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MDM - MVC

DDX - MVC

Blunt trauma, contusion, fracture, intracranial injury, spinal injury, intrathoracic injury, cardiac contusion, pneumothorax, hemothorax, intra-abdominal injury, solid organ injury, hemorrhage, vascular injury

MVC Low Risk Mechanism, No Scan

-VS Unremarkable. 
-ABCs intact(Primary survey intact)
-On secondary survey, there were no findings to suggest serious injury to the head, neck, chest, abdomen, pelvis, or extremities. The patent’s cspine was cleared clinically based on Canadian C-spine guidelines. Per Canadian CT-head guidelines, the patient is low risk for serious intracranial injury. They are overall well appearing. No seatbelt sign to neck/chest, or abdomen. No abnormal cardiopulmonary findings. No abdominal tenderness and no evidence of surgical abdomen or peritonitis. No neurologic deficits. Overall, there is no evidence of serious trauma. Bedside E-FAST exam was negative x 6. The patient is able to ambulate with minimal pain. At this point, there is no indication for further imaging or lab workup as there is no evidence of life threatening or surgical process. Based on exam and history, they can safely be discharged home. This was discussed with the patient and they feel comfortable going home. Return precautions were extensively discussed and they understand to return for any worsening symptoms or failure to improve.
-Writing prescription for anti-inflammatory meds

MVC High Risk Mechanism, Stable, Pan Scan

-VS [stable]
-Trauma team assembled
-ABCs intact(Primary survey intact)
-MVC with a dangerous mechanism and outward signs of trauma on physical exam. Initial vitals without tachycardia, hypotension, or hypoxia. Cannot clear C-collar at this point. E-FAST neg x 6. Bedside CXR/PXR without gross abnormality. Given dangerous mechanism and complaints, trauma pan-scans are indicated as well as trauma labs. 

Re-exam

Imaging unremarkable. No evidence of acute traumatic or surgical injury. Patient states they are feeling much better after medication although still somewhat sore which is to be expected. On repeat exam, no concerning findings. No abnormal cardiopulmonary findings. Abdomen still nontender. The patient has ambulated without difficulty. Stable for discharge. They feel comfortable going home. return precautions were extensively discussed and they understand to return for any worsening symptoms or failure to improve. Giving prescription for pain medication.
  • Last updated May 31, 2023

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