Motor Vehicule Accident

Age: ‍ years old

Gender: ‍malefemale



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



Symptoms include:

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍confusion

‍loss of consciousness

‍dizziness

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍chest pain, ‍retrosternal, ‍aching, ‍on exertionat restwith deep breath, ‍mild

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍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

Tdap vaccination: ‍up-to-dateincompleteunvaccinated





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Head: ‍normocephalicatraumatic, scalp ‍normalrashlesion

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal, cornea ‍intact, ‍PERRL, extraocular movements ‍intact, OD 20/‍, OS 20/‍

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Nose: ‍clear, discharge ‍clear, ‍

Throat: ‍normal, ‍erythema, ‍exudate, ‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Chest: ‍tenderness on ‍rightleft ‍

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Anorectal: DRE ‍normal, prostate ‍normal, ‍blood, ‍mass, anus ‍

Pelvic: external genitalia ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍cervical motion tenderness

Genital: penis ‍normal, testes and epididymis ‍normal, ‍inguinal hernia

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Cervical spine: ‍tenderness on ‍, range of motion ‍fulllimited

Shoulder: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Elbow: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Wrist: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Hand: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Lumbar spine: ‍tenderness on ‍, range of motion ‍fulllimited

Hip: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Knee: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Ankle: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Foot: ‍rightleft: ‍tenderness on ‍, range of motion ‍fulllimited

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady





ASSESSMENT:

‍Polytraumatized ‍likelysuspectedpossible

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: ‍cervical spine, ‍chest, ‍pelvis

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

Treatments:

- ‍Analgesics

- ‍NSAIDs

- ‍Opioids

- Physical therapy

- ‍Leave of absenceLight duty for ‍ ‍daysweeks

Further care:

- 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