Motor Vehicule Accident

HISTORY:

Presents for a ‍traumamotor vehicle accident

Event: ‍, ‍ ‍minhoursdays ago

Impact: ‍frontright sideleft siderear at around ‍ ‍km/hmph

Patient: ‍driver, ‍seatbelt worn, ‍airbag deployed

Able to exit on their own: ‍yesno

‍headache

‍confusion

‍loss of consciousness

‍dizziness

‍nausea

‍vomiting

‍chest pain

‍abdominal pain

‍pelvic pain

‍neck pain

‍shoulder pain

‍arm pain

‍elbow pain

‍wrist pain

‍hand pain

‍hip pain

‍leg pain

‍knee pain

‍calf pain

‍ankle pain

‍foot pain

‍tingling

‍numbness

‍weakness



Medications: ‍none, ‍anticoagulants

Allergies: ‍NKDA

Past medical history: ‍unremarkable

Last meal: ‍ hours ago

Tetanus vaccination: ‍up-to-dateincompleteunvaccinated



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Head: ‍normocephalicatraumaticnormal scalprashlesion

Eyes: -R: ‍normal, -L: ‍normal, ‍

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍normal

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Chest: ‍tenderness on ‍rightleft ‍

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Pelvic: vulva ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍no cervical motion tenderness

Genital: ‍normal, testicles ‍normal, penis ‍normal

Skin: ‍no rash

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍

Cervical spine: ‍no tenderness on ‍, range of motion ‍fulllimited

Shoulder: ‍rightleft: ‍no tenderness on ‍, range of motion ‍fulllimited

Elbow: ‍rightleft: ‍no tenderness on ‍, range of motion ‍fulllimited

Wrist: ‍rightleft: ‍no tenderness on ‍, range of motion ‍fulllimited

Hand: ‍rightleft: ‍no tenderness on ‍, range of motion ‍fulllimited

Lumbar spine: ‍no tenderness on ‍, range of motion ‍fulllimited

Hip: ‍rightleft: ‍no tenderness on ‍, range of motion ‍fulllimited

Knee: ‍rightleft: ‍no tenderness on ‍, range of motion ‍fulllimited

Ankle: ‍rightleft: ‍no tenderness on ‍, range of motion ‍fulllimited

Foot: ‍rightleft: ‍no tenderness on ‍, range of motion ‍fulllimited

Neurologic: cranial nerves ‍normal, strength ‍5/5 throughout, sensation ‍normal, reflexes ‍2+ throughout, cerebellar function ‍normal, gait ‍stable



ASSESSMENT:

‍Polytraumatized ‍likelysuspectedpossible

DDx: ‍



PLAN:

- X-ray: ‍cervical spine, ‍chest, ‍pelvis

- CT scan: ‍head, ‍cervical spine, ‍thorax, ‍abdomen, ‍pelvis

- ‍Analgesics

- ‍NSAIDs

- ‍Opioids

- Physical therapy

- ‍Leave of absenceLight duty for ‍ ‍daysweeks

- Referral to orthopedic surgeon

- Referral to neurologist

- Referral to trauma surgeon

- Follow-up in ‍ ‍daysweeks

- Return if pain worsens, if new symptoms develop, or if symptoms do not improve with treatment