Patient Age: 34, Patient Gender: M, BIBA, Patient was involved in a high-speed motor vehicle collision.
Secondary Survey:
AMPLE History:
- Allergies: NKDA
- Medications: Unknown
- Past Medical History: Nil Significant
- Last Meal: Unknown
- Events Leading to Injury: Patient was driving when another vehicle collided with the driver's side.
Physical Exam:
- Head & Face: Laceration on the scalp, facial asymmetry noted
- Cervical Spine: Tenderness present, imaging required
- Thorax: Rib fractures on the left side, HSDNM
- Abdomen/Pelvis: Tenderness in the lower abdomen, pelvis stable
- Extremities: Deformity in the right leg, pulses present, gross sensation intact
- Back: No spinous process tenderness, large bruise on the lower back
- Digital Rectal Exam: Not indicated
Assessment & Plan
- Summary of Findings: GCS 14, hemodynamically stable, multiple rib fractures, right leg fracture
- Interventions Performed: Airway management, fluid resuscitation
- Pending Procedures & Investigations: CT scan of the cervical spine, X-ray of the right leg
- Disposition: ICU admission
- Consultations: Trauma surgery, orthopaedics
Timestamp: 1 November 2024, 14:30 - Airway management initiated
Timestamp: 1 November 2024, 15:00 - Fluid resuscitation started
[Patent Age] [Patient Gender, "M" for male, "F" for Female or "X" for non-binary] ["BIBA" if brought in by ambulance, or "PW" if presents via other means] [One line summary of presentation]
Secondary Survey:
AMPLE History:
- Allergies: [List if known, write "unknown" if not known or "NKDA" if no known drug allergy]
- Medications: [Include anticoagulants, insulin, steroids, etc. if unknown write "unknown"]
- Past Medical History: [Include significant conditions, if unknown write "unknown", If none write "Nil Significant"]
- Last Meal: [Time and contents, if unknown write "unknown"]
- Events Leading to Injury: [Details from patient, family, or EMS, if unknown write "unknown"]
Physical Exam:
- Head & Face: [Scalp injuries, facial fractures, hemotympanum, septal hematoma, facial asymmetry, battle sign]
- Cervical Spine: [Tenderness, need for imaging]
- Thorax: [Rib fractures, lung auscultation, heart sounds, if heart sounds are dual no murmurs write "HSDNM"]
- Abdomen/Pelvis: [Tenderness, guarding, rebound, bruising, if the pelvis is stable/unstable and if a pelvic binder is in situ]
- Extremities: [Deformities, pulse presence, sensory/motor function, Include neurovascular status of each limb and if gross sensation is intact in each limb]
- Back: [Spinous process tenderness, step-offs, any large bruises, wounds or lacerations]
- Digital Rectal Exam: [Only if indicated before urinary catheter placement]
Assessment & Plan
- Summary of Findings* [Summarize key injuries, GCS, hemodynamic status]
- Interventions Performed: [Airway management, chest tube placement, fluid resuscitation, blood products, etc.]
- Pending Procedures & Investigations: [Any procedures yet to be completed or investigations pending]
- Disposition: [ICU admission, OR, imaging, interventional radiology]
- Consultations: [List specialists consulted, e.g., trauma surgery, neurosurgery]
(Timestamp all major interventions and changes in patient condition. Use as many lines, paragraphs, or bullet points as needed to comprehensively document the nursing care plan. Never come up with your own patient details, assessment, plan, interventions, or evaluation—use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, do not state that the information has not been explicitly mentioned in your output—just leave the relevant placeholder blank or omit it completely.)
