42i Aeiceiti "f•nd Aeued.frzwill ,Fin/F­ setw7 /74$E ¦13? , .04.e5± DISPOSMON (Cheek dr that IPPO) NOME 119.ILL.DLrry 4.1 n:77 t'r.!•":1L: TERS . • 24 Hrs.-eq;: -. -. I fa HrIL 1 172 Hrt. 11e li p= 4k01 --litOCRPTEERSOTY-UNTIL:-14~ ; - -A.1-////4'. e22(Ig°ei;1 -REFERREO-Tr-Gastleatt elinfer Ov..,:ft•ucciA-49 4,14-.024 oaf" e _EMERGENCY_ tocIA•t '2"ROU-4•11:4-E . ADMIT.-T.CLMOSP. crigr/SERVICE O'Eld CONDITION UPON RELEASE imiDRovED UNCHANGED 7-:-1trme or RELE-Ast : 1,1 Xep fcmyroliiEfikskiafFravozat ioeNriFicA-no_t4 af ORINRITCEN:;IENWRIVS sPorns r hanical keritaratej • SSN; DOB. service status name am, amitambarielaTa or. nest vrc••-••.7 UTP.11 I It .WACUSCLIrestgaffe(lis.:orderad; any atr4tatittmats4:: •-7,6 "Ung ceo t.19 6(:;.:-If • — O'erziAor... 01-1' MEDCOM - 339 DOD 003466 558.1O1 NSN 7549-01t-975737as LOG NUMB -•-• EMERGENCY CARE AND TR EATMENT 7.77.7 RAN- poRTA "joN 0 HOS:. ;.A.L. • r...t.:ARR • • Y AIN-4a:, R (itrtnah-aant-enrOure shag . • . , PATI ENT 00TNER'.(Slitait4/ PR I VATEL cAMBULANCE: _ L7 V C-. ALLERGIES.. ,"I'EHI tjoTk-eg Oliegily) 4%4/ et/ 24.,A) T.P.TiENT,s HOME Agfa, ESS 0 0 ION (City, State and CH F CON! LAINT na I:-YES VITAL SIGNS datae(Fe t (21)Cetipictierid4a • TIME SEEN BY PROVIPER hits ett-rettA Air,'wirl;t3rairierirmoiigitnaeracr -TIME iltiA111111111101111011 &dere; -inalkielnediestion'tintirranci foiloirLup BP Wit1111111NEFAIM A f: tr,4‘4Y4-V-16ed ttr..1.4e 4SV1 PULSE ~MAIM rii•gmf: 7:014.-"="-,,i7 RESP. uriarstrArmst Pte' 7 i.e- TEMP. WT.Zarge) fr;(2Z.0-fi 4047 CATEGORY .4.** :•.,•_•!•• • ••:.; EMERGENT 5/,?*. _a URGENT e-- hr sr5a/ — 4-5pro 4Y-42 la.f( je+ / 4 5/ dR6•4\---/ .../44-ve.( ° f g _ 7042sEpriorePOSIS 70-( "+"7/4- '4-1(114"41',fir/2F.r.,1) - 77/ei/ S id-0 Cc - C.‘41:4freele--e-Pc.149 5-1 /"-°‘.4 ,2 2 DISPOSITION (Chock all.ellat apply) e,‘a4r,12,4Z ) 174.44- ". et47 - .4444,9 7r.,ei.al-e-e:; HOME' I . Fryl—Wiptrry 2e5 ""d61 Ge (2-,1/44:r /4C, /ft—ertt;(//i 40 jel . - eft_4(reil, apt;/577'N'' 1-4444, 5.;`6Catee-?",de'r-le : .- t=4`A* 72 MOORS ,444Vei-70#4\-- ‘...14. RvIC CONDITION UPON RELEASE: -We - IMPROVED UNCHANGED,. DETERIORATEg. TIR4E: OF :RELEALS - PATIENT'S IDENTIFICATION _Odrachanical inipridt) 1 I. FOR wRITTEN ENTRIES GIVE: Nana- last, first middle:b)(6)-2 .SSNi DOE. service status, _ middle: twee and relation of eParzeor or nazi" of km. PORTANT: ALENT FACILITY .gouriNG TREAT- (gap). - pilLi STRUCTIONSTOPATanol aritorta orderireieV; linsitatlens fmcf follogo•uP-061 — &01-il-o• r 04-tez' Zit 4 ,--;„"4,frfd -.c....-e„teerezr ive -1 MEDCOM - 340 DOD 003467 fof-1 egseetel/offri-- p- "AA 4( 4...ktf. . 464/01-2+-:ti Jer, .4 .0-amso4, iiee,,etekes) ,7 72 Awe- .5"e • eCte td-t-4-2-64 Ae.zaZeu . £4) 1-ta elette a /t.e OtGG e-s-5 riZOZ 10~ A 'c e 14.-4r • ce...1,9 4.4 c-e-e ge sr ¦ -ze,44.0 se )e es--e • 4.2,4 ik-P,teefles544., Z-744. 41144%. '4441410.1 ar6rie4414 '711.1.e tk., "xer."9.iteprea g,fit 44e, kgetle 7-74: Atf • 6i I arote.Le i(e.r:dj; WA." (21 st.g. rrl?w (1 IQs ?2g 41"40t4,'V ;4A.- 7.;3€ 7°-4"2 r j er+3 cato 44 -- rti."30-" txfre..4 bal,19 '511t4C., 1, lei cA"..)1 0N-44 /4.e a cp../ ostkeit-sp trigajtrArlhe+ LT: oe're-3, 771.4,,k•-rt, 141: 4 -"s 1 V01610P'-' Gid 1179,4 :66 44,=-1freeie ,i444.0"/ .7;04444-4 7:- Npif ro-4 ,7-S01-1 " /./e;;;Itia-e-rze-‘ dt (f.'s 4_4( 444' /2 $./f .)­ iiez,e. IreW 4-- 0") Ire", .171.41,4 z f 4 0 ac„. e y 17at-aw 4.1.:144".411 -re Ae--.--ce7 qtr G^ 6-„,/,4 4 eCt+. 4144- t-Z4".64444.4•6Y-/4 .A'ee4ree;z4-4 c..e. V fx 5 i 41' / /0.5,05 e6,.4-7. --5 ati .. 0, ti DOD 003468 r ff -efe-/4 "6.4 ..,/;;'.41_c e.„,.....e -47 .-. "telp.a.-4... -' . 46-X4-70 ....'"e, ,e,,,....... ,.,.. e.,- ,...'1_, ,41:4,.t., . 2.1 "..!,' n..;'," r•-e-ee- -::: rc ,",- .;.-1. Ar -' 'I AV :," ..01.., , / -if et/ 7-070.- .:" ,g2,0-_,i_e, e,..,.."....z. , ae,......4.4.,-(..4„. /t%„ ...0,..4e...., 01.-4,; /e...-, ,.., ,e',, se 5 (..z , es* -e...! (ere.47-.,-4-rj-t, 4.7) -?...ett. c.6¦-• (°,-- - / I . • . effell _S /)07"e4"1-44 C ip 0-5 AA/ Al- e Z Oe.teP c.c.) 4--1. ,.. • re,--..9( n't-ep----r--,,, . -- . -4.:-k.x--. Aix. ,4-­ ''' /-cf--‘-e- 5 '1., ,.'441.- :_f::4;,'4:--i.,-..-‘: / . cc e--6-(-eoef.7-41-2,_: ,e-e-il.,;44:7 ,.../ /a.....6.,e ..e.,/,‘..-7:­ .--4.-vei ...., 1-‘--1.4/7,--t..: --.‘"--"A-, /i.".4,./s-J.v,../.."( f 4.1 4,/3.f icra .. 6 `//51 -o 3 0 ' ee" ,ce • • "" . • _ •, . • • b)(6)-2 _ • MEDCOM - 342 DOD 003469 . - (Seer inszracriorts 6ti 3.)de --,:if147 Sherri ji,,,,.i NSN 40-G -075. 3 6 1 , RE_A -rmer4.-r FACI.LIT'i (Str.mp? . G NUmB-ER- EMERGENTE. AND: TR EATNINT r (--(0•5,.,).!“ .L. RANSPOATA TICN TO H-C3Pil".7%L. Cr..I-R RENT M EIS...[ Tetanus Irma% Un-H IS . AIN CCM ...AFIRIYAL . )01420Cii core enroute Meet) . isesion.atui °eller ddra) , . . . mut.: . • . ,: . '1)4- • 4... VI-1 c/A (A r, 4-; ) EPATIEN, , 3.,.y, DA-TS .• UG EA 2...DAY . :tvtoNTri• I •r.',..f,•,L j. 1 1. -L....! V EHICI....::: ANI 5 U LANCE F A Q E?G VE_. f :, r—r PR IV ATEi ,..d. . . .0. 4&4.--I.•D­ OTH ER • (snecitri ,..1. _. 2...6.1. . 'TO . -- 1 '''-'-: PRT-TENTS 19frne A-,P0 S OR OtrrY STATION (CItz,-, State and l.' .HOIr. ._— NO nr_ .-,-en ,raae T-7 CHIEF GONIPLAIN ilactuag-sl!rnProrsts). azirat30.) , SE c L•loo pacr-- ¦ 7 0-111: PESPRI-3E --i.r,triecrive case (?eminent aiator,f); (21 In46 •ZA-dt.r.,a„x .ATZ , (E.ramirtation • i72CiZICki results of tests and -v.:dm ; 411 Assexam iDikrena-/ _ `IJN E 002;i 6640 Pa); N Kan crreatmerd1Procedures brclude rriedicacion , riuszt and toil:our-up V MAI. SIGNS 3FT (ile1,4.4i.111 Lkityr PULSE 04"6. .,-r) 7-Nt —'--, ‘ ,-,,--. aESa • !NNW' c.,t, —t.....--,,..44 ,,": L. .-- C ..,--4., , ciff l ,..' 7 w-r.chilio 1 b f lecao NMI A7-7 --- 11.---/ . CA4 1.:WI:Pf f..546 reveTso 7f-' H-. ......,,,,,.- I URGENT . _ -_-_-__ ---- ORDERS iTS. I TIME (.4...,W- V C. 5 :6-6"-e-' ) -ofe-ott,, A / _ - • ,•• "." 14 Z- 3 7 S' =-L.--4-..L.e: c -7"--7` --7 r ,,aL¦•:• • L.L.: • • 7S 5' Yui Q -—1 , / DISPOSITION, faadeis an. that Lamb) 14PME •-1 - ..1.FULL.:COTY -QUARTERS'. 4-/ '4 it. 5 t24.!-Irs.; ..1 1#s I 721#s ( • .•' - .. '' . /.; 7 1-- -+ J... 7.-7_ -% _,...„..„,,,..,,._,--7:,,c.-- , , , I_" -''Y — r— x- CONDITION EiPON F. ( fe , / , ....„ A .„--; ' --.‘" ,A, I ,,_ PROVED I lumcwaN4ED -"-7 (cer.a-iuoRATED. :77-1-fmt.i:OrRill.:E.A .Vrti ----4:?'!7e14-=-1:-7--if f lArriMils7--/7 .507, .1.1 -iyEEDED; -b)(8y2 SF ' RAttWirr3 113ENT:i FICATIONIgdaohardanf 1%6.3St)- . -54 t.p7Srrikfrai.P C FOR WRI TTEN •04TA I ES.O1V.E.t:Nannv • lart- W.. ;:.SSIV:DCrEt.- titteibEses. Ondereletton:Of.. .,;.......' FteXt. p ...'•''' : n ' 't, e Wit . ampoltrAsvr. li.77- PACI=1.1.7'E 77 -, 4ut; it-14,rd ¦„/ r•A% : -a ,rr (birCi 044t1.60/.1{ o ,7c-gre4. y amiterdons..ane adialk y 7.2 g, s - e.-"--7 s- MEDCOM - 343 STANDARD FORM 5Z8. DOD 003470 , ' '-• • • ••• , ."-,... ais-Yai*iird**,S1404::.. 1.Tats€,.....,-:-csAff::.„.„...._•...„:::._...,..:..,...,......,..... . .. ..._. . Therarr.-.: . .. ¦:7-.....-...-.14. ,-.,-1.. 42,79?/.. .. • ....., -:. . Liza Nut.; - r"',' • ..,•;.T-..,.... , ' ..,..;:.. - .!"' .-•. ..:....„ •. ••- _ . . 7A7't43".:TC1-1-1. • .."--4,-• ,i•OL,R.F4 • • 7r..174EOS.../Mtames isn'arecuv- ..-tnairt.70.1747.psim:44100,t4¦ ,:, ,..,•-•,' :‘,.•;.;44.11..17:14,..a.mii..cititiar.dix.cak,.. . „... .. ' . , •. 0 . M• . . . OcrritEit - fSpecith lf '' frdIONM-k YR:: •., . • .. ; .. ,r ., ,..v, . ,,,,... . Dliditziff:tit t • ' • ' , ' I . . l'.....''... . 153 . 1: -6Y Z4`..11.'44:R'7:-•" . .., .... '.p.FIESS'OR.,..•.7:17Y-ST/7:., .7MM.... ;iv, SYscar; mkt , Coats, pA--4-tErrys-mOM ..;9 • •-, • .., ..,'••• .'..., , . , -:• . . • • C. a•MCC . • -.. , . • .. -. . Crit=5 C...04PLA fl-1z4uas:rma.g=m4si. 0.74:rampt . - POSSUM.