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    Endorsement Template SURGERY

    Uploaded by

    Elizalde Husband
    This document contains a medical form for collecting information on a patient, including their name, age, job, religion, address, chief complaint, and associated symptoms. It also includes tables for recording results of lab tests such as a CBC, chemistries, and urinalysis, as well as spaces for documenting findings from a physical exam using the AMPLE and DCAP-BTLS methods. The form provides areas to discuss the patient's history, assessment, and possible causes or pathophysiology relating to their condition. Imaging studies like x-rays and CT scans can also be evaluated and documented on the form.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Endorsement Template SURGERY

    Uploaded by

    Elizalde Husband
    36 views2 pages
    This document contains a medical form for collecting information on a patient, including their name, age, job, religion, address, chief complaint, and associated symptoms. It also includes tables for recording results of lab tests such as a CBC, chemistries, and urinalysis, as well as spaces for documenting findings from a physical exam using the AMPLE and DCAP-BTLS methods. The form provides areas to discuss the patient's history, assessment, and possible causes or pathophysiology relating to their condition. Imaging studies like x-rays and CT scans can also be evaluated and documented on the form.

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    Endorsement-Template-SURGERY

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    This document contains a medical form for collecting information on a patient, including their name, age, job, religion, address, chief complaint, and associated symptoms. It also includes tables for recording results of lab tests such as a CBC, chemistries, and urinalysis, as well as spaces for documenting findings from a physical exam using the AMPLE and DCAP-BTLS methods. The form provides areas to discuss the patient's history, assessment, and possible causes or pathophysiology relating to their condition. Imaging studies like x-rays and CT scans can also be evaluated and documented on the form.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    36 views2 pages

    Endorsement Template SURGERY

    Uploaded by

    Elizalde Husband
    This document contains a medical form for collecting information on a patient, including their name, age, job, religion, address, chief complaint, and associated symptoms. It also includes tables for recording results of lab tests such as a CBC, chemistries, and urinalysis, as well as spaces for documenting findings from a physical exam using the AMPLE and DCAP-BTLS methods. The form provides areas to discuss the patient's history, assessment, and possible causes or pathophysiology relating to their condition. Imaging studies like x-rays and CT scans can also be evaluated and documented on the form.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Patient’s name: ________________________ Age /Sex: ________ Job: _________________ Religion: ________

    Address: ___________________ Chief complaint: ________________________ Associated symptoms: ________


    CBC Values Remarks Possible cause/ Discussion /What was done to the patient History Assessment
    Hgb Pathophysiology of the case, rule in and out factors. MOI: Ejection from vehicle, Falls >20 feet, Roll-over of
    Hct vehicle high speed vehicle collision, vehicle-pedestrian
    WBC collision, motorcycle crash, found unresponsive or
    Seg altered MS, penetrations of the head, chest, abdomen
    Lym NOI: Ex, MVA, stabbing, mauling, fall, hacking, traumatic
    Eos POI: Place
    Mono DOI: Date
    Baso TOI: Time
    Plt A Airway: patent, patient is conversant
    RBC
    MCV B Breathing: spontaneous, RR ___ cpm
    MCH
    MCHC C Circulation: no active bleeding noted, BP __mmHg,
    Crea PR __bpm
    BUN D Disability: GCS ___ (E4V5M6)
    Uric
    Na E Exposure: multiple abrasions noted on R forehead,
    K R cheek, R upper arm and R knee
    TropI 2ndary survey: AMPLE DCAP-BTLS
    TropT A: no allergies Deformities
    CK-MB M: no maintenance meds Contusions
    SGPT P: PMH unremarkable Abrasions
    SGOT L: Last meal at ____ (time) Punctures/penetrations
    U/A E: events prior, ex: Px was Burns
    WBC driving a motorcycle and Tenderness
    RBC lost control of her vehicle as Lacerations
    Bacteria was turning a curve. Swelling

    Parkland formula: 4mL x %TBSA x kg = Total fluid Level of consciousness: (AVPU) GCS: E4: Spontaneous, Voice, Pain, None (SVPN); V5: Oriented, Confused, Inapp
    in 24hrs (1/2 x8 and 1/2 x16H Alert, Voice, Pain, Unresponsive words, Incompre sounds, None (OCWSN); M6: Obey, Localized pain, Withdraw
    from pain, Decorticate, Decerebrate, None (OLWDDN)

    XRAY CT Determine if with or without contrast Case Discussion


    A Airway: Midline (check trachea and carina) , no obvious B Blood: appears hyperdense (white) up to 7
    deformities, no paratracheal masses, no mediastinal shift days, no extracerebral hemorrhage: EDH, SDH,
    SAH or intracerebral like ICH & IVH
    B Bones and soft tissues: (check each rib, clavicles, scapula and C Cistern: are collection of CSF, check
    humeri) no fractures and SQ emphysema, soft tissues, any asymmetry.
    lucencies? Super white? Enlarged nodes, pneumoperitoneum Circum-mesencephalic—surrounding the midbrain
    Suprasellar—around the circle of Willis
    Quadrigeminal—located at the top of the midbrain
    Sylvian—between temporal and frontal lobes.
    C Cardiac size: silhouette and retro-cardiac density normal B Brain matter: trace falx, any compartmental
    cardiothoracic ratio: C/T <50% mass effect? Inconsistencies? Hyperdense
    regions with blood or calcifications?
    Hypodense means air, fat, ischemia or tumor.
    D Diaphragms: right above left by 1-3 cm, Costophrenic angles V Ventricles: lateral ventricles, 3rd and 4th
    sharp, diaphragmatic contrast with lung sharp ventricles for asymmetry, dilatation
    (hydrocephalus), effacement and hemorrhage.
    E Equal volume: count ribs, look for mediastinal shift B Bone: Cortical bone has the highest density on
    the CT scan (300–1000 HU)
    F Fine detail: pleura and lung parenchyma (pleura spaces appear Result:
    when abnormal)
    G Gastric bubble: above bubble no opacity more than 0.5cm width
    H Hilum: left normally above the right by 3 cm, no longer than a
    thumb (l higher than right)
    I Impression:
    Result:
    Patient’s name: ________________________ Age /Sex: ________ Job: _________________ Religion: ________
    Address: ___________________ Chief complaint: ________________________ Associated symptoms: ________

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