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MEDICAL HISTORY SUMMARY

Entry Number Month Day Year


Service ER OBSERVATION Date of Entry
738941-2016 11 19 2016
PERSONAL DETAILS
Full Name ID Document ID Number
OSCAR MAURICIO LOPEZ SEGURA NUIP CC CE TI RC 1110469075
Date of Birth Month Day Year Age Sex Insurance CAFESALUD
3 5 1988 28 M F OTHER FFD SOAT
Address Name of accompanying person
SANTA FE TINTAL 3 INT 1– 403 NO COMPANION
Chief Complaint Time 9:45 PM
“MY STOMACH HURTS, TWO GUYS BEAT ME THE AGUILAS NEGRAS”

History of Present Illness


THE PATIENT SHOWS A CLINICAL PICTURE OF BLUNT TRAUMA TO THE HEAD, UPPER AND LOWER LIMBS
AND ABDOMEN OF THREE HOURS OF EVOLUTION, WITHOUT LOSS OF CONSCIOUSNESS.

BACKGROUND
Pathological: NONE Pharmaceutical: NONE

Surgical: APPENDECTOMY IN 1998 – Allergies: NONE

Toxic: OCASSIONAL SMOKER Family: NONE


PHYSICAL EXAMINATION
BP 100/95 HR 120/min RR 22/min TEMP 36,2°C WEIGHT 67KG
HEAD: SCALP SUPERFICIAL TRAUMA, BRUISING OF THE EYELIDS AND PERIOCULAR REGION, MOIST ORAL
MUCOSA, MOBILE NECK WITHOUT ENLARGEMENTS, NO PAIN ON PALPATION, RHYTHMIC HEART SOUNDS, NO
MURMURS, NO ABNORMAL BREATH SOUNDS, ABDOMEN BRUISING OF THE ABDOMINAL WALL PAINFUL ON
PALPATION, UPPER LIMBS WITH SUPERFICIAL BRUISING ON OTHER PARTS OF THE FOREARM, THE REST
WITHOUT ALTERATIONS. GLASGLOW 15/15
DIAGNOSIS
Presumptive Diagnosis Definitive Diagnosis
CIE CODE CIE CODE
Main: POLYTRAUMA Main: POLYTRAUMA
10 10

Related 1: TBI S00 Related 1: MILD TBI S00-7

Related 2: BLUNT ABDOMINAL TRAUMA S30 Related 2: BLUNT ABDOMINAL TRAUMA S30-1

Related 3: Related 3:

Calle 80 Avenida Calle 80 No. 80 a 19 Bogotá


POBOX 095 3959211
MEDICAL HISTORY SUMMARY

TREATMENT PLAN
1. ER OBSERVATION
2. NVO
3. RINGER LACTATE SOLUTION 100CC/H
4. SIMPLE AP AND LATERAL ABDOMINAL X RAYS
5. NEUROLOGICAL EVALUATION EVERY 2 HOURS
EVOLUTION
NOVEMBER 20TH, 2016 TIME 4:00 AM
SATISFACTORY EVOLUTION, NEUROLOGICAL SYSTEM WITHOUT DEFICITS, GLASGLOW 15/15, SIMPLE
ABDOMINAL X RAYS NORMAL, PATIENT WAS DISCHARGED.
1. ACETAMINOPHEN 1 GRAM EVERY 6 HOURS / PAIN
2. MEDICAL INCAPACITY FOR 5 DAYS
3. FOLLOW UP APPOINTMENT IN 8 DAYS

[Signature]
[Stamp: Dr. Francisco Calderon Bejarano
General Surgeon
San Martin University – R.M. 370110]
Dr. FRANCISCO CALDERON BEJARANO
GENERAL SURGEON

Calle 80 Avenida Calle 80 No. 80 a 19 Bogotá


POBOX 095 3959211