BEASLEY BLISTER PROGRESSION**PHIPPS CLINIC DAYl DAY 3 DAYS I~~~ DAY 7 DAY 7 DAY 8 After Debridement BEASLEY BLISTER PROGRESSION**PHIPPS DAY 3 DAYS CLINIC DAY 7 ~'I"""'Ii':' r" ual ht Alert 0 Hot 0 Responds to Verbal 0 Cyanotic 0 Responds to PaJn 0 Diaph 0 Unresponsive 0Ciear D Muffled CapJlla : 0 second (normal) 0 >2 seconds del ed GCS· l$ Eyes I 4 Verbal I 5 Motor I 6 Total I 15 Sphincter Tone · O WN L 0 Weak O None SECONOAR"' SURVEY. 't=H~E~A~ D_IN~E~C_K~E~E~N~T--~ H~ EA ~~~RA ~C~IC ___________-TA~B~O~ INAUGU Drainage : Rhythm: fat ose {color 0 NSR (tachy/brady) 0 Distended CSF I 0 V-flbl lach 0 Obese R1L R 1L Reac•tve R I L Dilated R I L 0 PEA 0 Asystore 0 Other 0 Non-tender 0 Tender 0 Rrgid Pulses; S = Strong D W Weak A Caro 1d Femoral Brachtar 0 Guarding 0 Rebound Tenderness E)eS Equal Ftxed ----- - O'h r C·Spme Tender y s 0 Dental InJury Yes O No = Radta l Pedal .Tympan c r..~ embrane Clear R L Blood R L 0 Unable to R __ l R __ L R __ L 0 Assess Open Wound FAST DONE : Fracture/Dislocation: O RUE 0 RLE O LUE 0 LLE Binder: 0 Yes ,._, otor RU LUE RLE LLE + I + I • • + I - + I • ns I I I I .. eatusNagina: fJ Yes 0 No S I NEG I NA nown one ~ '- ( 332 EMOG, AFTH, SALAD AB, Iraq MTF: OM .., .. . ood at ,_____.__~PAST MED H~ DUKETT, PHILLIP MTF Transferred from. R __ L R __ L Pelvis Stable: DYes 0 No LOG ROLL TIME: Back exam: 0 WNL 0 ABNL (describe) JVO Distension: Flail Pft TII:LtT f.ni:~TII='JCATION ~ =Doppler =Absent EXTREMITIES 0 Respiratory hx 0 Seizure hx 0 Cardiac hx CURRENT MEDICATIONS Cl Unknown one 0 List Current Meds· D HTN D DM 0 Ulcers 0 Other. SubjeCt fo the Pnvacy Act of 1974 Pa e 1 of 3 - I I I - I • - • • "' • SECONDARY SU I . L L R R (AB)rasion (AMP)utation (AV)ulsion (BL)eeding (B) urn (C)repitus (D)eformity (DG)Degloving (E)cchymosis (FX)Fracture (F)oreign Body (GSW)Gun Shot Wound (H)ematoma (LAC)eration (PW)Puncture Wound (P)ain (SS)Seatbelt Sign (SW)Stab Wound • • •• PRE-HOS . . ' ,-. . . . >Fitifih D~ PROTE Deltoid/Axiii~~ Ext : Neck Prote¢tor: ""' ET Intubation (Adnl changes in Notes) Urina D Teeth D D D Amt D ---· Color D A-fine Thoracotom • • Test Time nasal oral nasal meatus su ra . L L L L Site: Chest tub Time oral Test ~--~C-8C----~--~~~T~&~S~--- ABG Chemist T &C UA PT/PTT TEG HCG Other R R R R Time # 0 0 D ETC0 2 Change TIME BBS Post Int. Verified TYPE TIME Chest Abdom. Suction Y N Heme Dip+ IResults cc Air Bood Air Blood Pelvis Extrem . TYPE Head Chest Abdom. Pelvis • 02 on : Gau e IVF 02 off: Nasal cannula NRB Mask 0 BVM D AmtU I~ Amt In x • Total: : (~as rst/ nt 10./SSN:' SD(HA) September 05 332nd EMDG. Balad AFTH 8 ,.· , • Subject to the Privacy Act of 1974 Page 2 of 3 • PATIENT MOV . JVlt:.l'ff .. KECORD D ATA P.C:~OTECTED BY PRIVACY A CT OF 1974 PERMANENT MEDICAL RECORD (S) - Information needed to submit patient movem ent record - "' S r-c.,...•o C ) I I"' 1 PATIENT !DENT!F!CATION (s) AGE ~s_S,E_ X-r----:--~ (s) STATUS 2.'