Secondary Survey Note

**Secondary Survey:** **AMPLE History:** Allergies: [List allergies if known] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note. If unknown, write "unknown". If no known drug allergies, write "NKDA".) Medications: [Current medications including anticoagulants, insulin, steroids] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note. If unknown, write "unknown".) Past Medical History: [Significant medical conditions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note. If unknown, write "unknown". If none, write "Nil Significant".) Last Meal: [Time and contents of last meal] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note. If unknown, write "unknown".) Events Leading to Injury: [Details of injury circumstances from patient, family, or EMS] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note. If unknown, write "unknown".) **Physical Exam:** Head & Face: [Scalp injuries, facial fractures, haemotympanum, septal haematoma, facial asymmetry, Battle's sign] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Cervical Spine: [Tenderness, need for imaging] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Thorax: [Rib fractures, lung auscultation findings, heart sounds] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. If heart sounds are dual with no murmurs, write "HSDNM".) Abdomen/Pelvis: [Tenderness, guarding, rebound, bruising, pelvic stability status, and whether pelvic binder is in situ] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Extremities: [Deformities, pulse presence, sensory and motor function, neurovascular status of each limb, and whether gross sensation is intact in each limb] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Back: [Spinous process tenderness, step-offs, large bruises, wounds, or lacerations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Digital Rectal Exam: [Findings if performed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Only document if indicated before urinary catheter placement.) Investigations: Blood results: [Laboratory values with specific parameters and results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Venous blood gas results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Chest X-ray findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Pelvic X-ray findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) CT Trauma: [CT trauma scan findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Out of binder pelvic X-ray findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Assessment & Plan:** Summary of Findings: [Key injuries, Glasgow Coma Scale, haemodynamic status] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. Write initial summary on one line, then list all subsequent findings as bullet points.) Interventions Performed: [Airway management, chest tube placement, fluid resuscitation, blood products administered] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) Pending Procedures & Investigations: [Procedures yet to be completed or investigations pending] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) Disposition: [ICU admission, operating room, imaging, interventional radiology] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) Consultations: [List of specialists consulted] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) (Timestamp all major interventions and changes in patient condition. Only summarise and reformat information provided in the transcript, contextual notes, or clinical note. Do not generate new diagnoses, assessments, treatment plans, or clinical recommendations. Do not invent patient details, examination findings, vital signs, investigation results, or professional judgements. If information for a section is not mentioned, follow the specific instruction for that section: either omit section entirely or write the specified default text as indicated. Write in a clear, professional emergency medicine clinical tone using standard medical abbreviations.)