= RO Pr C,2 -,7••-•',..arrt-.2 . ' )teti -9. t -Nio VITAL SIGNS ,rigscRise.0.1 Apirier-swe caw /Perdii • (21`07,icca't distil-seEN-e-Y :.RoviDER 1.61::=7-crsataga -saw-Jude nnuottsq f testa, .141414Alregzarlitl'.4•731agrO''' jat Ptiar iTre.gbnentifPrccir0Ork • 62ciideedidaavepo.FD: ---; CI swkRower • ''''-'4M521211EM AM11111111111111 :••• .. ' CONOTTIONMPON-- -, =: .,........, - it._ IiiiImoi.,0.4,:: . - r _Zc. beeiguqRATED.... , . ,::: 1 r =.;4,-.0t1",,_ tile TrEl'er'S'IOENTIMOR13 ¦ ''. , ehaiticrisrimpsinn - ' FO-Ft wparrr,,wgarrasgs•.#1 tieepool-birtatiut-alidigie - _ 4..3.-..ssaT: zoo. gefellee r : *Idactals-of soonaCir -or 'wow I'Marlekti -rIMPOR2WM,71:1&7 ' i' . . MEDCOM - 344 DOD 003471 ;See laarderioar ra, Sack of7? Shm•ri • • - - - N50.- - ....._ g4tty-4-....._... -.... •• • • -• • • •••. i ..__Z111:EFtGE1,1CY CARE AND TREATMENT-- -i Ritedall 2- - --.: -Wad44 1 . RANS.P.ORTA.1-1CN TC HOSPITAL i CURREN 7 'A L.".S...i:eionue inun un- : rtl ,R M ' (Am.c.n_erg._e-iros&te...theet)„ 1 ,radon other aer:-.) . OPT146:04pci.-771::_,.- tE I EPATNT , . lice caR e ni PRIVATEL I-7 , 1 m. ..,2 L., AM et_ LAN,I CS. 1 A LL•VI DIES. ,„ Y ' MON i H , i f r‘. ii , ,,, ..., I ,......., .., E H i .1" " 1 . wa...i-7.- .: kr;411/: .43 _r_.,_!_,... ___ .1 c...,THgth_isi.;.,., ______ -.....,....,,,s,...,,,g,,,,-...p.,....., .7.-,,,-,.., STA TION :Wiry. jrace Ana .. . , •A La,..... ..-oss,:aL..- ,NI RD OAR PAY,..."? _ !EF COM FLr, I NT (SI ir:c.tuat rYr::=Tarrlfp. . I I i YES ¦ ; NO .___. VER: 71-as taq $lablecrw€ darn (Periiiiini-Yrii6-rft7.TTZLIVareitl,Froce.- - --- - ITIMESEEN BY. PR, VITAL SIGNS: c•Esc7-irsaiude restal=: of tostg and---rej; ;3) AgarettemarraT• rOffrer.a- ;44,-.0.. .0Ve...e • . siq; Fqth's :Thadriaar/Pi-dardand -Inez:tie tnedicaTiatrlilior!T FtriTt :=a04 1-4141 • • " 3P ase I G3 /r4elP a). e--7/2 .1 • • "7•AP..."-i r ::44P 6:". s. pow c4-mpony 14T•44*1 -1 e a ritt tGEN-i i. ..-e.....0.^7. 1219e7.i.r. 7iVgURG ENT_ :: _ . ORDERS . ; iNIT.S7:1TNg:.; : id e .....,p,t 427 ;:a.Ir/Aill-..:: . '----1' : — -e-'4 1.-/e";-C . . . i• • • • • i-,-.-----E'— , -17---.,'' let a-tri art""--C7 • /"PV/e 5V .17e): . ..,;:::,' 49 i: /. 6.6.4.'e#: . - ....-- a,e. 01 .1..-V . Cel c., ", • '''''+`' -.1'.; 4 1 Cif 0:-.7--::,.**;.:,--. . -61.4.-wfivxot,e. 4."---- 7:5.;::;..._.... ' ..14egl---:- ------ ' .. .7. • 1 ...5.5.MENTipr.e:G71, 4$4,41' . ,.. • -" ''''• i'(114 AI e-.2/1Z : 71iftM 74 -"---i.;..----- ,-.. -r. -(1.1""4...-1... 0°4y-reteti 0-0,44/1.5 it , -e V 1-4'"­ ispesttow?:o,......k:,,iit ti..ii;iiiii..,4:. -.11.91‘1 -'.- .: ;.; tv4:1-07.-frts elia.11"— . .,..._ '•-• hADDI.EfE0 DUTY UNTIL: . . • 0/7,-;07 - . - .. 0.! c?‘ 7r-t:4;.i.aio: -, 7- I UNC1-1ANGEO 4,e DETEMORATE0 -, aeu. 2-e 257. :NM -• irnorsc.) • •-• •-• ,R, 10441-1-TEN ENTRIES 'IV E: h pt: ntidoie; *thIlesSSas;i1flareenJithe-eiotha..ncithe and , ekincnat soOneetreor nextIgrp2rjar.trite,'MteTPORT:e•WIT.' "LIST FACILT:THOLDLNG razArr . 1 INSTPUCTIONS.TC E:IT7:::_meluii „st t•2 7-tri;ivikr •LZec-rZ/44.0 /zeneoeN //z- DOD 003472 bto LABORATORY RESULTS FORM __list COMBAT.SUPPORT HOSPITAL (Sub.ect to Privac Act of 1974) ::FIRST MI.. • DOB SSN b)(3)-I e-D 5-r-G5 STAT Specimen Date and Time: Rerir) --• ate and Time7 -2 I by: ­ •01-2 Routine tfleiv a`3 (6olio/ (TA Oitigter RESULT I REF RANGE X TEST RESULT TEST WBC 4.8-10.8 0(3)/oi_ RBC K10(6)/o Hgb 12.0-18.0 g/cIL Hct 35.0-60.0% 80.0-99.0 fl 27.0-31 0 pg MCHC 33.0-37 0 g/dL Plt 130-400 x10(3)/uL LY% 15.0-55.0% LY# 0.7-4.3 x10(3)/uL Differential Mono Bands Eos Baso Atyp Ly Immature cells 3.3-4.7 mmol/L RBC Morph: TPrcitein 6.4-8.1 g/dL 128-145 mmoi/L Pit verify: Spun Grit 35-60% Mono - Negative Negative No Plasmodium Seen Negative NMI Negative Thick No Plasmodium Seen 4.3 ncyrn L SecLRate 1hr = 0-20 mm 10-13 seconds 22.1-33.7 seconds Negative D-Dimer Negative rng/cIL Fibrinogen 200-400 IIIA P3111-411111111111111 11111111=1111 :-M111 Negative OCCEICL EOM MOMYeast No bye/Parasite ABCY/Rh '114"1"11111= 2-AU•.) _IIIr ":‘:,4 •=111 '.ed T&S MM.A.1.1A Urine _ Serum Negative III MEDCOM - 346 1 f \ DOD 003473 EMERGENCY CARE AND' TREATMENT f htiectiezi Becathli. , RArNSPO TA TI N mospi MAL • N NI Ora: recanualan!MW!! lAttacia-. cane- cetrosuz.slatit) -.Ls.74;ides.• n4u1;:i:4i!lar. &bog :, • 7.77740A ;7r5.:',7- -7tritrte-- V EttitaS::. Ea cSaecifil' : 1..0; • , ..r.A.,:."771" s-rA.TION" 4Vg.7. : SbItte .cceacmse 4,'11:1tgar iaie darn.:wertniventsistpi-nazrotwOlipe'lAttg__ 71-mE s4 EN 'sr PwavnaER reanciti0i'ltistz.antx..-.7eyo.:111-41iicunutiriqpiar**°' • : / Y:577 7,:r1. 14-6 40*,*(-144 • -- dkce 4-6177, st-c. e5 :.$.;T44.1=iP'Okyji:(1:3::r4;(64A:‘,"6,0'.1-P+c4 eN4 ;0-4. ri e ba s. ID e rt • "i-x 20-4-• •-5".•m nr-?! ptg-ENT, oil,u$tqE!'07 1111152=ENOMINi= • EMERGE) cv-: : e4t• •P,:dltro­ • "Ns - -- 4011.1.teZ:- cotiorrrorcuPowittv&ft ­ - eV27, (46r: •!fLC,#.4g7-fAta IMPROVED I ONC4AticaED Den1R100211----:1—'' :" ettliAn516-47 776-0-"" -'PATIENTS t 13113MPacA-rteir aravimeacra tinprin" .„ "SYMP mourrErt Eterams.Vver maeszes emiPeamtirr.:;z131trc-crul-r mexpaga =caserosesessatus:_rronscandvariadrinefspoosor or Mina : a 4.- e Vrerari* MEDCOM - 347 DOD 003474 7540411-43V5-37315;:. LOG. Numfaer"--"---"--•""P*.• EMERGENCY CARE: AND . TREATMENT -tIviedical ;Tkcarea .)(3" 1;LS f AVISPORTA T1ON SPITAL )C:....izeLts,")1,7 ME tiv6166slm 14611,660,.retarget& CCP4.e2trimate meet): : pia ..cri,enci other • cia44,1-OTHISIt i'Srostrq,zi • • .• PIRMATE6 • I-- • -rya ; U VEHICLE Aui-AGIE.st Auul8ULAN " • -.::. CHIEF Cr•i'MPLA ti4 + 02147firp47111.1311 `.1111121:10n hr 6605.51134— 4,61.16613 .66x3.41 PX3.1A,?, . z."%•-,?-. ' -. .-. YES k•ti \-." -1/4— ¦ C__:-. -41:1ESCRI8E cja 'aitilier-ribe cats 01/4-Frinenrflirbif-ni tZlilkiectiPe 4466., TIME SEEN VITAL SIGNS . . . a•-e PRovIDER 1' •Zo,••,-, venation -tattekuiw.ratuitg of ?iretr¦aug"kr.cpW:,(.32.Agersiarlaifq •.. a"! _.... =ME--,•4.6"1 -i.C-J -, iair-141 Nan TrgablientlitclOss?rktiNAfffigyzulA saliguP' ­ _.; -.- ...: .. 7 L _ , 131•(1 '4d7•• Vb ILk it Lg .40 Se. -7--6-Y42 '4-17- ..:1.44/Krq`1.1"'!. .C. ;7" ;5 .:.i4.1441Tr Sit l".47.Z!. 1;i. 6 Foca. -altt-SE ., I 01, r•-• I ,1'7"Al‘E eS, .33 fc1914:-.1%46144''''115:-,.--,-­ D z,:g.ik,42...7::k 1z24;42?.C.: 14;i: ,i7:;°.T_.-f,:ri,,k5 : -15.. ,:,44w44;$ . Iva-T sirTfl%:. q - V-'t41---,ss .vz.k./ F .V45, )5., .1 ,..4.q.;.:14A15#.:_: ,._..: ,,±5.14:g-0,.,0:&.C:i -..V-IN,„ -L....,E,,, -..!-.:-::: t.,...,:iakb.;4-IC :1P k.4 -. r0 ,c.,gkri,.....— __-...•__4: f. ;VX 0-4 . t6 iArV., f4 :43if -ir —.._ . .i ---iji .q-.i: , ,•-•:f :.4_TEUIL".:..:.:.•_AC04 0 _ :Oq _15-5,tES.,;..MV Vt4N1''ttikb?-0: SI1.7 f A.SLI(KbAlato , '..r,zooracRITki e , -.CA-rEGOAV fsor .7x7erze).: 444 4„,e...-4:,:, ...,/.:-Nrc,..i,cr".•'.-. . . . .. .. : . . • • -, - , ei:a:4-t. -v 4 f•41 . 1.±f.Q;4t. •-• s4rw-,,s1+114124-ria140..r.140s45.• - • ?z res: • 1,L;_. .....4,00.11FIED•13UTY tdlierre .• • T'S TOENTIFICATter4 iMpriat2 .'giztiLwRITT.E.beEKTRIES:411Magemprie-- Mgt Mid49,!. i•jit. .S$Mr-Dait-SINIVICILSZOtUrz-MIVVRIV-747:130, ascismix„Abir; Z.237. X6 MEDCOM - 348 sTAPICadderfORD/p61010,4 DOD 003475 . , dSee trect•erif;ns nn..3aes of &r ,Slieeft Ptsr-+ 540-0 2 ,075 -;?-11i16 T =ATM • =Ammo NUN. HE EMERGENCY CARE AND TREATMENT fhletokrd Recant" , . A ANS? RT.. • I®1.4 TO HOSPITAL ' 0',.4 R RE.N.T M 05-.i0 8 i Ai re I-Attach cars. enroeste.-sheirt.) Isdrfan. end other dam! ARRIVAL r trign" I mrn WI -' '11 SROM . _. 01-HER (Slacc...tj) 1 EIPATIENT 1 r-TPRIVATE" 7 AdoEULANCF..•-! Ai 1 etla le1_.•= _..._L VEtficLE :—. 1i • !- OTHER-al:very) 4 1010 i .........: OIR Ma:V..5T H , c..3.-ra... . r RC.' area 21.1c, 1 C}irc:P-C...61P-L...R¦ 114T (Si (Inetucue..nrewornts& dunznon) . `d^FA SIGNS Ito,_scalae.ill..athidte.' tiara. CPeninenr ."iiitofrp);. m0bk.:dm-rim-a [TIME ..5E-E..1.4 3Y PRO V I DEA p.T..--../leijeatiatt • InciudiCrftaits. 0f.ltett: aistr-t -ntX1a;:(M-Sg61:gtnnt Ofatfl** I rJ 44,krem-itZmatnyerttfPivva -r. dirres ,-.