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Medical history relevant to this medical condition
What medical history should you seek relevant to this issue? Questions you need to answer. Human health symptoms & signs A-Z List. Criminal Investigations Complaint Is there a recent history of trauma? When, where, and how did the trauma occur? Is the patient in coma? Is there distress of airway, breathing, or circulation? Unconsciousness How did the injury occur? Did the person lose consciousness? How long was the person unconscious? Did you observe any other changes in alertness, speaking, coordination or other signs of injury? What body part got injured? (Left leg, right arm, lower back, both shoulders, etc.) How did it happen? (Fell, lifted, struck by, bumped into, etc.) What caused it? (box, metal parts, car, patient, etc.) What injury resulted? (Strain, fracture, bruise, cut, etc.) Where was the head or other parts of the body struck? Can you provide any information about the force of the injury? For example, what hit the person's head, how far did he or she fall, or was the person thrown from a vehicle? Was the person's body whipped around or severely jarred? (ABCDEF) Airway (Can the patient talk? Can the patient respond to verbal questions accurately? Does the patient respond to painful stimulus?) What are the vital signs? Breathing (respiratory rate, bilateral equal, diaphragmatic breathing) Circulation (pulse, BP) Dysfunction of movement (Is there any deficit of movement? If yes, what are the details of the deficit of movement?) Exposure to injury (Is there any blunt or penetrating injury? If yes, what are the details of the blunt or penetrating injury? Where exactly is the injury? What type of injury is it? When and how did this injury occur? Does the patient respond to painful stimulus? Where exactly is the injury? 1. Head 2. Face 3. Neck 4. Thorax 5. Abdomen 6. Spine 7. Upper Extremity 8. Lower Extremity 9. External and other. What is the relative severity of acute injury? 1. Minor 2. Moderate 3. Serious 4. Severe 5. Critical 6. Maximal (currently untreatable). This is also called acute injury severity score. What organ has been injured? Minor Injury - minor sprain, bruise, cut, or requiring only roadside attention. Serious Injury - fracture, concussion, internal injuries, crushing, severe cuts, and severe shock type of injury. Serious secondary injury - Disruption of everyday activity. What is the injury type? Amputation Blunt injury Contusion Complete disruption Fracture Hematoma Laceration Nerve injury Penetrating injury Partial disruption Stretch injury Soft tissue injury Vascular What is the description of injury? How are his or her 10 physical functions? How have these 10 physical functions remained for the last 12 months? Is there a difference between severity of acute injury and severity of disability? Yes. What is the difference between severity of acute injury and severity of disability? What is the relative severity of disability? Regarding diagnosis: Did individual present with a history of some sort of traumatic event (i.e., vehicle accident, fall, altercation)? _____________________________________________ Was trauma from a blunt force or fall? _____________________________________________ Did individual present with any obvious tissue injury or deformity? _____________________________________________ Did individual sustain blunt trauma to the head, chest, abdomen, or pelvis? If so, did individual display any symptoms suggestive of injury to the underlying organs (change in level of consciousness or shock symptoms)? _____________________________________________ Was a thorough physical exam and diagnostic workup done by a specialist in trauma care? _____________________________________________ Were spinal x-rays done to rule out fractures or dislocations? _____________________________________________ Was spinal tap necessary? _____________________________________________ Was there evidence of internal bleeding detected with a hemoglobin and hematocrit level? _____________________________________________ Was a CT done of the areas of injury to look for injury to underlying structures? _____________________________________________ Was diagnostic peritoneal lavage done? Ultrasonography? _____________________________________________ If gunshot wound was present, did individual have exploratory surgery? _____________________________________________ Were all injuries immediately recognized (in the emergency room or trauma center), or were some injuries not discovered until later in the hospital stay? _____________________________________________ If the diagnosis of trauma was uncertain, were other conditions considered in the differential