7/30/2019 Template Trauma Long Case Presentation
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TEMPLATE ORTHO / TRAUMA LONG CASE PRESENTATION
Patient details (age sex)# days post OT/ POST INJURY
ETCPRESENTING COMPLAINT (e,g, high speed MVA car v truck)- summary
(brief) of injuries)On scene: details of ambulance arrival
(MIST)
Transported to JHH (mode/ times)
Arrival- trauma call: time
Primary survey:A- airway and c spineB- o2 sat/ AE/ RR/ etcC-
circulation- IV acess/ fluid resis/ blood given/ results of
VBG/ABGD- pupils and GCSE- Temp
Trauma series: CXR/ PXR/ Fast scan
Then where to from here///?ot / CT
Secondary survery (details of head to toes exam once pt
stable)
AMPLE (allergy/ medications/ past hx/ last ate/ )
Then track through events of admission
ICU admissionOT
WARD ISSUES
EXAMINATION- when I saw patient
o Lines/ Walking aids/ O2chest drains etc
- Do as much of physical exam as injuries permit- Present
relevant clinical findings in relation to injuries (i.e. think what
is
relevant to each injury)
IN SUMMARY:- summarize injuries and where up to in rehab/ plans
for further OT
- short term issues/ goals- medium term issues/ goals- long term
issues/ goals