{ M (s) SERVICE A~\-\y~ F DATE OF BIRTH (s) SSN (s) NAME (Last, First, Middle Initial) (s) GRADE E0 A<""\'\'\'( SECTlON ll CITE NUMBER (s) UNIT OF RECORD AND PHONE NUMBER ~~ c\6 ~ Sc..h -. ~ s VALIDATION INFORMATION (s)· Ready Date (Julian Date) APPOINTMENT DATE NUMBER OF ATTEN DANTS (s) Medical Treatment Facil1ty Orig ination and Phone Number l- . (s) Medica l Treatment Facility Destination .._ -0 fV\a- S+c-~ l)l\; d Phone Nu ber ~"- tf~ < \ Max# Stops 'Max# RONS (s) Reason Regu lated (s) ME fJ~r/L Llt1 Altitude Restriction (s) ON-MED s) CLASSIFICATION 1A-5F LITTER AMBULATORY s CCATI I SECTION HI l OTHER INFORMATION • • 1c1an na (s) Accepting Physician name. Phone Number and e-mail (s) Origlne1tlon Transportation 24 Hour Phone Number (s} Insurance Company (s) Destination Transportation 24 Hour Phone Number Address • Relationship to policy holder Policy# Phone# (s) VJaivers (med equi p, etc) • SECTION IV CLINICAL INFORMATION LABS (Date and time drawn in Zulu) (s) Allergies Nlt..oA WBC H CT HGB (S) Blood type (s) WEIGHT: Other Labs Vital Signs (Date and time taken in Zulu) battle casualty disease Date ~--~-n-o-n--b-att_l_einju....... ry_ __.___ _ _ _~-~Zd Time (Zulu) AU 1/64 l I CLINICAL ISSUES Pulse Resp I Pain Levei: Last Pain Med: 0 2 /LPM: Route: f,( I /10 Baseline 02 Sat If Applicable I Infection Control Precautions: LMP: Temp SPECIAL EQUIPMENT (Check all that apply} Suction Orthopedic devices Traction GTHER: I Date of last bowel movement: yes High Risk for Skin Breakdown no Initial appropriate boxes: • Yes No es No Ventilator Ventilator Settings: DiET iNFORMATiON (Check ali that app~y) Vision Impaired Voiding difficulty Cardiac Hx *Takes long-term meds Diabetes *Will sef-medicate NPO Renal Soft - - Motion Sickness Has adequate supply of med Tube Feeding Ears/Sinus Problems Knows how to take meds Cardiac Respiratory difficulty (verbalized understanding) TPN: Full Lig Gm Protein • • Gm Na Type Cl Liq - cc/hr - Meq K - - Mag Sulfate Discontinue for Fiight 1---+r~ ~--------------+-~~~ *Medication listed on physician's orders SECTION V Diabetic Infant formula: cal Pediatric Age: Other( specify): PERTINENT CLINICAL HISTORY (Transfer Suml'pary) 'k_. kQ ~. o C.. ·h fi\Wf-Cll 60 day me dlcal management . Denies PMH: PS H:. Ass e ssme nt: AOx3 , NAD. Ambulates with mini ma l diffi cu l ty. Bl~sters now open, covered wi th cream a n d d r e s s ing. Dr ess i ngs not saturated, c hanging d~lly. Can to l erate prolonged s it tin g . Pa in is s ignifi cantly decreased with o i ntme nt. 1:10 Wlth meds, 3:10 without meds. Wi l l hav e a mpl e supply o f meds and can self medicated as needed. No other p hy sical l i mi t a ti on s . No dis comfort wi t h flying. Has Mil ID for travel. No vis1ble wounds or b r uises . Can egre ss / d i g res s AC wi t hout a s sistance . Can c arry own bag s and Wlll use cart at airport. Use o f s t a nda rd a nd MRSA contac t p r e c a u t 1ons for Ac inotebactor as pe r AFI 41 - 3 0 7 ATCH 12. May fly c omme r c i a l as per MD n o te I highly recommended DWMMC AE. Sa f e Flig ht . CDR NC US N. Pt pre f erence is : DWMMC PROGRESS NOTES DO NOT REMOVE (REVERSE) Vers1on 1 0 0.0 PHYSICAL PROFILE For use of this form , see AR 40-501 ; the proponent a ency is the Office of the Suroeon General. 