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Doctors Initial Assessment Form Gaurishetty

The document summarizes a 67-year-old female patient's initial assessment after being admitted to the hospital following a motorcycle accident. It details her medical history of hypertension and diabetes. It provides information on her treatment including 12 days in the ICU, 2 days on a ventilator, and an operation to relieve pressure on her brain. Her examination finds her responding to pain, on a feeding tube and catheter, with normal vital signs. She is diagnosed with a severe brain injury from the motor vehicle accident requiring decompressive craniectomy.

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chetha kundi
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729 views1 page

Doctors Initial Assessment Form Gaurishetty

The document summarizes a 67-year-old female patient's initial assessment after being admitted to the hospital following a motorcycle accident. It details her medical history of hypertension and diabetes. It provides information on her treatment including 12 days in the ICU, 2 days on a ventilator, and an operation to relieve pressure on her brain. Her examination finds her responding to pain, on a feeding tube and catheter, with normal vital signs. She is diagnosed with a severe brain injury from the motor vehicle accident requiring decompressive craniectomy.

Uploaded by

chetha kundi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Patient: GOURISHETTY LAXMI, 

 67 years,  F Bed: Unit 1 -3 -304 A.D: 2/11/2021 Doctors Initial Assessment Form

Doctors Initial Assessment Form


Summary

Created By : Dr Sathwick Peram Date : Tue Nov 02 2021, 5:21:23 PM

History

Informant Relative
Son
Name RAVI KUMAR
Chief Complaints

Alleged history of RTA with Head injury due to sudden fall from bike at 6:30 PM on 20 October 2021.
History of Present Illness
Motor Vehicle Accident : On 20/10/21 at 6:30pm
Treatment History
Medical Treatment
ICU Care : 12 days
Ventilatory Support : 2 days
Tracheostomy : 8 days
Surgical Treatment
Craniotomy : FTP DECOMPRESSIVE CRANIECTOMY
Patient placed in supine position with head turned to opposite side, skin incision given in FTP fashion. Burr hole placed and FTP Craniotomy
done. Temporal bone nibbling done. Sphenoid ridge drilling done. Dura tense upon craniotomy. Dura incised and opened. Temporal
contusion with SDH noted which was evacuated. Drain placed and wound closed. :
Past Medical History
Hypertension Since 8 Years, Well Controlled
Diabetes Since 8 Years, Well Controlled
Past Surgical History :  None
Past Surgical History No
Personal History
Marital Status Married
Educational Qualification High Schooling
Smoking Non Smoker
Alcohol Non Alcoholic
Previous Functional Capacity Independent
Known Allergies None

Medication at the Time of Admission

Medications ADD ROW

Form Name Dose Frequency Route Advised by Actions

Examination

General Examination
Built Cachectic
Respiratory Distress Mild
Respiratory Support Yes
Tracheostomy Yes
Type Non-Fenestrated
No of Days 8
Secretion Heavy
Level of consciousness
AVPU scale P- Responding to Painful Stimulation
Flexor Response
GCS SCALE

Score :4 - E2V0M2 , Interpretation:Severe Brain Injury

Pupils
Bilaterally Normal Size, Reacting to light
Pupils Bilateral NSRL
Hydration Good
Pallor None
Icterus None
Cyanosis None
Edema

None
IV Access
Peripheral Cannula No
Central Line Yes
Cumulative Days 6 days
Feeding Tube Yes
NG Tube
Position Intact
Tube Aspiration None
Drain
ADD ROW

Drain Type Chest Side Drain Number Volume Drain Colour Underwater seal Air Column Negative Pressure Actions

Urinery Catheter Yes


Foleys Catheter
Type Rubber
Urobag
No of cummulative days 27
24 Hr Urine Output
Urinary Leakage No
Urine Examination Normal
External Splints No
Vitals at the time of Admission
Temperature 98.6 Degrees F
Pulse Rate 109 beats/min
Respiratory Rate 22 breaths/min
Systolic BP 169 mmHg
Diastolic BP 90 mmHg
SpO2 95 %
Systemic Examination
Skin
Pressure Sore

Open Wounds
ADD ROW

Area Actions

Cardio Vascular System


Peripheral Pulses
Respiratory System
Abdomen
Appearance Normal
Bowel Sounds Present
Bowel Movements Constipation
Musculo Skeletal
Central Nervous System

Meningeal Signs
Functional Examination
Ambulation Assisted
Wheel Chair
Bowel Incontinence No
Bladder Incontinence Catheterized

Investigations Initial

InvestigationsInitial

Clinical Impression/ Diagnosis

Clinical Impression/ Diagnosis


Trauma

Motor Vehicle Accident


Others RIGHT FTP DECOMPRESSIVE CRANIECTOMY WITH EVACUATION OF CONTUSIONS
PLACEMENT OF BONE FLAP IN ABDOMINAL PARIETUS
SAH WITH MIDLINE SHIFT

Plan of Management

Follow Doctors Order Sheet

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