Introduction ( my name , ask for permission )

Personal information : name , age , nationality

Chief complain : site , duration , mechanism of injury
History of presenting illness :
Pain :
1- site
2- onset
3- cheracter
4- radiation
5- timing
6- exacerbation + relieving factor
7- progression
8- severity
9- functionality
10- Associated symptom

Swelling :

1- Site
2- Another swelling
3- Mechanism
4- Severity
5- Prosgression + regression + same
6- Timing
7- Off +on
8- Exacerbation + relieving factor
9- Associated symptom

Redflag :

1- Weight
2- Fever
3- Neurological symptom
4- Dominant hand

Past medical :
1- Have you experienced this before
2- Chronic medical illness ( diabetic , hypertension )
3- Malignancy
4- Medication

Past surgical :
1- Site
2- When
3- Where

Social history :
1- Smoking
2- Alcoholic
3- Occupation
4- Iv drug used
5- Travel
6- Type of diet

Family history :
1- Mother , father , brother , sister
2- Any disease
3- Travel history

Immunization history :
Full or not

Allegry history :
1- Drugs
2- Food

Review of system :
1- CVS ( palpitation , fatigue after work )
2- CNS ( headache , syncope , seizure
3- Respiratory ( shortness of breath , URTI )
4- GIT ( abdominal pain , diarrhoea , constipation )
5- Genitourinary/renal ( urine retention , haematuria )
6- Psychiatry
7- Endocrine ( cold intolerance , polyurea polydipsia

Pediatric deformity :
1- Onset
2- Isolated + multiple
3- Any precipitating event
4- On +off
5- Progression + regression + same
6- Milestone
7- exacerbation + relieving factor
8- associated symptom ( fever , weight , )
9- functionality ( affecting his life )
10- prenatal + postnatal complication
11- normal vaginal delivery or CS

physical examination :
general appearance : well built ,well nourishes

vital sign : temperature , pulse , RR , BP , O2 sat , weight , Hight

general examination :
by systems

local examination
look , feel , move , neurovascular , measurement , special test

ATLS :
Announce trauma code

While I am conducting ATLS code , I will ask the responsible staff to :

M : monitor the patient

O : administer O2

V : vital

I : insert to enlarge IV

T : trauma Labs test

1ry survey :
A: airway and C collar

B : breathing and ventilation ( inspection , palpation , percussion , auscultation )

C : circulation ( abdominal examination : inspection , palpation ,percussion) pelvis

instability , thigh deformity , external bleeding

D : disability : GCS , pupil , lateralization sign

E : exposure and environmental control :

Adjunct 1ry survey :
Chest xray , pelvis x ray . Labs ( ABG + cross match )

Folly catheter

NG tube

FAST

CT scan

B-hcg

AMPLE history :
A : allergy

M : medication

P : past medical , past surgical , pregnancy

L : last meal

E : event

2ry survey :
Complete history , complete physical from head to toe

Summury of history :
Review old Labs and x-ray
New Labs investigation and X-ray
Admission order
1. Diet:
2. Activity:
3. Vitals:
4. Investigations: ECG, CXR
5. Drugs:
A. Pain
B. Pus (antibiotics)
C. Prophylaxis (enoxa, vomiting, strss ulcer, constipation)
6. N nursing instructions: ice , elevation and weight of traction.
7. C consultation
8. OR preparation:
A. Surgical consent
B. Marking
C. NPO IVF
D. PRE-OP ANTIBIOTICS
E. OR REQUEST
F. INSTRUMENT AND C-ARM. TYPE OF TABLE
 9. B BLOOD

Intra op:
1. Position
2. Shaving
3. Tourniquet
4. Scrubbing and draping.
5. Time out