1. MEDICAL CONDITION: (Description in lay terminology) 0 1NJURY? Or 0 ILLNESS/DISEASE? s'p k1dney removal left 2. CODES (Table 7-2 AR 40-501) P 3 3. Temporary i u 1 ,. L L H 1 1 ~ - · 1 l E ' S ~ 1 1 Permanent YES 4. PROFILE TYPE - a TEMPORARY PROFILE (Expiration date YYYYMMDD) - - 2009/11 /05 - - ---• - - --- -(Limited to 3 months duration) ·~ _ - - - - - ---- b PERMANENT PROFILE (Reviewed and validated as a minimum with every periodic physical exam or after 5 years from the date of issue) NO _ c IF A PERMANENT PROFILE W ITH A 3 OR 4 PULHES, DOES THE SOLDIER MEET RETENTION STAND ARDS lAW CHAPTER 3 AR 4 0-50 1? (IF USARIARNGIARNGUS SOLDIER NOT ON ACTIVE DUTY SEE PARA. 9-10 & 10-26, AR 40-501 1F SOLDIER DOES NOT MEET RETENTION STANDARDS.) 5 FUNCTIONAL ACTIVITIES FOR PERMANENT AND TEMPORARY PROFILES (If any answer (a-f) is NO then the profile should be at least a 3) - - -- - - - - - - a ABLE TO CARRY AND FIRE INDIVIDUAL ASSIGNED WEAPON - - - - - - - -.-- ./- - r- - - ./ - - ./ f. IS SOLDIER HEALTHY WITHOUT ANY MEDICAL CONDITION THAT PREVENTS DEPLOYMENT? 6 APFT - 2 MILE RUN - --- - - - - - - - - - APFT SIT-UPS ----------APFT PUSH UPS YES NO - - - - 4 - - - - - + - ./- - - ./ ---~· - · - ---+./ - -- ----t-- APFT WALK APFT SWIM -1--- - APFT BIKE NO YES ALTERNATE APFT (Fill out if unable to do APFT run otherwise NIA) - N/A -- - ./ ./ - ./ --------------------~- N/A -N/A - 7. STANDARD OR MODIFIED AEROBIC CONDITIONlNG ACTIVITIES (Check all applicable boxes) - -- ---- - - OR RUN AT OWN PACE & DISTANCE - - - - - - + - - - ./ OR WALK AT OWN PAC E & DISTANCE - ,/ UNLIMITED RUNNING UNLIMITED WALKING UNLIMITED BIKING IUNLIMITED SWIMMING - 8. UPPER BODY WEIGHT TRAIN ING (See FM 21-20) 1 ./ 1 -OR BIKE AT OWN PACE & DISTANCE OR SWIM AT OWN PACE & DISTANC E --4----·- / v --------+-_:_--+---./ I ./ 9. LOWER BODY WEIGHT TRAINING (See FM 21-20) I 10. OTHER· e .g. Functional hm1tattons and capabilities and other comments: (May continue on page 2) 11 . THESE PARAMETERS ARE OPTIONAL USE AS NEEDED PT to tolerance Crunches ok. No sit-ups. No gear Lifting or carrying max weight or 45 d'stance Running maximum distance tolerance Prolonged standing - maximum time per episode Marching with standard field gear except rucksack max distance Impact activities such as jumping max# reps in one day Th1s temporary profile is an extens1on of a temporary profile first issued on .I 12 TYPE NAME & GRADE OF PROFILING OFFICER Amy E Hawkins, MPAS, PA-C CPT, SP RE 14. DATE (YYYYMMDD) 2009/10/15 15 ACTION BY APPROVING AUTHORITY APPROVED 16. TYPE NAME & GRADE OF SENIOR PROFILING