Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Subjective:
Describe the mechanism of injury (blunt trauma, penetrating injury, iatrogenic).
Characterize the patient’s current symptoms:
Abdominal pain (location, severity, radiation)
Nausea and vomiting
Hematemesis (vomiting blood)
Melena (dark, tarry stools)
Distension
Inquire about associated injuries and past medical history.
Objective:
Vital Signs: Include heart rate, blood pressure, respiratory rate, oxygen saturation (SpO2).
Physical Exam:
General: Assess for signs of shock (tachycardia, hypotension, pallor, diaphoresis).
Abdominal:
Inspect for distention, discoloration, bruising, guarding (involuntary muscle rigidity).
Palpate for tenderness, mass, free fluid.
Auscultate for bowel sounds (absent or high-pitched sounds may suggest perforation).
Imaging:
Mention findings of recent X-ray (may show signs of ileus – gas trapped in the intestines) or ultrasound (limited sensitivity for duodenal injury).
If available, discuss findings of CT scan with contrast (gold standard for diagnosing duodenal injury).
Assessment:
Suspected duodenal trauma based on mechanism of injury and clinical presentation.
Consider the grading of duodenal injury based on imaging findings (if available) using a classification system like the AAST (American Association for the Surgery of Trauma) classification.
Hemodynamic stability (stable, unstable)
Plan:
Resuscitation:
Address hemodynamic instability with intravenous fluids, blood products (if needed) and vasopressors.
Diagnostic workup:
If CT scan not yet performed, expedite to confirm diagnosis and assess injury severity.
Consultations:
Immediate surgical consultation is crucial for suspected duodenal perforation.
Non-operative Management (rare):
Consider non-operative management only for isolated, minor duodenal injuries with close monitoring under specific criteria determined by the surgical team.
This would involve:
Nasogastric tube placement (NG tube) to decompress the stomach and prevent further injury.
Intravenous fluids and antibiotics.
Serial clinical examinations and close monitoring.
Operative Management (most common):
Surgical exploration and repair of the duodenal injury is the mainstay of treatment for most duodenal traumas. The specific surgical approach depends on the location and severity of the injury.
Follow-up:
Close monitoring in the surgical intensive care unit (ICU) post-operatively.
Serial abdominal examinations to assess for signs of infection or complications.
Repeat imaging studies as needed.
Gradual return to oral diet as tolerated.
Consider long-term follow-up with a surgeon to monitor for potential complications.
Note: This is a template and should be adapted to the specific patient encounter. Document all relevant details regarding mechanism of injury, symptoms, physical exam findings, imaging results, assessment of injury severity, and treatment plan. Duodenal trauma is a surgical emergency, and timely intervention is crucial for optimal outcomes.