2/14/22, Monday

5:00 pm
General data and History of Present Trauma:
Pertido Agapito was brought by his brother because he was stabbed at Carcar by an ice
pick 30 minutes ago prior to admission at the LLQ. There was no reported bleeding, no
difficulty of breathing, he is conscious and can still talk, and can still the feel the pain
when he walked. The ice pick is still in his abdomen, stabbed once and half penetration.
Vital signs:
 PR:110
 BP:80/60 bpm
 RR: 27 cpm
 TEMP: 36.5
 O2 STAT:
Primary survey:
 Airway: intact
 Breathing:
o RR:
o O2 sat:
 Circulation:
 Pulse:
 color of skin:
 CRT: 2 sec
 Carotid pulse
 Femoral pulse
 Radial pulse
 What type of shock?:
 Classify the shock:
 How do you approach to shock?
 Disability:
o GCS:
o Pupil size:
o Motor & sensory:
o Glucose level:
o Spinal injury:
o How do we manage disability?:
Set up IV access infusion of saline, LR, or blood products:
1. _______
2. _______
3. _______
Secondary survey: (HEAD TO TOE EXAMINATION, SPECIAL PROCEDURES)
o ALLERGIES:
o MEDICATIONS:
o PAST MEDICAL HISTORY:
o LAST MEAL:
o EVENTS AND ENVIRONMENT RELATED TO INJURY:
o MANAGEMENT:
 CHECK FOR (yes or no):
 Bowel sounds
 Tenderness
 Rigidity:
 Contusions:
 Open wounds
DIAGNOSIS AND MANAGEMENT OF PENETRATING ABDOMINAL TRAUMA: (fill in
the results of the px)
1. Physical examination: (identify the location entry and exit)
2. Radiographs (AP AND Lateral abdominal films)
3. Local wound exploration: (det. Whether fascial or peritoneal penetration)
4. DPL:
5. FAST:
6. CT scan:
Surgical treatment:
 Laparatomy
o Procedures:
o Indications:
o Priorities during exploratory laparotomy:

Specific Abdominal Organ Injuries: (also give management):

1.