diagnosis? _____________________________________________ Regarding treatment: Was care rendered by emergency personnel (Medical doctor, EMT, RN, paramedic) at the scene of the accident? _____________________________________________ Did individual receive immediate control of life-threatening injuries? _____________________________________________ Was individual treated promptly in an emergency department or trauma center? _____________________________________________ Was individual stabilized? _____________________________________________ Did individual need blood transfusion(s)? _____________________________________________ Did individual require urgent surgical intervention? _____________________________________________ Is individual receiving appropriate physical, occupational, and behavioral rehabilitation therapy? Regarding prognosis: Did individual have a severe injury? Multiple injuries? _____________________________________________ Based on the extent and severity of injuries, what was the expected outcome? _____________________________________________ Did individual receive prompt medical attention by a facility that specializes in trauma care? _____________________________________________ Does individual have any comorbid conditions that may affect the ability to recover? _____________________________________________ Did individual suffer any complications that may have affected the length of disability? _____________________________________________ Trauma History and Physical DATE: TIME: PHYSICIAN WHO SAW PATIENT WITH YOU: CC: Patient's specific compliant, i.e. "My Neck Hurts" HPI: 1) Age, Sex, Ethnic group 2) Mechanism of Action (descriptive form) Example: MVA • Rate of speed • Number of cars involved • Damage to vehicle, direction of impact • Restrained driver/passenger found in/out of car, airbags deployed • Ambulatory/non-ambulatory at scene • ETOH/drugs involved • Time of accident • MOST IMPORTANT-- any fatalities in the accident and if so, make RESIDENT aware IMMEDIATELY! Example: GSW • Location of wounds • Number of shots heard • Where patient believes they are injured • Handgun versus rifle/shotgun • Estimated distance from shooter • Did the bullet travel through any walls or car part before wounding patient? 3) Things that are not appropriate to include in the documentation The reason you must be careful in the context and wording of your documentation is that, although these are medical records, non-medical professionals may review them. Therefore, it is important to document only facts that YOU can personally confirm and second hand information that is directly relevant to the medical care of the individual. We all like a good story, but the medical record is not the appropriate place for them. Criminal Investigations 4) Pre-Hospital Care a) How transported (ambulance, air, personal car) b) What medical intervention was given up to this point (fluids, monitoring, backboard, C-collar) c) Has the patient, at any time, been unconscious, hypotensive or dropped oxygen saturation d) Was the patient transferred or brought from the scene 5) How is the Patient Now? a) Awake, alert and oriented to person, place, time? b) Confused? c) Respiratory distress? d) Is the patient able to interact and communicate? PMH: self-explanatory PSH: self-explanatory Meds: including aspirin, BC powder, Goodies, Coumadin, Plavix, etc. (These can all predispose to bleeding) Allergies: self-explanatory Specific Mechanism of Action and What to Include: MVA • Driver/passenger; front/back seat • Seatbelt? Airbag? Shoulder harness? • Speed • Damage to vehicle, with specific location of patient in relation to damage/impact. • Loss of Consciousness? (LOC) • Was the seat back, windshield or steering wheel broken? • Were there any fatalities in the accident? • Were others injured in the accident? • Prolonged extrication? GSW to Extremities • How many shots heard? • Handgun versus rifle? • Distance from shooter? • Ability to use extremity after being shot. • Was there "jet-like" or aggressive bleeding at the scene. • Attempt to quantify how much blood-loss at the scene/in transport (small, moderate, large) • Where was the patient standing in relation to the shooter? KSW • How may times stabbed • Motion/trajectory of knife (upper movement, straight in, slash) • Amount and character of bleeding at scene/in transport. • Length and type of instrument used (i.e., steak knife vs. stiletto). • Other types of injuries (i.e. assault with fist or kicked?). Assault • Where on the body was the patient hit? • What they were hit with and how may times? • Where they hit in head or neck, and if so was there loss of consciousness? • Nausea or Vomiting since injuries? • Were there other mechanisms involved (i.e. KSW, thrown from car)? Same