Chest Wall Injury
Age: years old
Gender:
HISTORY:
Presents with a chest pain following an injury ago
Mecanism of injury:
Location is:
Radiation to
Rated at / 10
Described as
Pattern
Worsening factors:
Alleviating factors: ,
Occupation:
Associated symptoms: *Try using right-click for negatives*
, of phlegm
,
, episodes , ,
Contributing factors:
no history of: , ,
no use of:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Chest: on
Breasts: , ,
Abdomen: , , , , bowel sounds , ,
Skin: on
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
DDx: chest wall contusion, rib fracture, muscle strain, sternal fracture, thoracic spine fracture, pneumothorax, hemothorax, pulmonary contusion, myocardial contusion, traumatic aortic disruption, esophageal injury, diaphragmatic injury, anxiety/panic disorder related to trauma
PLAN:
Investigations:
- Chest X-ray
- ECG
- Troponin
Treatments:
-
-
-
- Activity as tolerated
- Respiratory exercises
Further care:
- Referral to ER
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as shortness of breath
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: