This is a 40 year old male who presents on [date] as a P2 after non-helmeted motorcycle vs car.
Trauma bay course:
GCS: 15
Blood/fluids: 1L LR
Primary survey: unremarkable
Secondary survey: right ptx
Procedures: right open chest tube
Injuries (by system)
Head:
SAH
Spine:
Chest:
right ptx
Intraperitoneal:
Retroperitoneal:
MSK:
road rash right shoulder, fractured left thumb
Consults:
NSGY
Ortho
# SAH
GCS15, neuro intact
NSGY following
- ticu admission
- repeat 24hrs
- q1 neuro exams
# right ptx
CT to -20
daily CXR
# road rash
Bacitracin BID
# fracture left thumb
Ortho consulted
- no intervention
- follow up outpatient 2 weeks after discharge. Call 867-5309 for apt.
# HTN
On metoprolol at home
hold metoprolol for now
Diet: Regular
IVF: None
Pain: ATC tylenol, PRN morphine
GI ppx: none
DVT ppx: LVX
Activity: Up ad lib
Dispo: Floor
Anticipated discharge dispo: Home
Service: Trauma
Author: Garrett Skinner