TRAUMA CLERKING

PATIENT NAME:YAP KAI LIANG

NRIC:040810-08-0193
AGE/SEX:

ALLERGY: NIL

UNDERLYING:NO KNOWN MEDICAL ILLNESS

P/W:
ALLEGED MVA (MB VS MB)

POST TRAUMA SUSTAINED WITH:

OTHERWISE,
NO HEAD INJURY
NO ENT BLEEDING
NO BLURRING OF VISION/OPTHAL INJURY
NO SOB/CHEST PAIN/ABDOMINAL PAIN
NO NAUSEA/VOMITING
NO URINARY/BOWEL INCONTINENCE
ABLE TO AMBULATE WELL
ROM ALL 4 LIMBS FULL

O/E:
PINK, CRT LESS THAN 2 SECONDS, GOOD PULSE VOLUME
NO HEAD INJURY
GCS FULL
NO OPTHAL INJURY, VISION CLEAR
NO ENT BLEEDING/MISSING TOOTH
NO STRIDOR/TACHYPNEA, SPEAKING IN FULL SENTENCES
TRACHEA CENTRAL
NO CHEST WALL TENDERNESS
PELVIC SPRING NEGATIVE
POWER ALL 4 LIMBS 5/5

BP:156/75
HR:81
SPO2:99

LUNGS:CLEAR
CVS: DRNM
PA:SOFT, NON TENDER

L/E OF
- DEFORMITY:
- WOUND:
- ACTIVE BLEEDING:
- ROM:
- CRT:
- SENSATION:

IMP:

PLAN:
1. IM ATT 0.5MLS STAT
2. DRESSING WITH POVIDONE + EUSOL OVER RT KNEE