Diagnosis: Hypothermia ICD-Diagnosis for T.68 for ICD-10 (1997-)
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Diagnosis: Hypothermia ICD-diagnosis for T.68 for ICD-10 (1997-) Frostbite ICD-diagnosis for T.33.0-T35.7 for ICD-10 (1997-) Drowning ICD-diagnosis for T.75.1 for ICD-10 (1997-)
give diagnosis:______
Person-number:______Name:______
Address:______
Hospital:______
Accident site information
Date (year/month/day):______Time:______
Found outdoors, shere:______ indoors, where (ex. room with open window)______How long was the person incapacitated before they were found?______Outdoor temp: air:______oC if indoors:______oC water:______oC
Wind: ______m/s precipitation: ______mm Type (ex. rain, snow, wet snow):______
Clothing:______Hat:______Gloves:______Shoes:______Life vest:______
Status at accident site Core body temperature:______oC Temp taken (where?): oral rectal axillary ear other:______
For frostbite: Localization: Area:
Previous medical condition:______Alcohol intoxication: yes no describe:______Drug intox: yes no describe:______
Level of consciousness (GCS/RLS/describe): ______Pulse: ______BP: ______Resp rate:______Pupils: ______Reflexes: ______Muscle activity: shivering stiff Speech: distinct slurring no speech Coordination and balance: normal defective, desc describe:______TRANSPORT
Date (year/month/day):______time:______
Temperature i vehicle during transport, Time for transport Sled ______oC ______hours, minutes Ambulance ______oC ______hours, minutes Helicopter ______oC ______hours, minutes Airplane ______oC ______hours, minutes Other ______oC ______hours, minutes
Body core temperature when transport started: ______oC where measured: ______ended: ______oC where measured? ______
Status during transport
For Frostbite: Localization: Area?:
Level of consciousness GCS/RLS/describe): ______Pulse: ______BP: ______Resp rate:______Pupils: ______Reflexes: ______Muscle activity: shivering stiff Speech: distinct slurring no speech Coordination and balance: normal defective, Describe: ______Hospital/ward
Hospital:______Ward:______
A) Status at arrival When? Date:______Time:______Core body temperature: oral: ______oC esophageal: : ______oC axillary: ______oC ear: ______oC rectal: : ______oC other/where: ______oC
Level of consciousness (GCS/RLS/describe): ______Pulse: ______BP: ______Resp rate:______Pupils: ______Reflexes: ______Muscle activity: shivering stiff Speech: distinct slurring no speech Coordination and balance: normal defective, Describe: ______
Size of cold injury: Describe depth:______Describe area/size:______
Other injuries/describe? ______B) Laboratory results at admission EKG ______platelets ______Hb, leucocytes ______PT ______hematocrit ______aPTT ______sodium ______B-glucose ______potassium ______Krea ______Amylase ______
O2Hb Sat% ______Ethanol ______pO2 ______pCO2 ______other ______pH ______
C) X-ray findings Chest x-ray ______Skeletal ______CT ______Other ______
D) Rewarming Hypothermia/drowning Core body temerature at start: ______oC measured by: ______At finish: ______oC measured by:______
*Rewarming method passive, describe ______rewarming time:______ active, describe ______rewarming time: ______Cold injury/frostbite: Method, describe ______rewarming time: ______Flushing after ______min Teknetium scintiagraphy: yes no findings:______ Heart, describe (ex. arythmias, VF):______ Respiratory, describe (ex secretions, pulmonary edema)______ Neurological, describe (ex. seizures, deficits): ______ Bleeding, describe:______ Other, describe:______ Operations, describe:______
E) Rewarmings end Core body temperature, where :______oC Status when rewarming completed: Level of consciousness (GCS/RLS/describe): ______Pulse: ______BP: ______Resp rate:______Pupils: ______Reflexes: ______Muscle activity: shivering stiff Speech: distinct slurring no speech Coordination and balance: normal defective, Describe: ______Extent of cold injury/frostbite: Describe depth:______Desctrbe extent/area:______
Teknetium scintiagraphy: yes no findings:______ Heart, describe (ex. arythmias, VF):______ Respiratory, describe (ex secretions, pulmonary edema)______ Neurological, describe (ex. seizures, deficits): ______ Bleeding, describe:______ Other, describe:______ Operations/amputation, describe:______
F) Discharged from hospital When (year/month/day):______Season:______General status including: level of consciousness, neurological deficit, extent of cold injury/frostbite:______Follow up/return visit
When? How long after injury (year/month/day):______
General status including: level of consciousness, neurological deficit, extent of cold injury/frostbite______
Cold sensitivity, describe:______Impaired balance, describe:______Impaired walk, describe:______Quality of life:______Other:______