*ctssole,nedismtianigliman-Ouidr-rti8etp-.1,11 fa ftwes ebt -/-r 6-,14 '7-77-chi, -: -Fever, i-La , 60clyygc1(,r/0. yg LS. c--51'; 11 W1440 vv/2), "45 " --4)e E', . CATEGORY Mee. iinht,X44 .. ...&CA.,.; -( !;tMERGEIT.i-.. .. -PL:If-,,,,,,, ..1... 6: .4.....v.,„.../. 2. ; une,..Ercr r. F-1 , AA a...4 c.,,,,_.,,' ...r .er._ . '('-',.k A•1!•il 1 54 ri i k I., . _ , . _( .. ,P,'-',''' • ' ' ORDERS 1-101MS:71.ME y i" ec....7—4.4(.. -f(,_. LAif (..-1 . r ...,-.! . ....a, !-4 4 C.. i, . ..3T1 1.:::,_ c J....A.. ... -...-, • .1 ;.-1••• --4-4. 4 . " .... . Elit;MIRI ZMIll il t a r. ,,„r --44..,; / 1.: .......“.. • e-6).roa.•._ L. ,..,,,,e-t.d..A.,c4.A.,--k al- ‘, I--C- . - .1- ? - • IfI C fia. c am , , e 1 woriva,r/P014 ItiptemArieso- 74"4" bETEWORATED - - sespiewstatisr niugui-a;e1,""'' "d`kui:iFolvviRiTzeitk trnites,:atv -:13.ATIENT'SIbtrerAc.A.1^10111.:Mraisaidc.i. bnpri2sel ,••oria- ti• azertninuNn tzsr Frgir,a) 4Q­C45-ieWlECOCreullitr (CMYTINII iMP4A rt.; b)(8)-2 (5191457 A:uc't 5FRI.7,. Oa I Ci STAMP mils _ • y umtatiorts' aarct 4.14, 841 b)(8)-4 MEDCOM - 349 Avrraaan, FORMA • 5511 rt-3..• 6,412) DOD 003476 ....SeruIrtsrmerforir nn- Back or chi: Sherd NSN 75.40-01,17S -37a b)(31-1 i PACIL..; TV ararap EM-ERGENCY-DARE AND TREATMENT ihrleeficed Freesierli 17tAr.4SPO:RtATION 1%; RENT (tea:gnaw HIS ROM "Laotian and other data; LIPATIENT ThtSFIt CdDectl" ) PRIVA7-'• --±" I ."-"k, Anet.ut.,ANcz R5t R (Spaeth!): 1-145Q1,-.1 %) "1 SO Li NIT % •1:10fa. 11/4J A ATr 1.1175.rrabt ACM (1..%w„ Start arta moat rte. area L:orae/ .3r. f ril.cF .....tPt..AINT(S) .034war at, pro nsf).. t"Lanct:tor r , .A.G.8 . ,o5s-ia,...... . Hi640 PART, .r4s,..,..., , 1 i f ) Li 'Es ---- L No CLESCRT5E.. ;;24 agetisether...,dgeca (Perm-i); (4. obiec e.--e :fats 4w Ills.tor-;t ITIME 7.-PReVIDER .EEN 3y fx.r4aritmatioia. , :22.1' ate:resuatte."artattel and •;:4,5-441,f -: (31.Silar4Wirif Me ViagnO• r KV',47c4 , Mop int.. 1';...ttal :qat 77,?-• ,..agt_tfltverIgtiter- tnt. de inedicadjapo.:.giktptoird follow ...1 aspi,oi )7. 7....4 P`..-C"FF'. F1-05. 1'? 7 1:',C. P 1 CnALS1.-wt ''''' Y -\ -04 4"-C. .-.--r A-rt s , I-1-e i- ' 4 rr i. ;.-..e7c/.4 ": a:7' $4(... S tr,'6-' Pa a I. 4,,f.i.—. 'P''t' 5.' -i-Aq--% t*e ""` i; 014 Tr.;.'.4.77Pere NASc. P..e a ... ... .. ,- -4 5 i. s r..!6 • 2 1 , C‘it..A-• ,.„ FP 4. Dal9 I ' -17:pkERgagrct N' kopa, A ie. 1 FR..* r 7r- s c, s , • s 7 ,A f,t4A, I ter . p,s c is 6A_, L2f ca:-tf r r t11-{ c.f r .1,2at"",i4as: 72,Hrs. t CiLtiF NE.E0 EDI raro SI.Cb)(13)-2 , • *aat;:ttualciae:. a.' service ,ffaii*eaiali414,"-°AVVr47e :‘..Lra • ,1 -P.AFTE-iT rAwfoada-medicarartroraaned, an y,4nsitattapanci follow-AP MEDCOM - 350 DOD 003477 LABORATORY RESULTS FORM 21-st COMBAT SUPPORT HOSPITAL -Sub'ect to Privacy. Act of 1974 P e an bX6)-2 T-77. ROutittk..; 00:9:BA40.VSV •""-• Wir TEST RESULT REF. RANGE X TEST RESULT REF. RANGE TEST RESULT REF. RANGE 128-145 mmollL ALB WBC 4.8-10.8 x10(3)/uL • K - • ALP- • 28-8411/L. RBC 4.2-8.1 x10(6)/uL CI 98Lf OS:Mina& ALT 10-47 UIL Hgb 12.0-18.0 g/dL PH- er •-• -. AMY 14-97 U/L Hct 35.0-60.0% PCO2 - —35-45 mmHg AST 11-3&U/L MCV 80.0-99.0 fl 02 11-80-90mmHg TN! 0.2-1.6 mg/dL MCH 27.0-31.0 pg 2 18-33 mmol/L BUN 7-22 mgfdL MCHC 33.0-37.0 g/dL HCO3 22‘28-mmoUL Ca 8.0-10.3-ing/dL. Pit 130-400 x10(3)/uL 6 95-99% Chol LY% 15.0-55.0% (-2) - (+3) CK 30,170A . • LY# 0.7-4.3 x10(3)A1 8-18 mmol/L CL •• 98-4081tanollt Differential ilea 0.11-1.23 mmol/L TCO2 18-33-rnirkil/L Segs Mono -•.7-22 mg/dL. Bands Eos 7,24_ 73,118..mg/dt. 5-65-U/L. --Lyetph Baso 11.11fingat, Atyply_ Immature cells —Jalaa-Marph• Hi 12.0-18,0 g/dt. 2/0.1- Lactate 0.90-1.70 mmol/L Na 128-145 mine& Pit verify: ''4111#1...0#44te'" Spun rit 35-80% ................................................. Geier Straw/Yellow Negative • teizeitro--Negatke Thin. •No Plasmodium Seen Cs& Negative Mirubui. N Negative Thick No Plasmodium Seen Ketbne Negative Negative 10.115-1.025 -4:3ing/mL Wad Negative ' • 011•91VIML Sect Rate lht= 0-20 mm 0 pH-5.0-8.0 107 ng/mL 00:464414e: Protein htsgut-Negative-Trace ?' catitivo, PT 10-13 seconds Ucobili ont-moel Negative APTT 221-33.7 seconds itnte Negative -FDP Negative Leuke. Negative IX-Ditner Negative 'Ibinahliccoscopic Negative Fibrirsig 200-400 mg/dL No FungifElements. 13rigNifitE::::10166S 4 (Aerie-Yeast.. No.Ova/rinasite 7 AB01R11- Casts: spirinatozoa T&C DOD 003478 • ;:„See 1171711:CtiCtirS -:01`7 dtiit N'SP4-7340.0:11-015-17 qER=.A.1.19s..F_P¦rF L'Es't cs • EMERGZ-NCY CARE AND TREATMENT: NUrvi-SE 5765-1;4 ' ‘R, A • . 0 '1.4051,q7AL. CUR T AfElaS. ROMPS ann1"--115 Y ROMtracir.afinef,risroutirsrieFtp, • • i iaratiavanci..keizerOsbs•V -' PATLE -0Thefl '--T'aii#VsiTii 'Cr Aille.r4114. YR • MBLItANC-­ • •... - I 5 •FL_ ib\ • Mileagt!i -) CDAY ) :akta"..F, COMPLAINT:;Si!anetrazd's3! TIVItPrn rS.1, arAIX100q*1.. ,AOSSI EL.:: 11-ti RD PARTY PA.-4 = 7.11 1--"' / ! i YES ¦er.r.i._ SIGNS _ pesCR-IZE ':.; Av.triszexe =fa iPrnaterat fattorzt; (2/ Oblect0e. Agra • . TIME SEE.1,4 EY 1,RcNI IDEA i.,Lzinizsgtio;t - irr-filide-maggIU of Pes-b-Grad-sol;:(av nscoalgesaxrksititPLier0- tlfile -14J _I.: .,:_.„.. _ . ; . , ..,. ..., „„ig .1,;!ikl P kI2T 1-1' ..tWATISCR-PrlICedarMS -inciude Isumtcsation*svirees44,afEtm-isit4: . \ 4/15(3i 1 ' :15.2'Lrclit/P 617-" CP f'' ''t ("'": -..t ..\(1r'1`7'. ' \AC) / 7C'"E -T40.--14 :5?1.1V-.-)(-2 \ ) 1c, s C '-\ \..\ k_•-( ,-,-.T.A. - ¦ ., OCi .. . -)FI Y;VtAt.....¦?1: \ A 14 01.44 '-'. s ?.1 3 011 :4r.12, ICSTAkkUkk',-. 1 '4.'AN,43'D•:'. 1 ak"- e--VNYC..-----) \°1 \* E VL, ' IV:....:::" -.1(•:::-.--..1 --. . ,...: . -. . - ' -- 5:,114..::.J.V: ' -15-.1 .-- .471.• tj: :-:}11 .s.LJ'ajt1.'''''‘ - ....QC ,,r A. -.- -4,-----.i • N.r..:•iy.. --:-. - ':. .,.,........., .?'#;•4;,.r.;-,.... 5...o s.: -.__ ice... il: . . ),-r-Lt--,—;-0!i-,e,c'' .....,,„..--,.-L,....e,.. t'4'.. ..7 ck s ,.„, 4. • /lam V --.-.' ,•.:.•',;•,-. 0.013-0R!;-... atolgail;Mrallao 04. 1 e • - Ats ..9.10.POTMIZOOTY _ •Z'MOV.111EF.7-7. -%." ,...........¦¦„.1.--ilPf * ivAllEbErSTMEMTIP4-CATION iNtrisaniiigii lrepkinz) -i : ..Si.".2.•..b)(6)-2 ;,±i'_._ PA!' FFO.F4=%1A/RIT•Trebr4ORrgiES. GM, el. -M611.10..•11104 . eirli::If -.. 4;4005,. ' •,.. :': - i. b5=1 -3014117,41121“14 ,ITIVIM-0711i Otiatb218,0eXP FUllet.7: 4irleire.?!ThiPaarAM.1";:=577..tattrrY!. HP4.4 12W4Z74;.;.' "' •"••¦•• tv....mii ,, '.4' i•niie • imogantr--wasecr,:ors-ordlowd. w.. ¦-•,....hvywria - s'...1......" MEDCOM - 352 - x. err. awe seem • DOD 003479 oTu`5 pp() LABORATORY RESULTS FORM 29st COMBAT SUPPORT HOSPITAL (Subject to Privacy Act of 1974) ST.,--FIRST, x0-4 PhYSitiOn: Ward: b)(13)-2 TEST RESULT Na CI. TCO2 HCO3 se27--BEiacf- Burc- et— H b. Leda . Corte ' a a Ketone O Y2t.... • kifr/61 4-4 Protein Urobili Leuka REF. RANGE 128-145 mmoUL mmoUL 98-108 mmoUL 7.35-7.45 35-45 mmHg 80-90 mmHg 1853 mmoUL 22-28 mmoUL 95-99% (-2) - (+3) 8-16 mmoVL 0.11-1.23 nunoVL 7‘22 mg/dL 73-118 ipgiui. 35:47-60.0%- 12.0-18.0 g/dL 0.90-1.70 mmoUL ,‘• Straw/Yellow Clear et--. -- rociative . • Negative Negative ECTICFr.025- tr Negative 5.0-8.0 Negative-Trace Negative Negative NegatiVe. Urine_Microscopic MUCUS - Yeast Cas SPorrnatom 8: Arivirph Sed ,UNIT_ _ (­ _,1 STAT Specimen Date and Time: ROutioe_. '"J`) , . : AC TEST RESULT REF. RANGE- ALB 3.3-5.5 g/c11.. ALP 26-84 U/L ALT 10-47 U/L AMY 14-97 U/L AST 11-38 U/L 0.2-1 6 mg/dL BUN 7-22 mg/dL Ca s- 9 8.0-10.3 mg/dL -Choi 1.00-200.mg/dL CK 30-170 U/L CL 9 5 98-108 mmol/L TCO2 18-33 mmoUL . Creat 0.6-1.2 mg/dL GGT 5-65 U/E .1Erotein 6.4-8.1 g/dL Na 128-145 itirnoVL Mono Negative RPR Negative Negative meeilii614 Negative DOA Negative CK-16th 4.3 ng/mL Tfoponiit .e 0.19 ng/mL 107 rig/ml. aasigy Source-: "FecLenk-Negative Gram-Stain WetPrep Negative NO Fungal Elements .O&P No Ova/Parasite thine, _Negative pdive-- MEDCOM - 353 DOB RANK SSN — HT1 ' rko -) 0tcl000lIfer ../". ate and ime 22 Never) 1528 HeMptplOgy Iti/falarfa.: b)(6)-;. TEST RES1JL T REF RANGE WBC 4.8-10.8 xi 0(3)tuL RBC 4.2-6 x10(6)./uL S. 3C Hgb 12.0-i8 0 Hct 1,42, 4 _ 350_80 0% MCV 80.0-99.0 fl MCH 7., 7 27.0-31 0 pg MCHC 334---2 33.0-37 0 g/dL Pit Lrok 130-409 x10(3)/uL LY% 1 -27.7 15_0-55.0% LY# I.. 7 0 7-4.3x10pyui. Differential Segs Mono Bands Eos Lymph • Baso Atyp I,y Immature cells REG ,Morph: Pit verify: Spun Ca 35-60% Malaga z-mear Thin i_No Plasmodium Seen Thick No Plasmodium Seen Sod-Atte Sed Rate 1 ht = 0-20 mm Coaciptetion. PT 10-13 seconds APTT • 22 1 -33 7 seconds FDP Negative 0-Dimer Negative Fibrinogen 200-400 mg/di ocitilori " ABO/Rh T&C T&S DOD 003480 MstrvCriotir-erir 01‘ iv sheer:r; sheer: NSN 7540-01-075-2786 1 -5Z.