Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Liver trauma (suspected or confirmed)
History of Present Illness:
Describe the mechanism of injury (blunt trauma – e.g., motor vehicle accident, fall from height; penetrating trauma – e.g., gunshot wound, stab wound).
Inquire about the time of injury and any immediate symptoms (abdominal pain, nausea, vomiting, hemodynamic instability).
Mention any pre-hospital care received.
Past Medical History:
Include any relevant past medical history, such as:
Bleeding disorders or coagulopathies
Prior abdominal surgeries
Liver disease (may increase risk of bleeding)
List any current medications, including anticoagulants.
Social History:
Inquire about alcohol or illicit drug use, which can worsen bleeding.
Physical Exam:
Vital signs: Include temperature, pulse, respiratory rate, blood pressure (assess for signs of shock – hypotension, tachycardia).
Abdominal exam: Check for tenderness, guarding, distension, or signs of internal bleeding (e.g., Cullen sign – periumbilical ecchymosis, Grey Turner sign – flank ecchymosis).
Evaluate for referred shoulder pain (may indicate diaphragmatic injury).
Diagnostic Studies:
Imaging studies (performed to confirm or assess the extent of liver injury):
Ultrasound (FAST exam): Rapid bedside assessment for free fluid in the abdomen suggestive of bleeding.
CT scan with contrast: Definitive imaging study to evaluate for liver lacerations, bleeding, and other injuries.
Laboratory tests:
Complete blood count (CBC): Monitor for anemia due to blood loss.
Coagulation profile: Assess clotting function (prothrombin time (PT), international normalized ratio (INR)).
Liver function tests (LFTs): May show abnormalities if there is significant liver injury.
Assessment:
Diagnosis: State the diagnosis of liver trauma (confirmed if imaging studies show a laceration or hematoma).
Grade of injury: Briefly describe the grade of liver injury using a scoring system (e.g., American Association for the Surgery of Trauma (AAST) classification).
Hemodynamic status: Describe the patient’s hemodynamic stability (stable, unstable).
Associated injuries: Mention any other injuries identified during evaluation.
Plan:
Treatment:
The treatment plan depends on the severity of liver injury and hemodynamic stability. It may involve:
Non-operative management: For minor injuries with hemodynamic stability, close monitoring with serial physical exams and imaging studies may be sufficient.
Interventional radiology: Techniques like angioembolization can be used to control bleeding in some cases.
Surgery: Laparotomy (exploratory surgery) may be necessary for severe injuries with ongoing bleeding or hemodynamic instability.
Blood transfusion: May be required to replace blood loss and maintain hemodynamic stability.
Pain management: Medications to address abdominal pain.
Antibiotics (prophylactic): May be used to prevent infections after liver injury.
Follow-up:
Depending on the severity of injury and treatment approach, the patient may require hospitalization for ongoing monitoring and management.
Schedule follow-up clinic visits to monitor for complications like bleeding or infection.