Scribe BC - Trauma note

**IDENTIFICATION:** - John Smith, 35-year-old male **MECHANISM OF INJURY:** - Motor vehicle collision. **PREHOSPITAL COURSE:** - Patient involved in a motor vehicle collision at 14:00. Patient was found to be unresponsive at the scene. Paramedics initiated advanced life support measures including airway management and intravenous access. Patient was given 1L of crystalloid and transported to the hospital. **PRIMARY SURVEY:** - General appearance: Unresponsive, pale, diaphoretic. - Vital signs: BP 80/40 mmHg, HR 130 bpm, RR 28 breaths/min, SpO2 92% on 15L NRB. - Airway assessment: Airway patent, requiring oropharyngeal suctioning of blood. - Breathing assessment: Bilateral chest rise and fall, decreased breath sounds on the left side, chest wall crepitus. - Circulation assessment: Active bleeding from a laceration on the left leg, weak peripheral pulses. - Disability assessment: GCS 3 (E1, V1, M1), pupils 3mm and sluggishly reactive to light. - Bedside ultrasound assessment: FAST exam positive for free fluid in the abdomen. **SECONDARY SURVEY:** - Head, eyes, ears, nose, mouth assessment: Significant facial trauma with multiple lacerations and swelling. - Neck assessment: Cervical spine tenderness noted. - Cardiac assessment: Tachycardia, regular rhythm. - Respiratory assessment: Decreased breath sounds on the left side. - Chest assessment: Chest wall crepitus, ecchymosis over the left chest. - Abdomen assessment: Abdominal tenderness and distension. - Extremities and musculoskeletal assessment: Open fracture of the left femur, multiple lacerations. - Back assessment: Tenderness to palpation over the thoracic spine. **RESUSITATION:** - Patient received 2L of crystalloid, blood products, and was intubated. A chest tube was inserted on the left side for a suspected hemothorax. The patient was transferred to the operating room for further management. **HOME MEDICATIONS:** - See Pharmanet for medication list. **INVESTIGATIONS:** - Chest X-ray: Left-sided hemothorax and multiple rib fractures. - Pelvis X-ray: Stable pelvis. - CT scan of the head, chest, abdomen, and pelvis: Left-sided hemothorax, multiple rib fractures, splenic laceration, and a left femur fracture. **CONSULTANTS:** - 15:30 - Trauma surgery consulted. Discussed the need for emergent laparotomy and orthopedic consultation. **PROCEDURES:** - 15:15 - Chest tube insertion on the left side. **SUMMARY OF INJURIES:** - Left-sided hemothorax - Multiple rib fractures - Splenic laceration - Left femur fracture - Facial lacerations - Thoracic spine tenderness **IMPRESSION / PLAN:** - Polytrauma secondary to motor vehicle collision. Patient requires emergent laparotomy for splenic injury and orthopedic intervention for femur fracture. Continued resuscitation and monitoring in the ICU. - Follow-up: Patient will be admitted to the ICU for ongoing monitoring and management. Orthopedics and general surgery will be following the patient. **RESUSCITATION TIME:** - 14:00 to 15:00 - Total time: 60 minutes "The patient provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and any associated privacy and security risks"