OFFICER OR APPROVING AUTHORITY - :> I 17. SIGNATURE 19. ACTION BY UNIT COMMANDER (See para 7-12, AR 40-501) THIS PROFILE REQUIRES A CHANG E IN THIS SOLDIER'S MOS or DUTY ASSIGNMENT ----~--- NOT APPROVED 18. DATE (YYYYMMDD) -----\-c YES NO -~ 20 COMMENT 1f this is a per. nanent orofile with a PULHES senal of 3 or 4 refer to block 4c 21 . TYP ED NAME & GRADE OF UNIT COMMANDER 22. SIGNATURE 24. PATIENT'S IDENTIFICATION (For typed or wotten entries gtve Name(last, first), grade, SSN; 25. UNIT hosp1tal or med1cal facility) Dukett, Phili James 23. DATE (YYYYMMDD) WALUBO - 0014 IN BN 01 B CO 26. ISSUtNG CLINIC, PROVIDER E-MAIL & PHONE NUMBER SGT SBTMC PROFILING OFFICER (Or Approving Authority if applicable) IS RESPONSIBLE FOR ENSURING THE PULHES & DATE OF PROFILE ,5 ENTERED INTO MEDPROS. ORIGINAL COPY POSTED IN MEDICAL RECORDS, 1 COPY TO UNIT COMMANDER, 1 COPY GIVEN TO SOLDIER, 1 COPY TO MILPO. DA FORM 3348, FEB 2004 OA FORM 3349 MAY 86 IS OBSOLETE THIS INFORMATION IS PROTECTED BY THE PRIVACY ACT OF 197 4 (Pl-93-579). UNAUTHORIZED ACc'ESS TO THIS INFORMATION IS AVIO APO V1 .01 P a g e 1 of 1 LATION OF FEDERAL LAW. VIOLATORS WILL BE UK M~U Uo-XXXX ct'lv U'=>UKt: L • All rCQuncd ctem.) oo tht l•st mu ~t 1. Narno (L 4. s t. Jrst. M l) c dl 5. Date ctur n to Hood S. Re(iuested L Li D v 0 tos 7. Origin I Deployment Date 1.00 8. ..m. il Addr ..,.., (AKO) 9. S p. ration 0 t (Frorn ep ration te (From Army} 11. Orders fn Hand 11 07 • ES I NO~~'"!"i tton Turn •n ~,ed•cat Records with DO Form 2766 Insert u *Schedule Household Goods Derive as ·complete On-line OOIM Users training (for Hood e-maH accoont holders) Reactivate Auto Insurance Update expired drivers license I vehicle registration I TX vehide inspection • - Signature Title Date CDR 11SG Signatu,.. & Date • More information on these topics can be found in the Iraqi Freedom Reintegration Handbook included in your -.wlcome packet . REPORT I I I II CIF 1974 -I Use Blanket PAS DD Form 2005) I I I I0 -IINAT-I First:iIIip :1 WOR CATION . I 1 3.0 I SI MBOL 9 INSTALLATION JSS R0 I d, Iraq . I I :2 9- 5 188 Roward, [rat] *0 etc? TION TI I 17 II I I SIJPE. vsoa (Name and Duty Infant. 1 jroop SIATISAT TIME OF EXPOSURE OFF DUTY LEAVE I4 NOFEITNI 8 (Name and 16 DE I TIONO . T- I I I i I \Jotit?fe I small - I1 stale er i; I -l iItg, Immediately sought medical attentionDIA: .4 SISAND EL. CA II am? Grit/OCICUPATIONAL SKIN DISEASE pound . ISEASE OF LUNOs a I I I I F'l' I .. I 1 RE :Pl ATORY CONDITION DUE TO TOXIC AOENT 2PHYSICAL AGENT (0t erthan toxic materialEFFECT OF TOXIC REPEATED TRAUMA . . LITY . CCUPATIONAL 29 16 1900I IDIC .L CILITY - - -- - . I I i i . OInt Base Baladt Iraq CARE (SpecIr?fy/n RemarksRETU REFE QUARTERS 24LR 'Menl Dew dupe dtd) 1115 Company Medic where again he was cffec I176 I'dillumd bleach 30111 25whi] Ii: . 0 I {be materiaI/agentrounds. I301) asked Siam round that was Iegking a ?uid (lamDAT 2-se It, a - I 2080 17 AFI