Emergency Trauma Assessment (Secondary Survey Notes)

[Patient Age] [Patient Gender, "M" for male, "F" for female, or "X" for non-binary] [Transport Method: "BIBA" if brought in by ambulance, or "PW" if presents via other means] [Brief one-line summary of presentation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) Secondary Survey: AMPLE History: - Allergies: [List any known allergies. If unknown, write "unknown" or "NKDA" if no known drug allergy.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) - Medications: [List medications such as anticoagulants, insulin, steroids, etc. If unknown, write "unknown."] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) - Past Medical History: [Include significant past medical conditions, if unknown, write "unknown." If none, write "Nil Significant."] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) - Last Meal: [Time and contents of last meal. If unknown, write "unknown."] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) - Events Leading to Injury: [Details about the injury or trauma as reported by the patient, family, or EMS. If unknown, write "unknown."] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) Physical Exam: - Head & Face: [Details of scalp injuries, facial fractures, hemotympanum, septal hematoma, facial asymmetry, battle sign.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) - Cervical Spine: [Examine for tenderness, need for imaging or immobilization.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) - Thorax: [Details of rib fractures, lung auscultation, heart sounds. If heart sounds are dual with no murmurs, write "HSDNM" (Heart Sounds Dual No Murmurs).] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) - Abdomen/Pelvis: [Examine for tenderness, guarding, rebound tenderness, bruising. Also, note if the pelvis is stable or unstable, and if a pelvic binder is in situ.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) - Extremities: [Examine for deformities, pulse presence, sensory and motor function. Include neurovascular status of each limb, and if gross sensation is intact in each limb.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) - Back: [Check for spinous process tenderness, step-offs, large bruises, or any wounds/lacerations.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) - Digital Rectal Exam: [Only include if indicated before urinary catheter placement.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) Assessment & Plan: - Summary of Findings: [Summarize key injuries, GCS (Glasgow Coma Scale), hemodynamic status, and significant physical findings.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) - Interventions Performed: [Detail any interventions performed, such as airway management, chest tube placement, fluid resuscitation, administration of blood products, etc.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) - Pending Procedures & Investigations: [List any procedures or investigations that are pending, such as CT scans, X-rays, lab results, etc.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) - Disposition: [Specify patient disposition, such as ICU admission, operating room (OR) for surgery, imaging, or interventional radiology.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) - Consultations: [List any specialists consulted, such as trauma surgery, neurosurgery, orthopedic surgery, etc.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise, omit completely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in your output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript. Ensure clinical terminology, measurement units, and other regional or institutional practices are consistent with the electronic system being used, and adjust for the system’s standards, e.g., metric vs. imperial units.)