-1--:+17,1c.N1 PAC:;.; :Z forr•-p) NUMBER ENC" CARE AND TREATMENT N-C , . 4 LmatC1.17 -„RY Om. Ai reeo cpw eriTOUR mar :radon and ottger b)(3)-1 RIVAL FROM ........_ PATIENT Ej ori)g,vp,,_ry, PRIVATE.. .71 L,.A.;tviptiy LANCE] .lev-42,4/0;c44/ .LS: I•tutONT)-1-1-,•:74•_ y. .. ; *4/ fl :1ThEa .41,/fri4k A/kr d .,OGRESS OR CU S.7 .,1••=0N; (Cfry. pact ana f•10. ne. aqeo L.--Jare I =' Gii.1PLnINT (5'i cncua. -a:anon) • RLT,ry PAN. ."W „Gs No • tCESC:..t5ZE (1; -51:biter:tie derra (?ciiiiierit Hiriort0: :21 4.I TIME SEE:14 a YRCvlP.;,...":) c 014_ ,24,-,,g. g../ i Tat. G NS -at:w :14 1`.-.0m:mar.i.on • inCiue.4 results of testa rict x-msygq ; 1. 3) Aixessment rviogr...0- r SW; 4. P-In ''' Th'eettnserst/POcedurrz. include,!*diCarion ricin and taa°w-“p) " 14. 0.45 t),I IA, A 1:)t., if.3/1 . ,- .,• 41; .,_ 5.,,, 0 eL / iJ,-L, 4,:.„ . ;,001-1111. Jr/ 7, p-4744,1-67,4eiefer-rW7 /jr-e-Lifj.c.e -•ee" (I/a y „ r‘9..c7 e. e --Ole r -Ay I, ofr-d-vee/ /40 1 i icy". Au-e!d cr.,3 ,Awee..:oed eleteeec; ,ce,5 d4,0y ENCEAGENT kvois 6.4e feel aZblei.5 n'tdrei V4R6P4t 11-01) ''&*•ear!k' letk Cf' ‘e-14. hr .fir.2•cd ; ora,-u 4G-a ,rc e&Foe ot+ti" a 7)-&-ter 444, 'ailyferk—oloy,, .5,44 te.015Z,1"A 7. :ORDERS' /64. 1-kr,e4 tr..;.4794r4 a 7,-/;_s / , 144," . Tty .094 / / 1 ireekoS ejA C151;7_L )7- Ge-c-ter" Ga-r6*-Fr-of 4,0,-,1,11"/041.• I 3f e -:ZISPOSITI;00:ItytiZiFeKituie,inif24i i?‘ NOME -s7tir-3=:.-0,ttrr 3 1-`:e: z3 r"1.2471=1. :e47. 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INSTRuc-rtoNs . ns-or-g-siidfreciicapoand •"•"" "e.4.•517: .04°O.re-4t7e•-e-0.'"4417.0,F----te-7/ • Ae-c. e2 rest,7.21 _ _ Ae2ce, „of ¦ • MEDCOM - 354 TM It. lip¦ FiD FORM' ititted DOD 003481 c.! ', I.!":`''..°) N ' ''''` ; '‘" 7.': • . •E:A:ERG'il:74C-r a',AP, E _::,, N,Q: TRE.-2,TMiENT. Tar.;--'''''" (b)(3)-1 _ . 4'1 .eyil -.3s.,1Tc•q•••.1 • • ' ..,.. .. ,• _. r .; I,Vecl.m. n I , ,Nc_ Fa!, -1 P....Atr.5;•,.......^,R7 A 7 i:ON, r 0 1-,?_s21...-.1.... ..,.._ . E.4 -ARkiVAL -` it 7.:r..-c- care, e,rot..qt ' lee f; . I i4aP on -,,q 0 CA ..-07,, ER (SP. -• IPA.TIENT : . - -1 1 . ¦ 7N•t-r-: 3 • " - . E'.,At...17-7...2:=1tV.A. i. ..• L . ; G AM.NC • - • ,g7T -.-! :(... -.-.) .t.2*.i5,,,,. 1 .__; ,... ,,,C4:-.,• •,.,..: •;. 0 1-41.3!, .`=?-?tr:74.?.. , 1..E...•DTI-iE n („S'2;,•ccit..¦9 i. 1 COCCI ._._. Y. S ,.....- 7! 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DING T J-- MEDCOM - 355 -ti7504'17 ST •kiipt;iRD FOAM 5 5a _Ho". DOD 003482 •- . • ...• _ 47.;t tio,ar _ NSN :540.0 NumacP. - " -crICv r. • t4 • 7g.z.r.esPc RTATION :C:-4:.SPITAL CUR R-N" ront-s arum rItS Y r-ROM -S. R c5c :.,gc, r. :jag Other r-7-• Pall NT EC/7-4 E.1 (4P`` 7') PF',1Nr4TE.s ! • r.e.1 t•-• I • . . • • . ! i t ,OTI-14 9. t'Sp.eit.../ " , 1 O :HomE.1-E.L.-NO. ;sac. area came) Ale E1:-IR ass, aFt 57/=-7!ON (Ciry, Salmand C3a,c1 w.S.c“..,L".,770, .f P" '.....,:=, c.::;:.1 .."1-14Wit "riserrm-.-..-1-... ,3). -,:u. „0„, —,7-,,,-:— • i.t....-Y,^? ,z.„ : r ! ycc r ; NO 5" rrtm a-!: E'EN i','Y :. 40 V irLIER .Ti ; ••-• • les. ft-.;'----;_m,10€ ...i1.-...zrz•—e??-r.cute ..,--rurafw.i.:; -71.0-0.:7,;‘, .1.r... TAL sI dit incia.t. rnsuIrr. ol. :1st/ and ,3i• fi ; r.3 j sti;,......,sg.r eCi.g 16- i (Z.r.r.r,crial7 • lid r ..•‘' . , . . 7:1E /709 i . _ fr-iti : 1 4- • P•:71 ..7..7.s.-CIILM.411 ,CM..fldLt. • :4-1C1 ' ',-, die= C . ;14•-• •-e---144.-i •fiu-.0.---7-7, ec :-.31,";. 1,11 ¦ -: : r . I (6)(6).2 !.C-72. ail' .thcrr Pt7-, • . R • • DETE Ft tAi-E 0 75fiCncnis1: im2rtr.41 R wRITTEN ENTRIES. 471VE:•:/.e,:le • : efr, , DOS, larrice Ltassu nti-ege frci• Pe id don. bri-,onscr or Ile !LI; PaarA.ACT. 7REA. DOD 003483 fSee ifisaiiCikins on 3act• of arts Sheer) NSN 7540.01$75.3735 R.EATMEN7 iStnnspi• SAIPAdE ix-CrTE—ANC:f T i est.] Ib)(3)--r,„„) CL:A Ptum IA:30S care earauce meat, it-0110.11 and odsar WWI ,.:r$P4tet31)TIME pc, /00 Vri3,4 PP/4741,› "RANSPO I 0 MOSP I 7.3 ererMC.S.Iretamis I 7 PRIVATE,-A.) Amsu LANCE I ALL.- I PC Olar E OTHER ISpacifY) • n. Gael. :MOM OME °Z. M metrrotern IV!. =LAiron/ ,SEX : • 0 .2a 4 AO PAR PAVER?E NO 1 Y ES VI DER l'Exzommatizm • bicide realtitr• of rests aitd x.mays.;: (1)AasThestrierat rraatir..0-' pEsc se (1; zActreanur darn. (Prrcuteatt History); (21 0 bjectiur :Lira ITIME .seav SY PR it rt-:41-Nan-rribestmertzeProcedserruqiciude mtmistacion itrovs.wid Togo:ow-up CM. Or1ie4;4°K, z7r heitt-qt de/6444---..._. fat/ 5-0z-vn‘ /tee.~Ply decoe--e 1e-eer 29 T /Apis.a /le Glfir se,aw".e, $'Ave,e Ae--7 A'Cle cl#9 ,004. /94,e-t e' ~et le-42-5" e5,v, 64.7„4 L av2e./4/e s 1,9 e-/DO elle.edp..e.,‘ frte4 ex,/ , Gees-7,40,e eece, ,e7re...r.-44-64-..-c,,, 424e "0 CA' orr-st ; e-,dercz, si4e15 .1 LAGNOSIS. .efate,,ert Ai4e-g).1 Afx14; e-ge.e.I st/e-S.4--e • Se0SYZI-0r0eiiiiall, CA that WAY) 4, 0 G-s- 01-42-3 .e.tt Or?. e wig -/de/ee £2 3-7.-e2.----„061kilsolrf 44.-s4A-kee-3 „ 137 -tcr"..Z. • '•4‘.v.,•:,•it,,,,.! Aa-f4,5- . _ • ‘,„2. 47:2:;;., toe/f /it CI 4•1•••4'''. ot../ S 441 . jagAATINIM,ON SF 507, IF NEEDED; . leimmthreisuricrai-onprinth --:75. -EcrwrakerrENMNTRFES7 cat v Yaenr. War. Ant. middle: naMa'and reigaion of sPdonsor ar .ex ri /CM-1/447 ze_AclumrsoLD:wo TREAT-:9•171*!?•777:'2i-2--, ' :moat:awn? r a a aiurt 1-REarmErry_ MEDCOM - 357 DOD 003484 , • . .. ....... . . _. _ .. ... , , _4€--.,..-...,..::: ....,,,-....., • - 7-,:-..,...--... iSetthstructlarts nn 3aci-,.0 ids -Shead • NSN 73.10.61.11753.746 •• ur I R..KTMe, 7 .... i-tv...„,. Il AmetgNT ii"-%.8EMERGENtY ,-.7.A.F,!t4......-;.ii.ND.... -f4i.:::!¦ 1--(CSF-t, Mosul_ rra L RANs R ,toN 0 HOSPI TAL C.:1-iRR NT M CS. attantat mutt-cit 0 A N ROM-„ Mre enemas sheet) /tattoo and atber data, -t" ZtME 1:::JORtitkr. [:1 °THIER. c*Cit.1 . _ r--,ARtv-A.m-, IALLVIGi -607— . -VEHiCtE NION IVR ; 1. iSpecitY) . ( try, ..tave and . 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'- -----_,-.- , _ QUARTFAS MODIFIED DUTY UNTIL: 4 '9)1 ' • 'IPAPfKtY 10 porrratirs 'cern FICATION ,Wdoehanicai :marina _ salves siatisr.mfORS and :elation of ..tininsor or next -E0111-WEterrtittANTIIIRS GIVE: Name Wet. amt. ariffn7ralktPaardLIET:. 7247 PAC.11..rTY fo3L-D.ING TREAT; ": .*ECORak— In7if 11.0173 DOD 003485 - -($4edZinstrud.eonson-3ac.t ot.lta-Shoeri - 7 .:Shart.pi T_RZATMEN.1 MDSat. .7:77 - sZt6S:til _ _ *Oka, .--zocorpl ot-o TO i-ICSPI -7AL C•...43 mtcs..(traanua (Arwcis care enrouts sneer) liana, and other elehu P,14.,v,Ac7.` E AmauLANcs 5 A•State and Coact • ".41.¦ad il.raPtOrn (61, :111112elen.1 , SEX AGE • t CESCRISE (1: &calumny, dace (Perratent (21 obiect:ue data VITAL 31GNS ( •.carninelian • hietude nholitat of ma and .s.niva.a (3) .&iiteetnnent faluatatut• Gif MIN (prrtibliellt/Pbeectigtra -include medication (Wan and .147 y z c/o piE9E-+/1-6--i -, r.r • /1- --1c-- TEMP . q "?th.(04417.194...-k-7t 11 '174. Aj4"'s: -L‘ Tt10.11711. S.4-1'7.CQP-V-/Site 1704.12.4-¦ J IA -4-;• !NITS.: 7: 'C A ^^ OISPOS1T1 e N cx 2- Elker4C 77Z • • ...-r•Tf. aft t:tr_T•T,Juirr.