Emergency Trauma Assessment (Primary Survey Notes)

Patient Information: - [Patient name] (Include the full name of the patient as mentioned in the clinical notes. Ensure accuracy. Omit if not mentioned.) - [Age] (Include the age of the patient as per the clinical notes. If not specified, omit this section.) - [Sex] (Include the sex (male/female) of the patient as per the clinical notes. Specify if neutered or intact if mentioned, and omit this section if not specified.) - [Weight] (Include weight of the patient if explicitly mentioned in the clinical notes. If not provided, omit this section.) Date of Examination: [DD/MM/YYYY] (Include the date the trauma assessment was conducted. Omit if not mentioned.) Reason for Trauma Assessment: [Describe the presenting trauma or incident] (Include a detailed description of the incident, such as fall, vehicle collision, blunt force injury, or assault. Mention the mechanism of injury if provided, e.g., head trauma, chest injury, etc. Only include if explicitly mentioned in the clinical notes or transcript. If not mentioned, omit this section.) Primary Survey (ABCDE Assessment) 1. Airway: - [Airway status] (Describe the status of the airway, including whether the airway is patent or if any obstruction is present. Include any intervention or techniques used to maintain airway, e.g., endotracheal tube placement, oral airway, etc. If no issues, state “airway patent.”) - [Intervention performed] (Include details of any airway interventions performed, such as intubation or suction. Omit if no intervention is mentioned.) 2. Breathing: - [Respiratory rate] (Include the respiratory rate if explicitly mentioned, e.g., 18 breaths per minute. If not mentioned, omit this section.) - [Oxygen saturation] (Include the oxygen saturation if explicitly mentioned (SpO2), e.g., 95%. If not mentioned, omit this section.) - [Breathing sounds] (Include any findings related to lung sounds, such as clear, wheezes, crackles, or absence of breath sounds. If no details are provided, omit this section.) - [Intervention performed] (Include if any interventions were performed to assist with breathing, such as oxygen supplementation, mechanical ventilation, or chest tube insertion. Omit if no intervention is mentioned.) 3. Circulation: - [Heart rate] (Include the heart rate if explicitly mentioned, e.g., 100 bpm. If not specified, omit this section.) - [Blood pressure] (Include blood pressure if explicitly mentioned. If not provided, omit this section.) - [Capillary refill time] (Include the capillary refill time if explicitly mentioned. If not, omit this section.) - [Perfusion status] (Include any description of the perfusion status, such as adequate or poor perfusion. If no details provided, omit.) - [Intervention performed] (Include any interventions such as IV fluid resuscitation, blood transfusions, or vasopressors. Omit if no intervention is mentioned.) 4. Disability (Neurological): - [Glasgow Coma Scale (GCS)] (Include the GCS score if explicitly mentioned, specifying the eye, verbal, and motor responses. If not mentioned, omit this section.) - [Pupillary response] (Include any details regarding pupillary response to light, such as “reactive,” “non-reactive,” or “unequal pupils.” If not mentioned, omit.) - [Level of consciousness] (Describe the patient’s level of consciousness, such as alert, confused, lethargic, or unconscious. If not explicitly mentioned, omit this section.) 5. Exposure/Environment: - [Temperature] (Include body temperature if explicitly mentioned, e.g., 37.5°C. If not mentioned, omit this section.) - [Skin condition] (Describe the skin condition, including any signs of trauma such as abrasions, lacerations, bruises, burns, or deformities. Mention if the skin is warm and dry or cool and clammy. If not mentioned, omit this section.) - [Bleeding] (Note any visible bleeding, the location, and severity. Include whether it’s controlled or if further intervention is needed. If no bleeding is mentioned, omit this section.) Secondary Survey (Head to Toe Assessment): [Brief summary of findings based on detailed physical exam] (Include a summary of any additional findings beyond the primary survey, including any head-to-toe assessments, such as fractures, dislocations, or soft tissue injuries. If not mentioned, omit this section.) Diagnostic Testing: [Include any diagnostic testing performed, such as X-rays, CT scans, or lab results. Only include if explicitly mentioned in the transcript or clinical notes. If no testing is mentioned, omit this section.] Plan and Recommendations: [Suggested interventions, follow-up actions, or treatment plans] (Include suggested treatments, interventions, or follow-up actions as explicitly mentioned. For example, “intubate and stabilise for surgery,” “order CT scan for further evaluation,” or “IV fluids and observation for 24 hours.” Omit if not explicitly mentioned.) Report prepared by: [Clinician's Name] Date: [DD/MM/YYYY] (Include if explicitly mentioned. Omit if not provided.) (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. Ensure measurement units and clinical terminology are consistent with regional or institutional guidelines, and adjust based on the electronic system being used, such as the use of metric vs. imperial units, as needed.)