Emergency Trauma Assessment (Secondary Survey Notes)

68 F BIBA presented after a fall down stairs, complaining of severe right hip pain. Secondary Survey: AMPLE History: - Allergies: Penicillin (rash) - Medications: Aspirin 81mg daily, Metformin 500mg BID - Past Medical History: Type 2 Diabetes Mellitus, Hypertension, Osteoarthritis - Last Meal: 18:00 (porridge and tea) on 31 October 2024 - Events Leading to Injury: Patient states she tripped on the top step and fell approximately 10 steps down, landing on her right side. Found by her daughter approximately 30 minutes later. Complains of immediate and severe right hip pain, unable to bear weight. Physical Exam: - Head & Face: No signs of trauma, pupils equal and reactive to light. No facial asymmetry or Battle sign. - Cervical Spine: No tenderness to palpation, full range of motion without pain. No step-offs. Immobilized with a rigid cervical collar upon arrival due to mechanism of injury, now cleared. - Thorax: Symmetrical chest wall movement, clear breath sounds bilaterally on auscultation. HSDNM. No obvious signs of rib fractures or flail chest. - Abdomen/Pelvis: Soft, non-tender to palpation in all four quadrants. No guarding or rebound tenderness. Pelvis appears stable on gentle compression, no crepitus. No pelvic binder in situ. - Extremities: Right lower limb externally rotated and shortened. Gross deformity noted over the right hip. Strong femoral, popliteal, dorsalis pedis, and posterior tibial pulses bilaterally. Sensory intact to light touch in all four limbs. Motor function intact in left lower limb and bilateral upper limbs. Unable to assess motor function in right lower limb due to pain. Gross sensation intact in all limbs. - Back: No spinous process tenderness or step-offs. No large bruises or lacerations. - Digital Rectal Exam: Normal tone, no blood, no masses. Performed prior to urinary catheter placement (Foley catheter placed, clear yellow urine output). Assessment & Plan: - Summary of Findings: 68-year-old female sustained a significant fall down stairs, resulting in a clinically obvious right hip fracture. GCS 15. Hemodynamically stable. Significant deformity and pain in the right hip. No other major traumatic injuries identified during secondary survey. - Interventions Performed: IV access established (2 large bore cannulae). 1L 0.9% Normal Saline administered. Oxygen via nasal cannulae. Pain controlled with IV Fentanyl 50mcg. Right hip immobilised with traction splint. Foley catheter placed. - Pending Procedures & Investigations: Right Hip X-ray (AP and lateral views), Pelvic X-ray. CT Head and C-spine (as per local trauma protocol due to age and mechanism). Bloods: FBC, U&Es, Coagulation screen, Group and Save. ECG. - Disposition: Admission to Orthopaedic ward for urgent surgical review and probable Open Reduction Internal Fixation (ORIF) of right hip fracture. - Consultations: Orthopaedic Surgery consulted, awaiting review. General Surgery consulted to rule out abdominal injury, cleared.