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
deformities, no paratracheal masses, no mediastinal shift
B Bones and soft tissues: (check each rib, clavicles, scapula and
humeri) no fractures and SQ emphysema, soft tissues, any
lucencies? Super white? Enlarged nodes, pneumoperitoneum
C Cardiac size: silhouette and retro-cardiac density normal
cardiothoracic ratio: C/T <50%
D Diaphragms: right above left by 1-3 cm, Costophrenic angles
sharp, diaphragmatic contrast with lung sharp
E Equal volume: count ribs, look for mediastinal shift
F Fine detail: pleura and lung parenchyma (pleura spaces appear
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:
B Blood: appears hyperdense (white) up to 7
days, no extracerebral hemorrhage: EDH, SDH,
SAH or intracerebral like ICH & IVH
C Cistern: are collection of CSF, check
asymmetry.
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.
B Brain matter: trace falx, any compartmental
mass effect? Inconsistencies? Hyperdense
regions with blood or calcifications?
Hypodense means air, fat, ischemia or tumor.
V Ventricles: lateral ventricles, 3rd and 4th
ventricles for asymmetry, dilatation
(hydrocephalus), effacement and hemorrhage.
B Bone: Cortical bone has the highest density on
the CT scan (300–1000 HU)
Result:
Patient’s name: ________________________ Age /Sex: ________ Job: _________________ Religion: ________
Address: ___________________ Chief complaint: ________________________ Associated symptoms: ________