Secondary Survey Note

Emergency Medicine Registrar **Secondary Survey:** **AMPLE History:** Allergies: Penicillin (rash) Medications: Lisinopril 10mg OD, Metformin 500mg BD Past Medical History: Type 2 Diabetes, Hypertension Last Meal: 08:00, toast and coffee Events Leading to Injury: Patient states they were riding their bicycle and were struck by a car turning left at an intersection, causing them to be thrown from the bike and land on their left side. **Physical Exam:** Head & Face: No scalp injuries, no facial fractures noted. Pupils equal and reactive to light. No haemotympanum, no septal haematoma. Mild periorbital bruising on the left. Cervical Spine: Mild tenderness to palpation over C5-C6 spinous processes. No step-offs. Patient able to actively rotate head within pain limits. Imaging pending. Thorax: Crepitus noted over left 4th and 5th ribs anteriorly. Lung auscultation reveals diminished breath sounds in the left lower lobe. HSDNM. Abdomen/Pelvis: Mild tenderness to deep palpation in the left upper quadrant, no guarding or rebound. No bruising. Pelvis stable to compression. Pelvic binder in situ. Extremities: Left forearm with obvious deformity, suspected fracture. Peripheral pulses palpable (2+) in all four limbs. Sensory and motor function intact in right upper and lower limbs. Left upper limb with decreased sensation distal to deformity, unable to assess motor fully due to pain. Gross sensation intact in right upper and lower limbs, impaired in left upper limb, intact in left lower limb. Back: No spinous process tenderness or step-offs. Large contusion noted over left scapula. No open wounds or lacerations. Digital Rectal Exam: Normal sphincter tone, no blood on glove. Performed prior to urinary catheter insertion. Investigations: Blood results: Hb: 11.2 g/dL, WCC: 12.5 x 10^9/L, Platelets: 250 x 10^9/L, Creatinine: 90 µmol/L, Glucose: 8.5 mmol/L Venous blood gas results: pH 7.32, pCO2 5.0 kPa, pO2 8.5 kPa, HCO3 20 mmol/L, Lactate 3.2 mmol/L Chest X-ray findings: Left 4th and 5th rib fractures, small left pleural effusion. Pelvic X-ray findings: No fracture or instability detected. CT Trauma: Left forearm distal radius and ulna fractures. Small left pneumothorax. Small amount of free fluid in the abdomen. No significant intracranial injury. Out of binder pelvic X-ray findings: N/A **Assessment & Plan:** Summary of Findings: Polytrauma following MVC, GCS 15, haemodynamically stable. * Left forearm fracture * Left rib fractures (4th, 5th) * Small left pneumothorax * Mild left upper quadrant abdominal tenderness, likely superficial bruising. * Cervical spine tenderness, pending imaging. Interventions Performed: * Cervical collar applied at scene by EMS. * Pelvic binder applied by EMS. * IV access x2 (left AC, right hand). * Analgesia administered (Fentanyl 50 mcg IV). * Chest drain inserted for left pneumothorax. Pending Procedures & Investigations: * Orthopaedic review for left forearm fractures. * Neurosurgical review for C-spine assessment. * Abdominal ultrasound to further investigate free fluid. Disposition: * Admission to ICU for close monitoring post-chest drain insertion. * Transfer to Operating Room for left forearm fracture fixation after stabilisation. Consultations: * Orthopaedics * General Surgery * Neurosurgery