Essential Communication Skills

Hospital Experience
Phase Four
Module: Orthopedic and Traumatology

Student name: ………………………… Date: ………………………

Student number: ……………………… Time: ………………………
Level: …………… Tutor name: ……................

Patient clerking

Department: orthopedic Ward: ……………………….

File number: ……………. Bed number: ……………….
Physician in charge: ………………………………

* Source of information: -Patient -Relative

* Patient information:
Name: arafah Gender: -Male -Female
Age: 27
Marital status: -Single -Married -Divorced -Widow
Occupation: manager at airport Address: no data available
* Reason for admission:

RTA in high velocity car rolled over with multiple back injuries
Date of admission: 2022/2/27
*Past medical and surgical history

 Previous similar condition non

 Previous hospital admission non
 History of operation or procedure non
 History of investigation non
 Major illness (Childhood illness, Rheumatic fever, Diabetes, Heart disease or Jaundice)
 History of Blood Transfusion non
 Major accidents or injuries non

*Drug history
 Medication (Prescribed or over the counter) insulin
 Medication that the patient is known to be sensitive non

*Family history
 Similar problem in the family non
 Causes and age of death of parents no data available
 Health of siblings and childrenwell
 Chronic disease (heart disease, hypertension, diabetes, asthma) DM type 1
 Genetic disease (congenital abnormality in the family) non

* Reproductive history
 Duration of marriage 2
 Number of children (No. of pregnancies and miscarriages) ………………..…………….……………….
 Menstrual history (regular, irregular, last menstrual period) …………………………….…….…………
 History of infertility treatment…………………………………………………………….………………
 Family planning history…………………………………………………………………….……………..

*Social history
 General wellbeing ill
 Smoking heavy smoker
 Housing in almandina
 Family relationship and support well
 Occupation and job security manager
 Social problems non
 Financial problems non
 Education Bachelor's
- Summary of patient history and related investigation and management

27y male saudi patient Know case of DM-T1 married heavy smoker works as a manager
in the airport 

Referred from bader vitally stable after RTA in high velocity.

While he was driving He was hit by truck from the left side the car rolled over several times he
was wearing the seatbelt and he lost continuous 2 times.

There was a Pain in the neck back and chest area with difficulty breathing and restricted
respiratory movements.

Pain and difficulty movement in the left leg due to direct trauma to the hip.

Moving all his limps no neurological deficit.

CT showed:
Fracture vertebral body C2
Fracture vertebral body T4 and L 2 , L3.
Fracture ribs from 1 to 7.

Management 
Now he is waiting for MRI with contrast
-waiting thoracic consult 
-on IV Strong analgesics , clexane and omeprazole

…………………………………………………………………………….………………………….………………

Total Assignment: Total for clinical analysis:

Excellence Good Not Good Excellence Good Not Good