Level Fall • Why did they fall? Has this happened before? • Ambulatory/non-ambulatory after fall? • Loss-of-consciousness? • Is the patient on blood thinners? • Where does the patient hurt? • What position was their body in on impact? Fall • How high were they? • Did patient hit anything on way down? • What position was the body in at time of impact? • Loss-of-consciousness? • Ambulatory/non-ambulatory after? • Was ETOH/drugs involved? * IF NOT IMMOBILIZED-- have nurse place patient on a spine board and C-collar immediately! Physical Exam: note vitals upon presentation General: • Glasgow coma scale score should be recorded for ALL patients. • Is patient in distress? Head: • Atraumatic/normocephalic = no wounds. • Note location and describe wounds found. • Is there a depressed skull fracture on exam? Ears: • Is there any fluid leaking from the ears? • Look for hemotympanum (blood behind the eardrum indicates Basilar Skull Fracture). Eyes: • Pupil size and reaction. • Extra Ocular Muscles Movement • Contusions? • Bony step off of orbit Nose: • Any fluid or blood drainage? • Note obvious deformities. Mouth: • Loose teeth? • Malocclusion? • Tongue laceration (WATCH AIRWAY!!!) Neck: • Look for crepitus, indicating pneumothorax or tracheal injury. • Is trachea midline or deviated (tension pnemothorax) • Are there distended neck veins? • Note any abrasions/seat belt marks • Make sure the head is stabilized if C-collar is on. • Do not remove C-collar without Resident present!!! Chest: • Listen for breath sounds, and if they are equal (looking for pneumothorax). • Is the heart rhythm regular? • Are there abrasions or echymosis of the chest wall? • Are the clavicles intact? • Is the chest wall tender? • Is there crepitus? Abdomen: • Note abrasions/ecchymosis/wounds. • Is the abdomen distended? • Is there tenderness? • Is there rebound and if so, where? • Are there surgical scars (note location)? Pelvis: • Push on ASIS anterior-to-posterior, then from lateral to medial on iliac wings to determine stability. • If there is excess motion or creptius, tell someone about this. No one else should manipulate the pelvis if suspected to be unstable. This can cause damage to veins in pelvis and bleeding. • Note rectal/vaginal exam/blood at the meatus, scrotal hematoma. Extremities: • Note and describe any deformities or wounds. • Evaluate range of motion of all extremities. • Document presence of pulses at the radial, femoral, dorsalis pedis, posterior tibial regions (all bilaterally) and then show in diagram. • Note: when documenting GSW, do not designate "entrance/exit wounds", simply document "two wounds" versus "one wound." • Document gross muscle strength and symmetry. • Document gross sensory exam. • If there is any active bleeding, notify someone immediately! Spine: • After having someone log roll the patient, press on the spinous process of T1-L5 and note any tenderness or deformity. • If you do not know how to log roll, have someone show you; serious injury can occur if done improperly. • Note and document abrasions and other wounds. Lab Documentation: • CBC • BMP • P Amylase: • U/A X-rays: • Chest, lateral C spine; pelvis • CTL = cervical, thoracic, lumbar spinal x-rays • CT scans: HCAP = head, chest, abdomen, pelvis • X-ray areas of tenderness, swelling, lacerations, one joint above and below long bone in question • Impression: your diagnosis (ex: 1. assault, 2. fractured femur, 3. GSW) • Plan: what you will do to address the diagnoses. Special Note: The purpose of this rotation is for you to have exposure to procedures and suturing and to begin learning to identify life-threatening injuries by taking a good history and physical. The trauma H & P differs from that of other medical specialties, in that you are attempting to identify ACUTE injuries. Chronic diseases and disorders must be considered, but the acute life threatening issues are paramount. It is also important to have fun during this rotation. Make the most out of this time, because very few medical students have access to such an environment. Some of you may think that only those interested in surgery should be on this rotation, but all of us will be faced with trauma patients during our years in practice. It is probably even more important for those of you who are not going into surgery because you may never have this exposure again in your training. Make sure that if you are not comfortable with a procedure or even taking an H & P, that you ask one of the residents to help you. We are all happy to help and to teach, but be patient because the trauma center is very busy. I hope that this guide helps you get your feet on the ground and that you enjoy the Trauma Surgery Rotation!!! http://www.qureshiuniversity.com/trauma.html |