-.Isdr,,i-• IMPROVED Y.i.110474T4,0p 2-4 DETERIORATED ---7 bxey2 -71) '-/C TIME OF RELEAS PATIENTS I OE IFICATION 17Aesaansesi .onortnet-L FOR w1411-TEN'ENTstrF-S-raver:vairte-taistrtinrcirda SSAY: DOB. service slaws. rsanie and eriatiost4stsokneor et ktn. (IMPORTANT: LIST FACILITY ROL: DINO Da MB.NT .S.ECORD).. =ft. - rah NSN 75 -3736 NUM B OM 61S211 00041 . • , 71-11§ZITTIAT-7747E"Ar-' • i YES [TIME :SEEN SY ;IRO VI GE It s 1.1443. c: _ AAM, . /72 4.1 lo 7O a, c/,, /au d. any onutattons and follow-up STANDA-RD FORIA 3bi MC. 6-62/ roe. Cionm000.... bob MEDCOM - 359 DOD 003486 4 11.511(ctiOaxon,Bac.t of this Sheetl • -EMERGENCY,CARE App TREATMENT (Medical Record) TRANSPORTATION TO HOSPI AL CUR Rk.1 •MEDS• !tetanus WWI Wt. attach eera.ersranit theit) iscitfpn and other tizta) HISTORY 0,TAI Nep ffftonn, TIM Ei.pATFENT. 71 PFIIVATEL • •„ MONTH YR_ ,-..n. 4AMBU LANCE L—I VEHICLE ALLERGIES ' OTBEFI (Spe'Ofv) HOm ADDRESS OR 0 STA 0N•;(C 1•1.0M T NO:1 nc:-area code)' •e¦ (ncipsie:47mptentisk duration) YES . [1] NO -, VI zALSI'GNS DESCRIBE. (3.) aybsertve.dato,(Peitinaritflistar y); (21.0biectise•dets TIME SEEN BY PROVFOERcwicli-kijiag(3jAmassment (Dimple- n , arsamination -iiiciude .sr.sairti7ortisti­,:TIME i:NIS ..a): (4) Plan (Treabnint1Prooackurne .,,, include niediciaiori giant arid fatiqcocy,CE.46,-1-4,4-- -uP • Aute 614.20 fowl-2g,44, Cs 4 4-0 A.e_ . 4..2tils 4-6 1 4. -2-"m- L'" (A) L-Q-Sq cc.021,1 9-' )(6)-2 LA) qaac.,--ce_vct / I TEGORY ace rOvem) EMER6FNr{ iDc49 :0,,NONAJRGeKr , DERS UNITS. TIME 5-tje-4L2A--t.\t. • tiv•49-tra/u-Yraz,,-- .1%SES*MR97-01APNOSIE ' . . 2----,Ier42-)lGi OC)Atpx, -r c.3416 Tr STI INSPotirn.ciNgchear-aathqtrAp flOME in)LL (Wry QUARTERS 14... 1 • moDiFIED.ouTy UNtti7 , ;.fgaitt-:.: . monyni • REFg,RED 'r0-(Indaratt EMERGENCY: - rICOAY "72440iiett- F!oLreti'le. '"' • vie Fark4;tr".*CONOMONVPON.'REEP_ASE7 ..e."..*:,! .. . . . ..r.41....-4, . -,. ^t,APROVED - -UUNCHANGED onsu...r..n.,... . '''#.;=.,- DEMER .ORATEO . -.--7 --•. ,:-. ...7.2-‘:1,..T1ME OF RELEASE: (CONTINUE. ON SF 507, IF NEEDED') • -!---.7.-7FATtarrs DENTIFICAT1ON_Otecitan4eal imprint) SIGNATURE OF.PROVLDER-ANDi ID STAMP WPI. 'ENTRIES (21VEz /Tame-laid, Mad, 3.1147_,D9serelea.s.MMadieme.ona:.rektton..a$.sporssorsor-next— of krtt: "PaRTA.NT: LIST FACILITY HOLDING TREAT- . e-fr,°11/!.1Prff 9am' 3NSTRUCTIONS TO.PATIENT (Include medications ordered' anY 147 1"tic. (5C -11 b)(6)-4 • ,e MEDCOM - 360 • -- DOD 003487 ;'."540431-015.3786 • -AC: Li r. T f_a tery? Aqua', ..--Fecoiek. fC^S NI^ . 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"Same and relation of soonoar-or-reort- nu-Tx.srPORTANT: LIST PAc77..rrr FLO.C.DING u .y -COPX)„.. *- EMER.GalTe MEDCOM - 361 DOD 003488 "•-. Xi -Al -I 3CI [0 -. . . *". . ... - 0 ,. - ellCD ,... 'C If N C ¦-•'. CO CO 0 03 N ie 1.4 0 C1.93393 0 0 (// • (1) b)(3)- v). 1-1 , z r• c ito In - DOD 003489 Nisei 7540,431 -075-3786 . . _ feboznol. .uMa A ERaErii-Y--;;A-KEZNtrTR,SATNI-EINIT ,1)X3)-1 ffloStAi. r„z11 r itli,aeSPOR ¦ 10r1 0 H0513 1. AL i RENT 'NIEDS,. -fretantur un- egt g 'Y (-1,4,cm.W* can enraging sheet) • • teen and a ther data ; rSnlegrii & TIME (DATE - 1 .ctivArs.L A ' Al4ASULANC: ALL..7.77r - OTHER rSpesdri I f) tate and once NON nc_ area eaae) I r \ • S P411E1-1, • • I 'NO oEsCR I BE -(1; "iieetneatwenaccit'Perrigtent -Rietae-41:.(21 -0-tneatide :iota II IMA .T.VE„Niey PRCV I DER (Erizmifri¦ziiors - aeiudr ift..slis.„01-14gta and, : (4-Aia.uinerie TOistsfrki-• 1,.•• C.) rlitieseeteinedie' sttrairiad 'tramA-44 • —ntion , • \ LA. ) • -4 ! \it (.4.e—t." s r 5 24. 61-1-2-1."7 / • -'•I'D-R42Er!fr INtTS,: -:ME 4 •/ , 6, 1'4" 5: fleraSITZSMIEI•r7/01A0te09I5 72 KOIJR.S RotrziNE ‘1E 16Wovatt I-UNCHANGED 'oats RIORATE0 11 Pele CP RELEASE: -74 i- b)(6)-2 . Erl r "qt.Ak , F0RaWRITTEICENMR4E.SGIA/Sa••.Venner—issta tante, nanagei---- •Joreice statue. name and-relation of apOnanr.or nextw1test.ltut. IMPOIMI.A.NT.: 457 FAcirrmaczotwantacc - any iliniCationa and follaut•mgp vsz sir4; • f-V:a1771 -arcnrs^cv--aer^^srv . tet sTA140,. 01Feau afatffiepr_. (3-11P- MEDCOM - 363 DOD 003490 ". ens _lreed nn. Back, !Zee tai-ii-ut • ,bX3)-1 TEN-rti2 • '---;=TIZS:P17- -, • 08 AIN .ROM ..„ • RENT mEO.S. !rev:snug mun7. ; 15 . .., • 17)7*eivess4'. SP 17AL., • r --.F,',74.:+e:457••0-R-.,..c..Z,t0r4 TO:Hp L4¦qle.":i and 6,4e d4r4 tiPATIENTIZS- cait tritium ssicet) •- C 1.. 13 NO(..2e011,1EI,• iSnceit7) t41!c; r."1 CiOae _ DU. -:1" I ON. (Ctry: :Hs • " .••uractoin) .„ !•- ryqs 7.• NO C:+ii nIPPDM IS 1. -• Li, 1 r4 . „ E=.1.4 Y.... I.2C0VF Rik merit ir:it.4.17.11;:t2I'Obie•c•tue • , -,0 1-: e..5.0 P. I SE (I:. ay..6)4cItae Cant eP in (r,_,.rminatuan-• b2Ciltde reaults of .reiti.s4 " 4,C. / . ••••• 4 ?km , •",`crabitgrit/Praemdtly..= f,r!ce.1 14-.!7e, F!.??. ..,:„...... • • -- LatilinglilliaL . • . • . . ••••••••- -ewe : e.hrs.ii-cS3402-?oLin . ..-Y:;:.: ae. IliTtalreig‘r Cetts*--0-blispq - PULS E ' : •.q. 101 ,e4c1;-44's - . . ..,,.,•,:--,. TEMP.* ... et-1-7.444 :::.: ::::::. • 1,.....,-. .f..: f — . •1 LLe2. 1111) I.°. irg , .ITIMI1111331 7.41.77.4:..Te-F.r1:;:i:i.F. s. i:::'.: ".-:::!""- :. ' • ',-r;:il 0.,:;,:."7": 7,.: -1,ent:epde.rry__I ...f..:..;.:1?-• ':::.?."•.:-...,:,.. , •,- --' , T4....:::--.:j..,,L.',ig:::,,4,:,, ..., - ' 4i77Y,. GFr,r4: • . u . l'.. N os;-. .-4:11(!r4 " .. , . ¦ . ...1eel 9,131GE . . '.. „-.4.e;,(,fe l'...•:::,•,-- , ... . a 7, ' ,z.zeii.yezez-d ; / 6.44-3 A. o ede­ '...117422Sie=r _ MEM k • mermou".civic :¦,!.¦7:•;:}VIL ,- - • .. Xtr fc.44c.16-mg; 4164174DISI =73111M1 sz0/"C 1103011131=2 -rte" -44(.70(Et0100t • • _ 1+1 t' 4; 4. o . ? Øi CT EI=Fi • .HOURS • ,..t.trZZ 3 . . CONCITIM . 17mogovec ,Cfth • 11 ME OF! . bX8)-2 /8,i;414 -,z1ticiusarri.• -1•ATIENT-s lost¦rriFicA.Tidri, ag.t:svoneariir,... *Icti.p.10411,0ftur pc R. wigi rm.+. ErillU.:3:11.,qa...3. .SSN•13023.....ernocm "RP.P • . . • . ' ' ...• ' ' • - '., ....i7t.r• . , -,..,;.;-:::',....z......: .,­ ...„,,..„,..,6,......_,: ......,.,: .....T?...„,_.::...,.,,.......„.„,..,::......,.,:.,. •,.......,, ,..,.,., EATrat tS ' '-•,-: CV. t.'.-•t.FIV i.,.,.7 ,..::..:.ir ........."...,...:7"4.. -,".:4_,:',7551: .,, .,.....:_....,...„.:,..,„1; , ..,,...,.,..„_,g,,,,..,„.......":„.,,.,....z,.,,,,...w •,,.,77.:.•,::::: ..... ........ ...,y,,,,,_ ...........,....,:,...,..,„..,. ,„ ..:,...,...„:„....::....,...::.:.„.„,,..„.4.„..i,.,,,,:„...„.....=....,........,..„,.1„,„...._..:„.,..., „....„...,..,,......,„.„.,...,......,....:.,...:...„........„....:.,..„,..............„,„....,....„,..... '' .4-,.kv;•.,,,•4. ,,,.......t ,...... ••••••••• • MEDCOM - 364 . -74'.1--''''''''' '''''''.l.:-.''' ,''•r,'''-'''';''' DOD 003491 "VW15.5; "Tiretik.47.f, SYMPTOMS,.DIAGNOS1S; IAEA .M NTJR ATM. ANIZATI •N. go..frac -en ry kAnkmvq(ip , vas • Le15 8rAhni.f' •-r .•• . ... • • • Tt.":1=Z.77: • •, : DOD 003492 LAST -FIRST;: . D WVICX Ph -d: TEST ',7.‘RESULT -Tr:02-1 APAP-,.- :Clarity _ ilirubin ne. thCEIII4S111121111111 1 ¦ bX8)-4 REF., RANGE 128-145 mmol/L 36-46:mmt-ig 80-90 mmHg 18'33 rnMer/L —.. 95-99%. •-• -2)-_.(+3} 0.11-1.23 73-1. 18 nig riiiidL 35.0-60.0% 12.0-18.0 -. Straw/Yellow Negative NegitiVe blegative. :E 010y1:fl25 Negative LABORATORY RESULTS: 00RM Sub'ect to PrivaC : Act of 1074 : . "NIT DOB. • . SSN 12.14c16111 pe ime Date and Time: Date an ame -ROutindz: 09 :15.0.e..4 OS: *if .. ... 161 iii atoityam: WOW, X. -..TEST `ALB:. • RESULT . REF. RANGE. -13-6.5 01. WBC TEST RESULT 9: , ••REF;RANGE. 4.8-10.8 x10(3)/uL iNLp. 26-84 U/L. RBC 4: • 4.2-6,-1 x10(6)/.uL 12.0-1,110.01_ * 4/ 35.0-60.0% AST . -MCV . 80.0-99.0 . 11 . • MCHC . 33.0-37.0 g/dL LY% 3 • 1' '• 15.0-55.0% • • 30470 UR LY# 0.7-4.3 x10(3)/uL _ 8408;mniel/Ls.:. TCO2 5=65 U/L , Lym • h Baso 73-118 mg/dL AtW.Ly . , , Immature Gaits 13-4.7 rnmol/L RBC-Ntorph: te d ' Negative .