25 FORM -Trauma-Initial report for emergency department.pdf
- 1. INITIAL REPORT 1 Patient Information ID:……………………….. Date: / /2010 INJURY Date: / /2010 Age……………... Gender o Male o Female Past Ocular History o Negative/Normal If yes, indicate:……………………………………………. Previous eye injury:…………………………………... Previous eye surgery o Refrractive o Cataract o Unknown o Other: ____________________ Injury Information EYE o OD o OS Region where injury occurred o Jerusalem o Bethlehem o Hebron o Nablus o Jenin o Jericho o Ramallah o Other: ______________ Time of injury 12PM-3AM 3-6AM 6-9AM 9-12AM 12AM-3PM 3-6PM 6-9PM 9-12PM Time of exam 12PM-3AM 3-6AM 6-9AM 9-12AM 12AM-3PM 3-6PM 6-9PM 9-12PM Location at time of injury o Home o Office o Farm o Industrial Premises o Recreational venue & sports o School o Sports venue o Street/Hwy o Public building o Unknown o Other: _______________________ Intent o Unintentional o Self-inflicted (intentional) o Assault o Unknown o Assault Child spouse Elder Alcohol/Drug use o Yes o No o Unknown Eye protection worn? o No o Regular spectacles o Safety spectacles o Sports spectacles o Unknown Glasses shattered? o Yes o No o Unknown Patient a bystander o Yes o No o Unknown Time elapsed between injury and treatment o Less than one hour o Several hours o Next Day o Several Days o Other: ____________ Work-related: o No o Unknown o Yes Occupation:………………………….. Agent causing injury o Airbag o Furniture/Appliance o Blunt object o Sharp object o Projectile object o Burn o Household Chemical o Industrial Chemical o Finger, fist or other body part o Motor vehicle other than airbag o Sports equipment o Firearm o Explosion o Gun - other (Paintball, BB gun) o Fireworks o Garden equipment o Nail o Fall o Unknown o Other State specific agent: _________________ Tissues involved o Lids o Lacrimal o Cornea o Sclera o Iris o AC o Lens o Vitreous o Retina o Macula o Choroid o EOM o Orbit o Optic nerve o Other: ………………………………………………………... If RTA Seatbelts worn? o Yes o No o Unknown Airbag deployed? o Yes o No o Unknown Vision RE LE O……………………..………...NPL……………..………………..O O……………..………………...PL...…………...………………….O O………………………..……...HM.………...…………………….O O………………………..……...CF.……...……………..………….O ……………..……………….Specify………..…………………. O………………………..…..Not tested……..…...…………….O O………………….…….....Unknown.………....……………….O Eye normal before injury? o Yes o No o Unknown Previous treatment: o GP o Ophthalmologist o Pharmacist o None o Other_____________
- 2. INITIAL REPORT 2 Patient Exam Eye involved: OD OS OU INITIAL DIAGNOSIS Open globe injury o Yes o No o Postequatorial extension Laceration o Adenexal o Lacrimal Corneal burn o Thermal o Acid o Alkali Contusion o Contusion Partial thickness wound o Corneal o Scleral Rupture o Corneal……….mm o Scleral……….mm o Corneoscleral……….mm Penetrating injury o Corneal……….mm o Scleral……….mm o Corneoscleral……….mm IOFB o Magnetic o Ant. Seg. o Post. Seg. o Nonmagnetic o Ant. Seg. o Post. Seg. Perforating injury o Corneoscleral o Scleral Tissue in wound o In visual axis Uvea o Scleral o Cornea Vitreous o Scleral o Cornea Retina o Scleral o Cornea Vitreous prolapse into AC o Yes o No Wound dehiscence o Wound dehiscence Hyphema…………….% Iris/Pupil o Laceration/Dialysis o APD Iris loss o Partial o Total IOP o Angle recession o Hypotony o Glaucoma, secondary Lens o Cataract (traumatic) o Subluxed o Dislocated Vitreous o Hemorrhage o Penetration Retina o Hemorrhage o Retina o Macula o Edema o Retina o Macula o Defect o Tear o Giant tear o Laceration o Dialysis o Retinal detachment Number of quadrants? 1 2 3 4 RD type o Hemorrhagic o Tractional o Rhegmatogenous o Macular Choroid o Hemorrhage o Rupture Optic Nerve injury o Avulsion o Contusion Orbit o Fracture o FB o Hemorrhage Inflammation o Uveitis o Endophthalmitis Organism………………….. Other……………………………………………………….. INITIAL OPERATION Date: / /2010 Repair Eyelid o Partial o Full-thickness Repair Lacrimal o Globe o Exploration Repair o Cornea o Sclera o Corneo-scleral o Laceration o Rupture IOFB removal o Magnet o Forceps o Ant. Seg. o Post. Seg. Repair wound dehiscence o Hyphema o Removal Iris o Iridectomy o Iridoplasty o Iridotomy Lens o ECCE o Phaco o P. P. Lensectomy IOL o AC o PC Vitrectomy o Ant. o Post. o Open-sky Antibiotics o Intravitreal o Intracameral RD prophylaxis o Cryopexy o laser o Buckle Rd repair o Cryopexy o laser o Buckle o Vitrectomy o Air o Gas o Silicon oil o Pneum. retinop. Repair EOM o Orbit o # repair o FB removal o Decomp. Globe o evisceration o Enucleation Other………………………………………………………..