Date:
Patient:
Admitting Physician:
Current Progress Note:
History of Present Illness:
Briefly describe the mechanism of injury leading to hemorrhage (e.g., blunt trauma from motor vehicle accident, penetrating trauma from gunshot wound, fall from height)
Location of suspected hemorrhage (e.g., head, chest, abdomen)
Onset and nature of symptoms (e.g., pain, weakness, lightheadedness, shortness of breath)
Amount of blood loss (if witnessed)
Past medical history relevant to hemorrhage (e.g., bleeding disorders, anticoagulant medications)
Physical Examination:
Summarize the pertinent physical examination findings, including:
Vital signs (temperature, heart rate, blood pressure, respiratory rate)
Signs of local injury (e.g., swelling, bruising, tenderness)
Skin signs of blood loss (e.g., pallor, diaphoresis – sweating)
Focused examination of the suspected bleeding site (e.g., head exam, chest auscultation, abdominal exam)
Imaging Studies:
Describe the type of imaging studies performed to identify the source of bleeding (e.g., CT scan with contrast, angiography)
Summarize the findings, including:
Location and extent of the hemorrhage
Identification of the bleeding vessel (if possible)
Presence of any associated organ or tissue injury
Laboratory Studies:
List relevant laboratory tests performed (e.g., CBC, coagulation studies)
Briefly mention any abnormal findings (e.g., anemia from blood loss, elevated clotting time)
Assessment:
State the diagnosis of traumatic hemorrhage based on clinical presentation and imaging studies.
Describe the severity of the hemorrhage based on vital signs and blood loss.
Identify potential complications of hemorrhage (e.g., hypovolemic shock, organ dysfunction, death)
Plan:
Outline the treatment plan based on the severity of hemorrhage, including:
Resuscitation with intravenous fluids and blood products (if needed)
Control of bleeding source (e.g., surgical intervention, angiographic embolization)
Pain management
Monitoring of vital signs and blood loss
Consideration of blood transfusion protocols
Consultation with specialists (e.g., trauma surgeon, interventional radiologist)
Follow-up:
Describe the planned follow-up for monitoring and evaluation (e.g., repeat vital signs, serial blood tests, repeat imaging studies)
Education:
Document patient education regarding the nature of the injury, treatment plan, potential complications, and signs and symptoms to watch for.
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 traumatic hemorrhage