DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: ATV accident.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old who was driving an ATV. He went up over a hill and then the bike flipped back. He was thrown from the vehicle. The patient was wearing a helmet and chest protector. He may have hit his head, but there was no loss of consciousness. The patient was apparently initially, per EMS, complaining that his head hurt.
When we examined the patient, he was really having no pain whatsoever. He is kind of eager to get the cervical collar on and was placed pre-hospital by EMS. Pre-hospital, the patient was put in C-spine precautions. He had stable vital signs and a normal fingerstick blood sugar of 130.
The patient denies chest pain, difficulty breathing, abdominal pain or nausea. There is just one area under his chin where he thinks the chin strapped to his helmet sort of dug into him. His teeth are lined properly. There is no dental pain.
PAST MEDICAL HISTORY: Asthma.
PAST SURGICAL HISTORY: Tonsillectomy.
ALLERGIES: PENICILLIN.
MEDICATIONS: None.
REVIEW OF SYSTEMS: All other systems are reviewed and are negative.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is well developed, well nourished, well appearing, pleasant.
VITAL SIGNS: Blood pressure 142/96, pulse 88, respirations 20, temperature 96.2, and O2 saturation 100% on 2 liters.
HEENT: Normocephalic. Pupils are equal and round. Extraocular movements are intact. Oropharynx is clear. The teeth are lined properly. The midface is stable. The patient has an abrasion under the chin, which is superficial without soft tissue swelling.
NECK: There is no midline posterior tenderness, step-offs or crepitus. The patient freely moves around his neck without any pain or difficulty.
CHEST: Symmetrical chest wall rise, nontender, no crepitus.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
LUNGS: Clear to auscultation and symmetric bilaterally. No rales, rhonchi or wheezes.
ABDOMEN: Soft, nontender, obese for age. Positive bowel sounds. No mass.
BACK: No midline tenderness. No CVA tenderness.
EXTREMITIES: No cyanosis, clubbing or edema. Full, nontender range of motion in all extremities.
NEUROLOGIC: Awake, alert, and oriented. GCS 15.
SKIN: Warm, dry, and intact.
ASSESSMENT: Multiple blunt traumas, status post motor vehicle accident with some abrasions on his chin, rule out acute traumatic injury.
DIAGNOSTIC DATA: X-ray of the C-spine, chest, abdomen and pelvis were performed. Per our interpretations, no fracture, no dislocation, no acute traumatic injury.
EMERGENCY DEPARTMENT COURSE: The patient was cleared clinically from C-spine precautions and looked well. He was given IV Toradol with pain relief, 15 mg.
IMPRESSION:
1. Multiple blunt traumas, status post motor vehicle accident.
2. Chin abrasion.
PLAN:
1. Prescription for ibuprofen syrup as needed.
2. Follow up with regular doctor.
3. Return for worsening symptoms.
DISPOSITION AND CONDITION: Discharged in stable condition.
