EM Trauma note

ER Trauma Note Time of Assessment: 14:30 Patient: 45-year-old female --- HPI Patient presents after a motor vehicle collision (MVC) as a restrained driver. She reports being struck from the side at an intersection. Airbags deployed. She denies loss of consciousness at the scene or during transport. She experienced a brief period of confusion immediately after the impact but reports no current amnesia. She complains of neck pain, left-sided chest pain, and abdominal discomfort. No vomiting reported. --- AMPLE Allergies: Penicillin (hives), Ibuprofen (anaphylaxis) Medications: Lisinopril 10mg OD, Metformin 500mg BD Past Medical History: Hypertension, Type 2 Diabetes Mellitus, Cholecystectomy (2010) Last Meal: 10:00, toast and coffee Events Leading to Presentation: Patient was driving when her vehicle was T-boned at an intersection. EMS arrived within 10 minutes, immobilised her with a cervical collar and long board, and transported her to the emergency department. No pre-hospital interventions were performed beyond immobilisation. --- Primary Survey (ABCDE) A - Airway Airway patent and protected C-spine precautions maintained with hard collar B - Breathing Respiratory rate: 18 breaths/min Oxygen saturation: 98% on room air Breath sounds clear bilaterally with good air entry Chest wall non-tender, no crepitus, no paradoxical movement No oxygen or ventilatory support in use C - Circulation Heart rate: 92 bpm Blood pressure: 130/85 mmHg Temperature: 36.8°C Skin warm and dry, capillary refill <2 seconds No active external bleeding IV access: 18G cannula left antecubital fossa, 1L Hartmann's solution administered en route Abdomen soft but tender in left upper quadrant Pelvis stable to manual compression D - Disability Glasgow Coma Scale: E4 V5 M6 (GCS 15) Blood glucose level: 6.8 mmol/L Pupils equal, round, and reactive to light (3mm bilaterally) Motor: All four limbs strength 5/5, no focal neurological deficits Sensory: Intact to light touch in all dermatomes E - Exposure and Environment Bruising noted over left anterior chest wall (seatbelt sign) Left flank contusion No obvious deformities or open fractures Patient covered with warm blankets to maintain normothermia --- Secondary Survey Head and Neck: Mild tenderness to palpation of cervical spine C4-C6, no step-offs or deformities. No active bleeding or lacerations. Full range of motion of neck limited by pain. Chest: Left anterior chest wall tenderness, particularly over ribs 5-7. Bruising noted along seatbelt distribution. No crepitus or instability. Abdomen: Tenderness in the left upper quadrant. No distension or ecchymosis noted. Bowel sounds present. Pelvis: Stable to manual compression. No tenderness over symphysis pubis or iliac crests. Back: No step-offs or midline tenderness on log-roll examination. Extremities: Full range of motion in all limbs. No deformities or swelling. Distal pulses present and strong in all limbs. No neurovascular compromise. --- Investigations Ordered Labs: Full blood count, venous blood gas, INR, creatinine, electrolytes, type and screen, liver function tests, amylase, lipase Imaging: FAST ultrasound (negative for free fluid), CT cervical spine, CT chest, CT abdomen and pelvis ECG: Performed, sinus rhythm at 90 bpm, no acute ischemic changes Urine: Urine dipstick (negative for blood/protein), pregnancy test (negative) --- Working Impression 45-year-old female involved in high-speed MVC presenting with poly-trauma. Primary concerns include possible cervical spine injury, blunt chest trauma with potential rib fractures, and blunt abdominal trauma with suspected splenic injury given left upper quadrant tenderness. Patient is haemodynamically stable at present. --- Plan Continuous vital sign monitoring Pain control: IV Fentanyl 50 mcg PRN, IV Paracetamol 1g QDS Review CT imaging as soon as available Consult General Surgery for abdominal trauma Consult Orthopaedics for potential cervical spine injury pending CT results Administer Tetanus booster (last dose unknown) Admit to Trauma ward for ongoing observation and management