Case 4 - 25 yo M after MVA Flashcards
1
Q
Information gathering
A
CC Onset Severity Context Alleviating and exacerbating factors Cough, sputum production Fever, chills Other injuries Head trauma Discharge from ears, nose or mouth (clear or bloody) LOC Convulsions HA Change in vision Confusion, memory loss, change in personality Weakness or numbness in extremities Heart symptoms (palpitations) Abdominal pain N/V or stiff neck Last meal/drink Under the influence of alcohol or durgs Pain on urination Any prior events PMHx PSHx FHx Social Hx (occupation, tobacco, alcohol, drug use) Current medications Drug allergies
2
Q
Physical examination
A
Head and neck exam
CV exam
Pulmonary exam
Abdominal exam (including palpation for splenomegaly)
Neurologic exam (mental status, CNs, gross motor)
Skin exam (for lacerations)
3
Q
Closure
A
Observe you closely
Observe breathing and make sure you’re getting enough oxygen
Run a few tests and take some imaging studies of chest
Give you something for the pain
Do you have any questions?
4
Q
Differential diagnosis
A
Pneumothorax
Hemothorax
Pneumonia
5
Q
Diagnostic work-up
A
CXR Sputum and blood Gram stain and culture Urine toxicology and blood alcohol level FAST scan Pulse oximetry