„ Negative. : Thin: oPlasmodium-Seer, Negatiiie ening Negative T 'C No Plasmodium-Se•, 14­ 0'iinTE 1:137.441ML wogw•A'A. .10-13 seconds 22.1-13.7 Seconds dcLedic,:: m:Staln p: J :Negative : Fbfnol 200-400 mg/di_ n•• 9:fungal:Elements. fgaloggargaigri, • ive ==r--4=11 ••••• • .• •FIPPIRIPPMEMes inins ; ••.^ • xilioroh .sed a • - • • - • - -4. e othee, •-• • • • • •• ••.. • • • ¦ • • • MEDCOM -366 DOD 003493 ,-¦ LABORATORY RESULTS FORM A laCOMBAT.S.UPPORT :HOSPITAL Sub'ect to Privac • Act &1974 Specimen Date and Time: 03 ate and ime: dez_e5 tigivight •... ' ?.:ifietst dot:mtmo,:K.: INEt RESULT REF. RANGE 128.145 mmallL 3.34.7 mmol/l.. 21 7 4.2-6.1 x10(6)/uL /6 .s• 80-80 mmHg 18-33 mmol/l. 33.037.0g/dt 22-28 mmoUl. 95-99% _:10110:10,-At/OL a. (-2) - (÷3) 0.7-4.3 xi0(3)/uL 8-18 mmol/L 0.11-1.23 num& 7-22 mg/dL qe mg/dL 73-1. 18 mg/dL 12.0-18.0 g/dl. 0.90-1:70., mmel/L SbaavYiliaiw Minor Negative ' Clear. Negative _ Negative _ —Negative:77- ................ 8.0-8.0 farming. Nigattve-fricW 10-13 seconds 22.1-33.7 seconds ABO/Rh TSC T&S Canim MEDCOM - 367 DOD 003494 • -7-77 .?Ser: finTruarrons on 306-oe. -dlis-Sireer1 • NsN -.754o-0a..-075.3783 TRTwei - ;$11:1771,Pi UMB b)(3)-1 RTCS-.-Fr ITIOStkt rra . A.ANSPO I ON 0 NC5PITAL 0:J RENT MEDS. flittenhe (1t5T 0 AIN (A.:•=eh care torah= antion and other date/t) I LiPATIENT ErT)I'Ll ralftstin Pq AMBULANCE ,./E-HicLE 10k1 1234,..¦.)/) : "`tz 1 LA 4--)".. • .3MIER7SPeci1Y) DV =.A TION: jtare aria Cacti MOM 9r.pl .0064) frtc,_ sEve : AGE AOsslaLE TRIAD P. PAY EA? .01 YES7 E NO - CESCRI3E (I; 4..hitirertshe a a ra tPr,-nnear distortg (21 Obietttter :tam TIME SEEN 3Y P RO VT DER Rsminlion. • :7Citide reining of tette eLiod 4-iiraiaMkg 6364(4 ' ' Adg:„:_-Al_EldiniZre. atindittLetodartnrdr,.;.-inniude-rnddieirtion Litianntid f dant:I-all c;1 v )1. ' ; SC -U t-,)* C-c-e-4-14t 5i.-4(-541 r"; ''34-1);1:4 146•RA'j&t.. _ AilfP ^0.2-_-1.42's-4V 1 •"-"6 '451 ern:an:AL LL4 ¦ L L O t Ca›- : -:ME PAGNosis 11,,DLtre UNTIL: ROUTINE PON MELEASE - J112.4CHANGED ENTIFLIGATICre ..:teehaittesi 1., al rt -et r'ltrnnnhl, nm n • e, feintrarGi'VE: Nom -loam fait. ifitaaAg: b)(8)-2 toter. name and :dictum of e T'or 11;ein VT: LIST FACT propzj TRF X- • EMERGENCY CAREAND TREATMENT STANDARITFORMiatillgir43-421 MEDCOM - 368 DOD 003495 4;4 kietruc dons nn lack of Iiis.Sheed NSN 7344roz..475-378.8. , •..;Z:G NUMB • A3)-1Li TCS 12E6447 "1"R'...A.INI ENT • JZe b)(C•7'.• --1.1181,cel .•=.cord) . • 'S 13 nYOStA.1.: -B22 • 1777470CS. Iretanits • -Tr r 4.S RT..; 110N 0 iiO312t . AL, un- !XIS • '''''':"''''••-•-.77,-ARRtV AL: - ••• • (Amen care eftroute-aisest) I &scan aisd or cfRoll C)Ti4EFIL (Spectra the EIPATIEN TIME DATE PRA IvrE, AMmUL-V4-c-I /A-/ 1AL 111t=lftthWIt. =GB r9HtCL^ .J OTHER (Speed,/ e•ty.... J 7. • ETA ON (Cfr.7, •S tam and G•3641 ;NON rte.-area =ice, . Cr. °M ,-..„1777.1...1777311.11.e?yriptOM tIO Pr ) Se411 PICESI3LE • H1.AIMATY PAY bnk YES •it °MO 11 • • No S I .••• 0E5C I 9E Cl; .iptliecriset care ile.rrznant•liNtar.1); ( 2).E004Elue '1441! filMfOlePOPM116,.:- VITAL SIGNS ""lg4"it' -;14:41t7=14. toriiegVO414GrurOPrg'a 1=4f vi;c_c rtvcvi-i‘t athext• tut.% 'ctig ac77-7/12t1731 cl druslc,••••c• Rv•-fu.5e.s spe4.1c., asier,,,i,„,,4 4.6.5 nverkin.i • PE 15 ,L. a37/.eeresg-/ 4f7/9,..fftt---ort /e-or R ESP. 1 .•444.-eil•04••••­ 5 (1c.4.4.4 t. • "cer: , TEMP. 41111n49.1 .„ ce•--e r `t***-- wfuchild)..f 7.146.4 - : '. • eAre tle714,‘ 44-e..0 wilds 4 12q•zeit es -e77" 41/ $47;-OW k Z.0,-;7••••4: e.:.AL:7GOR`f Mee i...r.romei 14, e 4..• , .. ,,,,,,,,, e oc•••••• oge%-wf EMERGENT: j 5 ex,..0-Git 4..ez A— se...ott--ea ai/AGe 40. URGENT Air elm./ Non-uRcaffr 4,e .I•rj,%.41.-. 4 Ao leek 4,/ /22 OROERS INE T5 : 71MS 404ert:' !If Ala •••gocr/V00•4!.C4,4•C re1614000- e-/i/ a`-2.) "I' I' • 4;•‹-C-( er)^1.4. eiCe Ae•r3401: 4c-er•//064'eil 11""f/4t105" .1'(•"-ele K.) #44e 4-.1,4•1-1) fins. ,zappy...91P01.--e• re-wile -4 ( y . 10 fryer '1.2 27 41.0 r. 0.4 DISPOSITION iChfies ca that am /Zzoor/4)-0 ) JO" /21e FULLDUTY if- 4. ;--7.t/rr,d/ , GU TEAS ‘641e/4,14. /31 ?Ft Hz 444-4T. .MODIFIED DUTY UNTt I.; Y-ete ltd /0"2.7"(-4--&e4.: LAM z . earre-e/dredE "ed. de...ger ?‘t \*-3 oe-ti . 46 ,7/./e2- 4.4.. s cr-d ro •3 /94 e.".-'1•700-0 eac4 eie r..42e714'., 0 ece--0-ed?,, • 191/2/4.9. JNCMAN ED RIORATE0 eyer 01R- RELEASE: (CDNriNilifQN SF OZ. IF NEEDED; -tDENTNRCATICN7moianicsi ;nutria° __ wail:TEN ENTRIES :LVE: ,Vane lose. NW. middle: ,434.1;.005% :IMAM mew. name and Militia* at sponsor or ni ..a.:::•-•-zat km. ampaa?ANT: Z.ZST FACILITY HO:. LNG TRE„..t2.- •••••• • INS'_' U 1tcms-ra-Plizvp.111-iiiwiseqoattues,-o d. nny •••1-. ' - • /1•••• P.11 4,---,--,••¦• -•.,mr .110, tAW•Gfee20,V1087 /004.0-,, Gi 0 6 ¦K-- X6/4 7Vdt7oc­ 0MR.e.'• -• 4'700-A•Ler,,Vir : MEDCOM - 369 DOD 003496 LABORATORY RESULTS FORM 21st COMBAT SUPPORT HOSPITAL (Subject to Priva Act of 1974)- -- tAST -FIRSTFML-- UNIT • RANK STAT Date-and Time: Rout Te:-tG o to IV; . rgsr : CI • PCO2-PO2 TCO2 HCO3 02-BEecf AGap BUN -Grit:, REsar se-toe :mmoVL ALT ---7354.45-.-............ .AMY. 35.45 mmHg * AST 80-90 mmHg T i t8 33 mmol/L BUN Ca Chol CK 8-18 mmoUL CL 0.11-123 mmol/L. TCO2 7-22 mg/dL Creat ---71,1111mg/dL.. GGT.' . . 35.0464" RESULT 3 7 7 2 11 5 a-1-3 111_ 1 8 4=81 g/dL 128-145 rnrnof/L. REP: RANGE 33-5.;54/dL 2684 U/L 10-47 U/L 1497 WI-11-38 un-02-1.8 mg/di. 7-22 mg/dl 8.0-1CL3 t00-200 mg/dL 30-170 11/L 98-1 08 mmot/L 18-33 rrynol/L 0114.2 mg/dl 5-65 U/L —3­.3=eT.Trnin6n ioo 4.640.6id0(6)/iit 33.0-37_ .0 gidL Color, an y Sourcik-7 FerieUk: • ", • Ketone ram-St- - 1.010-1.025 =aim- r-I5eI-n 221x33 'soCon •= • RNI," DOD 003497 (See lartruerions nn sac* of dtis Sheer) NSN-7340-01475-3726 Ntn¦adIE ION t•405421 • Al-- C-JR NT 'M DS. Perertira Elit• i41 I .N r . • RAN5 R isatioo and otter data/ (A. =CA care onrouct sore) • I LIPATIENT C3cr! Ilm r,asstf31 pFlivAits,ii 1.1LANCF. t VEHiCLt AjK.0 , OTHER ispecitiot 4 • M Old N (C caae. I. THI O. R 1 C I negLuad rretprOITI IS 1. r.rar000n./ :AGE °Esc:RISE (1:, Syclanicrara tiara (Parunenr .ritstar://: (21 20.iaztide data VITAL SIGNS. (2-sarninstion Include nrauits of mai and n-nayt./:(3)41anamanant rnadia' atianyettnurand• follow-up -e., Y L S };rt c a 101 e.scji.,.. t-1-211 44, _ t-.‘ (4) An• Vt/ 3 . " nio. - 1-•.,e „pc - - PiA0Ggitcr-- f".1Y *1-7-;_ttr4A1;!igr,FF7-- - --zt--Ergos2v.R.GENT gi:-ag-ags§ re evalf • x. .A11CP•r7vidndnfacd driprint) ENT-21E5-2.1-VE: Name-loses ftnet. naldda; roots' stator. ammo and Pelagian of *poorer or nowt VYI am? FACILITY HOLDDIG rar-tr. liforfeif ":-. 141444.16t -ANC.C2 F.121U /TV. f.• tlaiteCTSUF ir7NAgNT, MEDCOM - 371 DOD 003498 P4SN. 7540-024175.37 ae 1See7nstryc&ir :3X1c-of Ws; Sheer) NUM '"En.°1 ate"' 'ARE :;.1¦11›. TR EATMENT_ SZT6S-Fri 1TWIA reaa • .14RAN5PORTAIION O 1-1c513 11-AL. V.:ARENT Nigb5- ("2"8. itGiEs "z•---••••."14141"--" ,'"" iZati•DIS and flat data/ 0THER (SPeett11 (Ar=scis care of:tract= anger) I LIWI ENT Lj .----T.-:tit7,5,:•*7:2;,:i,t1 DATE PRP/ ._4 AMOULANICc iALLz C.. _ THER-7Speef59 " /1/4i tf-Tig-4—" :MOM, (1,1F!` I • • ,SEX • AGE • ,K1.54kcil-c-TN( sT1547 TY ,s44:1:ZritCOM (YES Nq • .11\1 "---')71ESET.1/47( OESCAME (-1; ittbiacWae dam &err:must Sistar7); (2100a:0w 4an; .Agi : (3) hemmer:ant (Dieggsa- -3.!...aA of reso und 17:6° "Ni6}rrignie:Crd-7-_ . —ndi:4 .67-0,7( .)//47-%.‘,--..4 • tvi. 4 _ X rer-eys, Md-trt., 141-.44.&"10. a~ Of/0 te vi-64-get or.• c„4/t-t-r‘2, f-ft&vr-f- • oh -.7- 14--x-f? Ems`n, 4cri.**29:11-14 LL—e-d"t"A -;,- 4P.I. 7 1 0 . • a ••••,_'• 44-0 -7-17-e) /(rt i tt --,,,worgFtecy Dune'. UNTIL:. • . -3 11 *41,0' Or: ifr$41 4r te,I Adir...12 a4­ .7 . ....orr4.,erizeltii*,­ :47 • ;it,/ e-4 _ . 4.4—e• . T. -;•,..D4t.:4444, - -..-4-4­ *C.-1W-sP -:. r•• - --"=:-.