Car Crash
Age: years old
Gender:
HISTORY:
Presents for a
Event: , ago
Impact: at around
Patient: , ,
Able to exit on their own:
Symptoms include:
, , , ,
, episodes , ,
, , , ,
, , ,
Medications: ,
Allergies:
Past medical history:
Last meal: hours ago
Tdap vaccination:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Head: , scalp
Eyes: conjunctiva/sclera , lids/lashes , cornea , , extraocular movements , OD 20/, OS 20/
Ears: tympanic membranes , auditory canal on , hearing
Nose: , discharge ,
Throat: , , ,
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Chest: on
Abdomen: , , , , bowel sounds , ,
Anorectal: DRE , prostate , , , anus
Pelvic: external genitalia , vagina , cervix , uterus , adnexa ,
Genital: penis , testes and epididymis ,
Skin: on
Extremities: , , cap refill sec, pulses , ,
Cervical spine: on , range of motion
Shoulder: : on , range of motion
Elbow: : on , range of motion
Wrist: : on , range of motion
Hand: : on , range of motion
Lumbar spine: on , range of motion
Hip: : on , range of motion
Knee: : on , range of motion
Ankle: : on , range of motion
Foot: : on , range of motion
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
ASSESSMENT:
DDx: whiplash, concussion, cervical spine injury, thoracic spine injury, lumbar spine injury, seatbelt injury, airbag injury, skull fracture, intracranial hemorrhage, diffuse axonal injury, traumatic brain injury, rib fractures, internal organ injury, pneumothorax, hemothorax, abdominal trauma, pelvic fractures, urogenital injury, vascular injury, spinal cord injury, nerve root injury, muscle strain, ligament sprain, compartment syndrome, crush injury, burns from airbag deployment
PLAN:
Investigations:
- X-ray: , ,
- CT scan: , , , ,
Treatments:
-
-
-
- Physical therapy
- for
Further care:
- Referral to orthopedic surgeon
- Referral to neurologist
- Referral to trauma surgeon
- Follow-up in
- Return if pain worsens, if new symptoms develop, or if symptoms do not improve with treatment
HISTORY: EXAM: ASSESSMENT: PLAN: