A 47-year-old male driver was injured in a moderate speed lateral impact to the driver’s side of the auto. Upon examination: LOC – alert but confused and anxious Airway – patent Breathing – adequate with good chest rise SpO2 – 96% on ambient air Circulation – pulse deficit (left arm); skin – pale, cool, diaphoretic; no external bleeding noted Signs of injury found during secondary assessment: bruising over sternum, complaint of chest pain, increased chest pain upon palpation, breath sound equal bilaterally. Vital signs: unable to obtain vital signs on the left side; right side – BP – 90/60; pulse – 130, weak and regular; and respirations – 24, strong and regular Treatment? Rapid transport to level 1 trauma center. Reassessment performed every 5 minutes.
A 47-year-old male driver was injured in a moderate speed lateral impact to the driver’s side of the auto. Upon examination: LOC – alert but confused and anxious Airway – patent Breathing – adequate with good chest rise SpO2 – 96% on ambient air Circulation – pulse deficit (left arm); skin – pale, cool, diaphoretic; no external bleeding noted Signs of injury found during secondary assessment: bruising over sternum, complaint of chest pain, increased chest pain upon palpation, breath sound equal bilaterally. Vital signs: unable to obtain vital signs on the left side; right side – BP – 90/60; pulse – 130, weak and regular; and respirations – 24, strong and regular Treatment? Rapid transport to level 1 trauma center. Reassessment performed every 5 minutes.
Essentials Health Info Management Principles/Practices
4th Edition
ISBN:9780357191651
Author:Bowie
Publisher:Bowie
Chapter6: Patient Record Documentation Guidelines: Inpatient, Outpatient, And Physician Office
Section6.3: Hospital Inpatient Record— Clinical Data
Problem 6E
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A 47-year-old male driver was injured in a moderate speed lateral impact to the driver’s side of the auto.
Upon examination:
LOC – alert but confused and anxious
Airway – patent
Breathing – adequate with good chest rise
SpO2 – 96% on ambient air
Circulation – pulse deficit (left arm); skin – pale, cool, diaphoretic; no external bleeding noted
Signs of injury found during secondary assessment: bruising over sternum, complaint of chest pain, increased chest pain upon palpation, breath sound equal bilaterally.
Vital signs: unable to obtain vital signs on the left side; right side – BP – 90/60; pulse – 130, weak and regular; and respirations – 24, strong and regular
Treatment?
Rapid transport to level 1 trauma center. Reassessment performed every 5 minutes.
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