Emergency Trauma Assessment (Secondary Survey Notes)

Patient Age: 34, Patient Gender: M, BIBA, Patient was involved in a high-speed motor vehicle collision. Secondary Survey: AMPLE History: - Allergies: NKDA - Medications: Unknown - Past Medical History: Nil Significant - Last Meal: Unknown - Events Leading to Injury: Patient was driving when another vehicle collided with the driver's side. Physical Exam: - Head & Face: Laceration on the scalp, facial asymmetry noted - Cervical Spine: Tenderness present, imaging required - Thorax: Rib fractures on the left side, HSDNM - Abdomen/Pelvis: Tenderness in the lower abdomen, pelvis stable - Extremities: Deformity in the right leg, pulses present, gross sensation intact - Back: No spinous process tenderness, large bruise on the lower back - Digital Rectal Exam: Not indicated Assessment & Plan - Summary of Findings: GCS 14, hemodynamically stable, multiple rib fractures, right leg fracture - Interventions Performed: Airway management, fluid resuscitation - Pending Procedures & Investigations: CT scan of the cervical spine, X-ray of the right leg - Disposition: ICU admission - Consultations: Trauma surgery, orthopaedics Timestamp: 1 November 2024, 14:30 - Airway management initiated Timestamp: 1 November 2024, 15:00 - Fluid resuscitation started