Date:
Patient: [Patient Name], [Age], [Medical Record Number]
Attending: [Physician Name]
I. Subjective
Information obtained from patient (if alert and able) or from chart review:
Mechanism of injury (fall from height, motor vehicle accident, crush injury, etc.)
History of present illness:
Onset and severity of pain (location, character)
Difficulty walking or bearing weight
Urinary urgency, frequency, or incontinence
Vaginal bleeding (females)
Rectal bleeding or difficulty passing stool
Numbness or tingling in the groin or buttocks
Associated injuries (abdominal pain, head injury)
Past medical history (relevant conditions, previous surgeries)
Medications (current medications)
Allergies
II. Objective
Vital signs (temperature, heart rate, blood pressure)
Physical exam:
General (signs of shock, bleeding)
Abdominal examination (distention, tenderness)
Pelvic examination (internal and external):
Vaginal bleeding (females)
Rectal bleeding
Pelvic tenderness or instability
Genitourinary examination (males):
Scrotal swelling or tenderness
Presence of blood at the urethral meatus
Neurological examination:
Sensation and motor function in the lower extremities
Anal tone (optional)
III. Assessment
Pelvic trauma:
Suspected fracture (specify location – sacrum, coccyx, pubic rami, acetabulum) based on mechanism of injury and clinical presentation
Internal injuries (bladder, urethra, rectum, vagina) – considered based on history and physical exam findings
Hemorrhage (internal or external)
Severity of injury (stable vs. unstable fracture)
Consider differential diagnoses (abdominal injury, musculoskeletal injury without fracture)
IV. Plan
Imaging studies (depending on suspected injury):
Pelvic X-ray (initial imaging)
CT scan with contrast (for detailed evaluation of bony structures and soft tissue injuries)
Urography (intravenous pyelogram – IVP) to assess for urinary tract injuries (may be replaced by CT scan in some cases)
Cystourethroscopy (visualization of urethra and bladder) if indicated
Blood tests (complete blood count, electrolytes) to assess for blood loss and hydration status
Pain management (medications)
Blood transfusion (if needed)
Catheterization (urinary or Foley catheter) for urinary retention or monitoring urinary output
Depending on the severity and type of injury, consider:
Consultations with specialists (orthopedics, urology, vascular surgery) for definitive treatment
Surgical intervention (fracture repair, bleeding control, urethral or bladder repair)
Pelvic binder or external fixation for pelvic stability
V. Progress
Briefly summarize the patient’s progress over the past 24 hours:
Changes in vital signs and clinical status
Response to interventions (pain management, blood transfusion)
Imaging results (if available)
VI. Prognosis
Discuss the anticipated course of recovery based on injury severity:
Potential complications (infection, blood clots, long-term pain)
Rehabilitation needs (physical therapy, occupational therapy)
VII. Follow-up
Schedule for next appointment:
Close monitoring for signs of bleeding or hemodynamic instability
Follow-up imaging (if needed) to monitor healing
Physical therapy referral for rehabilitation
VIII. Notes
Document any additional information relevant to the patient’s care, such as:
Communication with family members
Need for social work or discharge planning
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of pelvic trauma.