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Seafarer Injury and Illness Medical Record
Republic of Panama
INJURY AND ILLNESS MEDICAL RECORD
(CONFIDENTIAL)
1. Vessel:
Case Number:
2.Voyage #:
4. Status
3. Cabin/Crew #:
5.Name: (LAST, FIRST, MIDDLE)
8. Birth date:
PAX
9. Social Security N°./ ID N°.:
Crew
6. Address: (CITY, STATE, ZIP CODE)
10. Home Phone N°:
Other (DESCRIBE)
11. Date:
7.Nationality
12. Time:
HISTORY PRESENT ILLNESS / INJURY
Age:
Gender:
CC:
VITAL SIGNS:
Blood pressure (systolic/diastolic):
Pulse (beats/min):
Body temperature (oral), note F or C:
MEDS (type, quantity, time):
ALLERGIES:
PAST HISTORY:
CAD, MI, HTN,CHF, Arthritis, DM, CVA, PUD, TAH, CABG, PTCA, Cancer, Appendectomy, Cholecystectomy
LMP:
TETANUS:
Urine / Dipstick
MEDICAL TESTS:
MEDICAL TREATMENT:
CBS
Amylase / Lipase
Platelets
Liver Profile
dT 0.5cc IM
Hypertet 250 UI IM
Electrolytes
KUB
IV Type / Rate
Bun
Flat / Erect Abdomen
02
Creatinine
CXR
Glucose
ABG
CPK and CPK-MB
EKG
Troponin
BHCG
Monitor / Tele
FiO2:
%
Pulse Oximetry
Inhaler Treatment
PT / PTT
PHYSICAL EXAM:
GENERAL:
HEENT:
BP:
P:
Well developed, nourished, in
RR:
distress
Yes
TEMP:
PULSE OXY:
No
Head atraumatic, PERRL, EOM’s intake, Nystagmus, Anicteric, Sharp discs, Throat clear, TM’s clear.
Mucosa:
Moist
/ Dry
/ Pink
/ Pale
NECK:
Supple.
Kernings.
CHEST:
Clear breath sound. Normal expansion. No wheezing, rales
CV:
PMII4 th ICS MCL.
ABD:
Non-distended. Bowel sounds:
Brudzinski.
JVD.
No gallops, Murmurs.
Stridor.
Regular rhythm.
Soft- Tenderness:
Rovsing. Rebound. Guarding. Organomegaly:
GU / GYN:
Flank pain: L
R
Hemmocult Stool:
Cyanosis.
EXT:
None
Pos
Clubbing.
Hernias:
Normal Genitalia. Testes Descended / Tender.
Neg
L
R
Color:
Edema.
Deformittes:
NEURO:
Patient is alert, attentive, cooperative. Oriented to person, situation, place and time. DTR’s symmetric.
Goal-oriented conversation. Clear speech. Coordinates well. Moves face and all four extremities symmetrically.
Good turgor, no rashes. Diaphoretic, warm, dry.
SKIN:
PH
LAB RESULTS:
HgB
WBC
Na
CL
Bun
K
CO2
Cr
Glu
EKG:
FiO2
PULSE OXYMETRY:
Rhythm:
Amy / Lipase
CK/MB / Troponin:
CO2
Hct
ACCUCHECK
INTERPRETATION:
O2
%
Other:
U/A:
Rate:
Impresion;
X-RAY:
TELEMEDICAL ADVICE RECEIVED:
FINAL DIAGNOSIS:
MAY RETURN TO DUTY:
INSTRUCTIONS / REFERRAL:
Return ASAP if worsening in your condition.
PHYSICIAN SIGNATURE:
PATIENT SIGNATURE :
Republic of Panama
Date:
IN RECEIPT OF DISCHARGE INSTRUCTIONS)
None