-_,7--. rr-^' - •-•— / ' 1, - fro- 70''' Arez, c-7rzr-P4p,-•07 r. • L.6 /-7---“5 ••7,;.r, atm Fic.xn.c.N RI ENTRIES GIVE: Narte• $RPINIOR-afle/Ditt statue. ?Ione Goa relation or stoolioaParlievxr" lirkus-' (IMPORTANT: LIST FAcuarr 1Y0o 1Y0;._ RECORD • -.,;F:•TY- ....• _ Att;OCENeSa',.._.-tiRK:A&AllY MEDCOM - 372 DOD 003499 CHIONOLOGICAL RECORD OF MEDICAL CARE SYMPTOMS, DIAGNOSIS; TR. EATMENT_ 'TREATING OR 197, ‘A ,z-:. z 1_751 a 62S5 ine(Se_ 4rj;4" 1(A)01 sof/ID:Mgr • •-n wa:wameaas-•-•• Presedtiter by GSMCPAR'72.,.' •. 1.17.V-APO DOD 003500 ••• • • • • • . . • ..s.,....._. _..-...,.,.?,...:::"-• --r­..•--­s ••:,..mv-. --.• .: • . . ... . . „ . .. . .„ . .... . . .. . . ,..4.n....:_.p., -.....-.,,S.VIJIRY.43.148 .. . . .. (IRENTMENTJREATINO0 • gikij Et: . • ...•: • ..-•.... ,;:i....eal,:clupkWr... ,!..4.1w.- -. ---.7--,,....,-.—,-",--• . . •. . , • - • • • .• • ¦ •, • • 7 " •-•,-; • -•••;:7 • (b)(13}2 w.,oktoiskA4mti-i&,,,ki-,-A•..„ 7 -- •-~ • .•¦• ^ rwil,6401W4•• -..r..4Qs.:kcokest; .... -Is' . -'.. 7.. ....MSZMIONFo _......_ •••:, 1...:;;;ZW.,,,,4.:. 474' • ,-.,1,I,-, . A 4,• :::re._ ;:' MEDCOM – 374 . . . DOD 003501 • : J 1, . • ',ASP=7.0., -. iriPlq:.). . . .. . 11;;;:il ar.ill'rirfZsr't'T.,r DOD 003502 • ••• . . ,, , . -• R-EA-P4 EN issiumin IYICS J.-.,-1 foe nun& swan un--. ri.t 1 1r4 445PC 4C'N-7-.C-.7•05P17AL-C . . . . . . . , . . . • 'PR • •• . •••• ••..7 , • ,••••• . . . . 12". tt, €(11.1- 6,.1,7*00,Z•lf..55:,-.P 0.,t.17.,.`4S Mee aria, -,... H M .:=--.-.. • J.W! • ..: ania #?•174.40 • ._-, 7:..::, tf:r„,-.1-....T-...z,:=7 gaaEflr.Ats.abhaatfr-_ • --,::-__,i;-,:::,,&_.:.,.:,t,:...5.-.24-...=L°::::;i-;'-..-,-..-,,.)L„,,:-',1H--L;IL':::-„c-:,,,,.3., •."...045,"WQ__:., ii - • ''',..:*,.,: rP4.. vtG 4S !0447::t.--.14:45' ....e.,,,...... , A.'.4 4 :, :.----- 4—....,-..,-.....7~.,--'4' ':.':'•'."-­ :......,,,,,. ''e ' :12 : -;'''' ;: , .,.,:: ‘• i''' .--A4-',1. ....,NS..„ . Z,; l''' ' -­ 4 -; t....,. -„, --- ..---..-.:,;' ..,;:c,,,, '-.:-.*- ---,dr- -7.1(--•. .."-?" 7 , , -,_=',,-4'./, -.,?,--,..-, , :. . • ' . ..-. Ercs,..4 . - - ...4,'.A.i..f,,,5..1_ ..t.:_-.?..--ra.or - .: ..-• -:,,...7. : -.,4_,..,..;,,„...,....1.i...-11 .•.7., ..%.,1,11-1,-.....,..,. 17...-T!!!,...,"f . ...f.. ..±..-L,,._,=leT_L-_,,L:.-;-..- _.,---”-''' '.'''-.1.,..k.e-eMiai.....461--,-.1-.,.... .3,....+1..--....-,-.. ....MCS _ . ,344.e.1;X DOD 003503 •' • E!1 . csre enrages Meaty elan, asitk5s,dgg amp% i-jspe-o*;-:.,,,,•! - -• • - • "-Art • PRIVATE. 1••••• OTHER' ./Sibeci6V • : -tr ' -, .and-C , t; e ksgaiiMei itkr AAFPLAe•--z.a.-sg.e.,--,Z.:',:e,,,---;Q • • z's*PA,..20.1--••',—Mherr;: • DOD 003504 (See.inatrui-.:fiani•ern 3ecit ?,!s Sheer) NSt. 7 5 4,.0 1,.3'/ 5 --5% k' , Z,VsTryi:=P4.T • • rStaAspi• •••umBER• • •-Elle' ZARE AND .T R EA MEN; . .•-.".... . 21,"CS14' • 11195.4 tred ,.. FEArisp c. -.....R.RENT mE.C_S. ; ma/Ia afftffIzart• . V t• -,-ioim ,C -...cspi -;Al... i _,---, re I S , ._. Ainit RUN, ARR.V.F.;+, ; crrac.phRiviss,Thr.7 :mi au LANcz. : LZ4Cion imi A. ears enit7N 140 .aCr‘er daC3) n PATTENT '7423:411a"‘6°..-151: ' 1 ;:, :9-AV MONTH -'2-• ; t -......1. VEHICLE :-........; i •-¦ LLEAc,, • ..i.QLalagEkSPIECte1 ------ : I . 1.4)010e- Ale.L¦ T -ZTV.,ceregy:z, '' ‘ -A ! ! YES' , 1 Vira.L.51CIKS OESC ISE _, LiadactrAL car !Pima 't HIstor7): (21 2 1e ,:::,,e ,-7,4 (r_r_wittn.rion -mcue,de rematao.rtsta anti. c-nonl : ;3/ A str...n, g^, -14,"- 7IME SE44 3Y 1'11°Y I E.'1 ,6.3); ;a) pi= ;"1:reutenent/Pr -ars4;48.7 -intiude medication given and .'240w-,,p)L ... / efii ,.........e. .:9 ,,,e , ..e. 6 ; ,./. /4 ds./i4c- ( C /d(C. ( TZ)(2) - : //e( I t4J c,c, C(ex-ve , tf NI-,4 1, , a 'Y L-57-0/4-. .A.Ger•rr 0 Ir‘clik. itidi-1 t--pc- RA (iAol "kJ) ORIZE-R5 . 1 IISITS. I TIME k:...),A. a vt ctutw _ 4., rit, / t- I, fii ire . 64- i . 7-! itrp ' . -410_ N Cx (ow rtv41, s k--y LLE('-'s1 4/e ecCf y 044 01'SS A L.4,a. i. 11.) 1%6_ r - ca./Gal t..°ce 1,,foy's let*:: _e„ririt49,441.4i_ 4 lidSleealae,ari 4 Ptc) AAA:, 4 rortnex.k dint' apPhot. 104',25/ e cif j4-c71tr76{7t4767.--17W—.25 Ste-V i/1 Gin - cile/Y1 1 14,2" " J • eifrwt..c. - p • 4,-;05 ;11 .1`-a ..-4" GC AW14 p L E rJ 4t 1:71567ii ff „ (4,it Lil.) Lie( cC-64-) e, 1‘. r C Cl Az 5 eliP"4-ei,e-----" Avil, •-tfis4iti*±-NEE..sAsa: „ *-,./54-oAs442fm°‘-e E4MTP1)CATtatt nitsusiena arspriFtt Si-X8)-2 Orrksas 38 V_AArv... .1,:d_:oati,arEL 1,1d . ur mist texklee,;FISIPORZZer: as Sr P14:71:1777;013114G 670.-) c tlE MEDCOM - 378 DOD 003505 otdil.cr) - -• Ts PEN CIL.ITY fEtarnpi. - 2-77---/-t= • PDRTATION +0- I-I O. attach cummenraata shoat) • *Olen and piker-data) TIENT' crrilEFi-(sPecta 1O L CUR RENT M . Vats:awe uninun-AIN • R A. .... . AzArc,rzt.W: PRI-VATE' AMBULANCE • „ •• Va-HCLE ... :,...-- :- • . :)MBEEL(SPecitr) • • . -.. • • ' Me-41-5 77 -• • --• HamE.R.00R • ORcktrry.STATI9N. re sloe :and ztp_c e,a..) HOME -reLz_ NO area mar) . • . . ig‘.. :#24YFRCO".014-dratNal . -.:, - 7; ". • • AGE POSSIBLE.TMR0 PARTY PAYER2 7i • . '-5-7--0 YES ONO . ' - .- - -Y. . ' cig.scR1.13E.(1)6$1-iiiiiM#5:4; data:MeNtaantlitstmy); -(210bieettiat.data . • TIME SEEN BY PRO VI DER ., ':.......trALSIGNS-i, -&alit& miii-. aial; (4j• Plan ITreatiriaMt/Piacedurit ,; tichzditmadiaatkm thinn and fallow-1W (ZXiiiishiadati -atii of tests ',Mat af•itos).:7(3) gfwesarren (Plainie7. 9 ,ti.,__-,,, *Af;/C-C. if,910 iji-7-¦ / . , 52. P- az c(0 . ck.:*-9-4--Q----1 t.x2-4,-.1 //, r) t- 1&s-i-,-..-4-.-- pe,-414 ‘,7.,_.(2 4- /C cAT WORY •ke'rebaria) tli4 ._...t.t ‘• . „e T-6 .atio V3 t/a b•sk 4:44:.:Assgssew•Frie.65kpokosss,-.. • • ' ' : • ocuaL-ca? • NOME DUTY ;7'4' • -.•,:z • • •¦ ••.• ..,•. 4,er ' ' 7t....44-re:72'77;:, 7-7 7*or'.df ..aqieop . 7 .,e(c.r.fi4;7f1M644.t...-.:" "I 7 A": • Wer • • x"*.: Aedtr -;.Eyttli" .,- "rIONCTM ON-UPON RELEA$ p • lizina;,eer..:- S.• • T DENT! F1CATION Mechanical an .4.4-,1 ,--.1a0R:7NRITTF-N ENTRIES OWE:Mama lasAr tategmkittoM nierererext- - flitiPORTA#P: FAcgrilr BOLD' 'MEND EECORDX e!eVI-e° gr.4, epF..er Ate"Ceet. Alleff Att. ' DOD 003506 LABORATORY RESULTS FORM (Subject to Privacy Act of i974) RANK SSN - UNIT. IRST‘MI: RESULT RESULT REF:,RAIV&e: ALB___ 3.35.5:g/dL WBC IL144 4.8-10.8 xt0(3)luL 3.3-4.7 mmoYL ALP 2S.84,(ui. RBC 4.asi 4.241 x10(5y0L 5..5­-166 mak AST 1047 U/L Hgb .Z.35-7.45 . 14:47. . Hct - 35.45:mmHg AST • 11*5-i1A. MCV 136:90 mmHg - Toil MCH 27.0-31 pg 18-31 mmol/L. BUN MCHC­ 33.037.0g/dL 22-28 numUL Ca Plt 130400.x10(3yuL 150a: (-2) - (43) 13-16 rnrnoi/L 0.11-1.23 rnmoUL • TCO2' - Mono 7-224cIL­ mat__ Eos 73-118 .iglu" Baer) , AtY mm 1238i8rIrgidL, 77= lid-010r P in Gri-Or;Ei strawiyegovr ..=^5E: . 11 at=„4.x ,= ,,ig?,SMOCK" Wir=sm7M7:7-­-ri-'­efla6°-- Vo NSPP1 11511.11111111EEME Er---M-­. -tslegagver -r-t-, El= E=IIIMMI tea- Rate.MEM=941 N.61 '''.1114L.' Mill 5441.0, E =II Urine MICroscopic. RPR HIV DOD 003507 • (Sea Instructforis on Back of this Shaer) N5N 7540-01-075-3786 G NUMBER ,:::EMERGENCY -CARE AND TREATMENT v7-7 (Alaclica/Asaimil TRANSPORTATION TO HOSPITAL ARRIVAL (Attaen dare ern-ante sheet) PRrVATEL AMBULANCE CLE 0 CLTHEELMaiii671-_ I (5) symptrants), • mutton} —rC1i1 g•.I! DES-I (I.) 4• tbjeoive data (Pertinent HistoeY);.(210tdectrve data IME SEEN BY PROVIDER-(E" on ,.tnahicii'reatilet of testa and x-rayi)::(3) .6-isoolorgent (Dimino-11181111 ; (41 Plien'eTrialfrikent/PrOceetioirx • include rnediciadon and fullOw-up 7 157102011111111 117A111111111111 4 ,--, 5 f 5,t, o ...7 5 12 , 4- V c.c.... /2 c a -/ , " 11=1111•11 Fyiyisamul GORY- Moo /50,1 o c., ----s--, c1-4t C ';-' oy ORDERS :TIME ' 6C75 / h;" 7 : ) c Y• 3. !0,--!-' ---t c'-----4.--- • 11 ­ -74-r---4-41-- 111 73 vim,c ./-Ze,un -e r 7L-, • 6¦ -t , gE 7in . / ¦/-C-7-2 .0•77ce c--C2 0—t/S A 7,e 7-1214,7- -210iFors, --4:1-44Z1 uiouripit cr cn7 NEFDED). • TIPtCATI ON -Mtoohanical.,Imprint )TAMP OPTEN­ ENTRI es-a we: Mania tart, first snithale:' .and-palation-of-sponaolmorlttext- PO- ANT: Ltd 43--f a^" FACILITY' HOLDWG_TXFAX---!medication. andema, any liznitatiorucand foliaio7uP;ri,'";3,, . • • • 0 ( j •?. ) v.