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Injury and Medical Report

This document is a confidential medical record for an injury or illness case, including patient details, medical history, vital signs, medications, allergies, and physical examination findings. It outlines medical tests conducted, treatment administered, and provides a final diagnosis along with instructions for the patient. The document requires signatures from both the physician and the patient upon receipt of discharge instructions.

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CARREL ATACADOR
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8 views1 page

Injury and Medical Report

This document is a confidential medical record for an injury or illness case, including patient details, medical history, vital signs, medications, allergies, and physical examination findings. It outlines medical tests conducted, treatment administered, and provides a final diagnosis along with instructions for the patient. The document requires signatures from both the physician and the patient upon receipt of discharge instructions.

Uploaded by

CARREL ATACADOR
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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INJURY AND ILLNESS MEDICAL RECORD (CONFIDENTIAL) Case Number:

1. Vessel: 2. Voyage #: 3. Cabin/Crew #:


4. Status 5. Name: (LAST, FIRST, MIDDLE) 8. Birth date:
PAX 9. Social Security No./ID #:
Crew 6. Address: (CITY, STATE, ZIP CODE) 10. Home Phone #:
Other (DESCRIBE) 11. Date:
7. Nationality: 12. Time:
HISTORY PRESENT ILLNESS / INJURY:
Age: Gender: CC:

VITAL SIGNS:
Blood pressure (systolic/diastolic): Pulse (beats/min): Body temperature (oral), note F or C:
MEDS (type, quantity, time):

ALLERGIES:

PAST HISTORY: CAD, MI, HTN, CHF, Arthritis, DM, CVA, PUD, TAH, CABG, PTCA, Cancer, Appendectomy, Cholecystectomy

LMP: TETANUS:
MEDICAL TESTS: Urine / Dipstick MEDICAL TREATMENT:
CBC Amylase / Lipase dT 0.5cc IM
Platelets Liver Profile Hypertet 250 UI IM
Electrolytes KUB IV Type / Rate:
Bun Flat / Erect Abdomen 02
Creatinine CXR Monitor / Tele
Glucose ABG FiO2: % Pulse Oximetry
CPK and CPK-MB EKG Inhaler Treatment
Troponin BHCG
PT / PTT
PHYSICAL EXAM: BP: P: RR: TEMP: PULSE OXY:
GENERAL: Well developed, nourished, in distress Yes No
HEENT: Head atraumatic. PERRL EOM’s intake. Nystagmus. Anicteric. Sharp discs. Throat clear. TM’s clear.
Mucosa: Moist / Dry / Pink / Pale
NECK: Supple. Kernigs. Brudzinski. JVD. Stridor.
CHEST: Clear breath sounds. Normal expansion. No wheezing, rales.
CV: PMII 4th ICS MCL. No gallops, murmurs. Regular rhythm.
ABD: Non-distended. Bowel sounds: Soft. Tenderness:
Rovsing. Rebound. Guarding. Organomegaly:
GU / GYN: Flank pain: L R None Normal Genitalia. Testes Descended / Tender. Hernias: L R None
Hemmocult Stool: Pos Neg Color:
EXT: Cyanosis. Clubbing. Edema.
Deformities:
NEURO: Patient is alert, attentive, cooperative. Oriented to person, situation, place and time. DTR’s symmetric.
Goal-oriented conversation. Clear speech. Coordinates well. Moves face and all four extremities symmetrically.
SKIN: Good turgor, no rashes. Diaphoretic, warm, dry.
LAB RESULTS: pH INTERPRETATION: Amy/Lipase:
HgB Na CL Bun Glu O2 CK/MB/Troponin:
WBC K CO2 Cr CO2
Hct FiO2 % Other:
ACCUCHECK: PULSE OXYMETRY: U/A:
EKG: Rhythm: Rate: Impression:
X-RAY:

TELEMEDICAL ADVICE RECEIVED:

FINAL DIAGNOSIS:
MAY RETURN TO DUTY:
INSTRUCTIONS / REFERRAL:

Return ASAP if worsening in your condition.

PHYSICIAN SIGNATURE: Date:

PATIENT SIGNATURE: (IN RECEIPT OF DISCHARGE INSTRUCTIONS)

Republic of the Marshall Islands Office of the Maritime Administrator MI-105MR (9/09)

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