-04 -WPANEIARD. MEDCOM -381 DOD 003508 klit.111777777771.77 ' ,•• • • • • -,- • -'Isoi-fastr!i!!ro#84T-#ack pf-oirsbier) Nsri 7S447.01"..4757;i7661, Y. FAC41 LOG NUMB - EMERGENCY CARE AND TREATMENT X3I-1 (Meda) Record) _ . _ . ARRIVAL - ' ' 17FLINs-44P9, RTA. TTOH_TO _HOSPITAL. 7._ CUR FIE v. ..0!tan= uructinz-HISTORY OBTAINED FROM z-_---• .t.74*0:garwemvumglreirti.' - - - " . TIME . Er'and 60111. "PI) ,,QAT.E. . _ .. . ...... . ..-. . DA-TIENT 8:132 isysetixi I-fro' - LA19C - .:-. DAY( MONTH1V 12FTE . • U AMBULANCEg • ALLERG1 As6 • TL_.. .-...--P..:._ :-1 : ,...-.....-.4,+, ri MOMS ADDRESS PR PY STATION, • ,, .9#04.44 _ „....— __ ..._ . •. !r4rfloP,1,14', nie.771— ' N; 57 421-7 YES VITAL SIGNS ESC RI GE 111 Itieudietivg-fiat.: (Perupt-dist His Lem); (212kiscilm. 44611• itTIME SEEN BY -PROVIDERIF4:17:Iipatio/1 z--i/w.b411: *nits of tesiti and x,nsill):(3).&Roinonsent (Dialno­ . TIME ski); e4y1I411: rrrecOnitaqprcielielaRys .irictrate titecGOirtion ripen , eiridoniazo,KP . .... . . — _ ,I-7 br!" .40 ;...:- ' T.-(TO f -...t. e -.... - -.L i fir{ . .4-..---. . .--- .)e i 4. 5; 4 TA 4, -,- aie-i.. - f-,e..f -A ; 1/7C744 " ri...701,...... 4 ......y..7 1".• `re-• ely,-/-/it-, -1 • ...;•/•¦ e C .., 4:7-f: *-e, U.EICIERIT-, • .C.-7,,,,,, f• / -••¦ ./::', 4,?( 0,t' 64 i , '.(.......;..;.'-.. 4'. • NOI•ORGENT•, 1,A ORDERS` ANITS. TIME g e.--.-7--- 95 111.41 11i 14,.„...,1- ••••; •ir./tZ---------- AMR j--_,- 7 CrY9 — • 'F-X4 ''''' ''• -. .DIGINIIStriG1440/00/8-454150“PPIPY-7' f IFPLL DUTY eg- •Cf IMPROVED • UNCHANGED i:..-TIME OF RELEASE: • • • tooreiNde.mtsFs0; IF Narita/. ...tIrTiFICATION _014echganical braprint) -s!Gra.c1.;ruagi..ofttoy42mA,NIztio; s7rAPAID LTIENT:Ma R WRI ENTRIES GIVssfamt -fast, rim =Wilt: es *talus. latton ino • RTANT: LIST .1? InCILITT Ifillr re HOLD1Nrar -°"urgt, • CE4',, -8 TRBAT ORM - INSTRUCTIONS 'TCY•PATIENT-atICIUCht: medscedorm orc • DOD 003509 • • • - . . . . • • • •,. _ • - . „. .; . . '-• • i-i—L, -.•:,-;:•-sL,„•;s::.*)9r-e.-14.-:, _: • MMMM i." MMMMMMMM ''''''''' '''''''''''''''''''''''''''' • • :::::::: :mg:. :: ::=: ••• ::::::: =..:= _ ::: MEDCOM - 383 DOD 003510 . , 47::::=4:iirA-'1Arrl t- •laV-C-, LABORATORY-RESULTS _FORM • -.21# COMBATSUPPORT41 Sub'ect:t0 Priya ct of 1974 . Mt" , EST. 10,4rUit: 7.35-7.45 .-„).;.; T-;4Erirk.. 27.031:0' PS: - .33.0137.0:gidL 13040(1 x40(3)/uli 15.0-55.0% (-2) 1 63f-777 07-43-xt0(3yuL. " • ;tilt . • _ 0.3-1.2: iiiVat typ•y 35.0-80.05k' 1P.[Qteliu = Negative . Yhjck NegidiVe DOD 003511 •1.0:L -. • • fr.ee inetruCtio-1..,tort:Bathr of this Shu-40. NSN 7540-01 -076 -3 786 b)1:(23)7.Tvi T FACI.LITY (Stump, •EMERGENCY CARE AND TREAT)AENT • tilf ormar -rdr - -TRANSPORTATION T , . ........ . L CURRENT IMEDS..itatimas onmen. :.-ARRIVAL .-- - HISTORY OBTAINED FROM -(jEttaCh care-etirtnire shee tj -• • &Fitton and -other data) 1:1421THER (Specif19 DATE IME PATIENT 1,01:1t1-VATE 'r DAY- MONTYR ti ALLERGIES. H _.....va ict. 'DAMS, ULA NCE k-,A/i:04.77 "---- ,..;-.. -- .. , PATI ENTSHOMEADORESS.O Ft OUT-41, STATION .re#7.,$iate'and-ZIP•Ooctej ,are ' HOME TELE. NcS.(Zee:.. • „CHIEF COMPLAINTS) (Include sYmPiemi*J. damition) —SEX POSSIBLE THIRD PARTY PAYER?1:444-6 CCR (m NO YES VITAL SIGNS DESCRIBE (1) 4Lskirecebre data (Parti:seat Hister7); (21 Objective data TIME SEEN BY PROVIDER (Er4s1nblaikill • include rendre of Pasts arid a -ra7s);• (3).gesuragat Wiffeng' 1 cn..-1. Arzzinimminmal 0010 (4) Plan (Tteatrnent)Piocedunts -include medication /Men and foliotn-up) '10-tS:1:11%%':76e-A I Oev-ikx iiiiAlrow=lwavA23 e 04-:440FS , si-pc+s-s. V1 13, A4',VI rb.6, )L-1;›,=‘ ,.k. ' Endr- - rfaimimarit me, /.6e-e2r. 6/...#1.0e . ,s 4 f sr f-iramieW-Atts‘...{.0( ‘ a 4 CATEGORY (See taueiss) e zy e://t-3 d1‘1-7-1. • -c-cii4 -zalt. " -EMERGENT URGENT' . etto 1.40 Gt1-4;c-re -NONMJRGENT e /401-f- kle 1:f wise / „ ORDERS INITS. TIME as-4-e Z.Z.;et..." zi T/4:0(--e-str.. e-GyK hre6-7-r-be- .-1,-t-re td, C \2,11A , ac ec..-4 Aeo4; -S ex./et-to. 01.1.44.; fe-44 ese CIS /PS g I-4x : \ ,keeAs SiGIS d "ti , /51 4/e-ei /-e' f : ./e/ ,c- At-e""'"4014-/f2Pe7e ( :405rreerfra4 7., 5- 6.er-c626e....... ,/e...6--6 ,. SZ-v--c.• , ---..--, r 40"4-,eie.on : Ge...u/a-.47/..e-0-6/ ,, z,'" oir A-7• 4-o-x... ./7!-X,-c-Z(e,f44,...-i e e.-e-:..--...,o-=..-.c,-6-- , 4 0 „1",et $ g.c.-e, DISPOSITION (Check all.that opptj) /".. rep- -Gr.Arr.glee •,4 ,v,e_._H2OME oury Az 3 7- 4( '8. difri Z Z I 39 i /04.) A.-GeZe-Ar7-4lor-r-u (4o! 1 z 7 "sr P? 5-9 7 .1? 75) QUARTERS ,-..-.: . t e 7-,9i d F 4v,:,•--e,,c 3,8 2 3 Hrs. f 14a rrs 1 472 A. .4„,, 41/7., g / ) ,. a 1 24 MODIFIED DUTY UNTIL: f/2/€..€ I A-C9 i.4..." s.,/,-i_ 'fro. l'''? tAo -5---.i / ... e 3c 646. DAY MONTH YEAR 57 7 4,..., fldr -eyo 1. 44 sv-vol .L.3, : 0 s._ REFERRED TO !Indicate canto 44-4-e-'4. set140 -9 • #3,',./..v.rra4, 0 .e....--e-list #,‘„?....„, A....e.,.., ,-,7. A.,--/c.....,___ _ 9..., z, EMERGENCY. TODAY eci-e-r-r-g..A. :72 HOURS ROUTINE 0 4 4---ADMIT. TO HOSP. u fsERvicE /2ex-494=11 e;IL 40./s--6 _sdt •• CONDITION UPON RELEASE l'ivea_19 IMPROVED UNCHANGED DETERIORATED :211::TTIVIE OF RELEASE: 49,01.,41 (CONTINUE ON SF 507 IF NEEDED) f, PATIENT'S IDENTIFICATION afechwiteal Imprint)* • ¦ •4...APOR WRITTF-N ENTRIES GIVE: Name -last. MN, middle: b) 1T31 :ssisr• Do2vAlkia. atn_piaaaLng and ralattan spopsor or next .t4 CANT: LIST' irADTLZTY HOLDING TREAT-rIACLUIS8 MteLLICatIOtts °Memel. ana limitations and fodow-upNana) CD e....z....t4e-6.4#4 ".ftr..e40/1e42-4"43-Grke.0 "1"e-fer-• Spm C /9/-4) ..teG vk 2,+‘ N iold-oisr-soteeilkz Zs-id j ree GENC-Y CARE EATMENT sTANDAHD Kau 558 (Rev. 6--82) ie.-‘3"---,/sell.--r-e--z• MEDCOM - 385 DOD 003512 vs•onmer••••-•- _ on-Ber-k-of oicsheer) 558-103 NSN 7540-01-075-3786 TREATMENT FACILITY (Stamp/ -LOG NUMBER EMERGENCY CARE AND-T.R.EATIA ENT #1056•.;( • - AfecliceiRenitita -CS I .RANSPORTATION.TO-HOSPLTAL. CUR REN1 ME-DS. rtetanan unnscut. HISTORY- OBTAINED PROM *stank Ogre enrositt draft ' . izatton and other data) (SPacitv) PATIENT 1OT1-I . ,1)A.TE $05 ,c) AMBU LANCE ALLERGIES DAY ' r p VEHICLE • PATIENTS HOME A• oRess. op_ purr STATIC5Mid. State and ZIP Code) HOME LE- NO- (inc.n area coda) ' • to • CHI • -1014:41.17101:07Bilh•- 51 DYES • DESCRIBE. (11 aiittittativi data. (Peillriant Ho lo'); (210b/catfwe data JrTIME SEEN EIYIP RO V I DER (Eneardria -•intiereautin , of tests and a-rays) ad (3): aaggarneht TIME P.Itig.CrietilitiazitiPitcaduras - Inciacle ',incite-anon Own. and faikna-IW (94 r ( % ey1: 4 -Prof P c 2.: op p hecdc c -tity--per *-cn si on. s Pc. e„,. 9/ ca E-Po ty tiu.d 640 (19 -,us.4„Aplot -44azgAILatiarin tr.44.44.4.,k4034.., -r­ c56-r-kka (25V--131 S ,'„i5s-141, NON-URGENT QRDERS. 4Nrf.S. P-c „, P -rc•• (.; -f ko asirn _ 131 33. 0 L .(1 a:3c? 1,010 . 17('3-f Sf 40 34 0-b 714.„ m Ns 100 101-7 9 4.5 c)L, 1 - Tharm a. DISPOSITION -Vi de 'ELOME 71-tqq10 .2_%D es) (k.a.4-tv-­ Az6-e-a) 6)W-el./LAI it" 93e-C-E- •24 Hist, /35o acio4 fed.ii sy....kg,/ -4-•,a:44•••.••• Et50- SP t")k-a-L.LOO4 ERG 72 HOURS ` 41 011,_zrv,:xc%., t-a-L ALA4E3--mist-T-tb • ;7::7utioel-2.1' # 6c,ael-d-d- 45:243-e • eatt..44-tt. PROVED '; ” DETERIO RATED TIME OF RELEASE: fPnArrntniP. N SF 507, IF NEESEDI PATIENT'S I DENTIFIGATION._011848071i00LIM=)...---RAND 10 . FOR WRITTEN. ENTRIES GIVE mane - last, middle; . -.SSN; DOB. servicsst., t. name-and•celetiorcofiDancar-0 of km ,LIRPPSTANT: FACILITY HOLDING TREAT= NEWTKEG:PRIX. • • T aneJ;addlnadisafionaorclarad. any limitations aria to w- LL- FlUdla rz.anit4y. t-STANDARD-FORM 558 gum 6-84 1,SAP MEDCOM - 386 DOD 003513

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3313
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72