CASE 4 - MVA

Question 1

Do you think I am going to die?

Answer 1

Your condition raises concern and is obviously urgent.

We will start by taking some images of your chest.

Then, once we have a better idea of what is wrong, we can give you some medication to help you with your pain.

If there is air or blood around your lungs, there is a procedure we can perform to relieve the pressure.

We will be monitoring you very closely from this point on, and if you have any significant problems, we will be available to help.

Question 2

Specific questions to ask if trauma patient:

Answer 2

1. Context — how did it happen?
2. Other injuries besides main site.
3. Head trauma.
4. Discharge from ears — mouth — nose (clear or bloody).
5. LoC.
6. Convulsions.
7. Headache — Change in vision — confusion, memory loss, personality changes.
8. Weakness, numbness on extremities.
9. Nausea/vomiting and stiff neck.
10. Under the influence of alcohol?
11. Pain on urination.

Question 3

PEx:

Answer 3

1. HEENT — I.
2. CV — A.
3. Pulmonary — I + A + P + P.
4. Abdo — I + A + P (examined specifically for organomegaly such as splenomegaly).
5. Neuro — Mental status, CNs, gross motor.
6. Skin — Inspection for abrasions, lacerations, bruising.

Question 4

Closure:

Answer 4

1. Discuss initial diagnostic impressions.
2. Discuss initial management plans — F/U tests.
3. Ask if the SP had any other questions or concerns.

Question 5

Sample closure:

Answer 5

1. Mr. Matthews, you should always seek medical treatment after an accident like this.
2. We must now observe you closely until we can determine what is causing your pain.
3. We are going to run a few tests and take some imaging studies of your chest.
4. We will also give you something for your pain and will observe your breathing to make sure you are getting enough oxygen.

DYHAQFM?

Question 6

DDx 1 — PTX:

Answer 6

1. Left-sided chest pain following an MVA.
2. Pain is exacerbated by movement and deep breaths.
3. Dyspnea.
4. Decreased breath sounds over left lung field.
5. RR 22/min.

Question 7

DDx 2 — Hemothorax:

Answer 7

1. Left-sided chest pain following an MVA.
2. Dyspnea.
3. Cough.
4. Decreased breath sounds over left lung field.
5. RR 22/min.

Question 8

DDx 3 — Pneumonia:

Answer 8

1. Unilateral chest pain.
2. Productive cough.
3. Low-grade fever.
4. Temp 100.
5. RR 22/min.

Question 9

Workup:

Answer 9

1. CXR.

2. Sputum + blood cultures and gram stain.

Question 10

Additional DDx:

Answer 10

1. Rib fracture.
2. Splenic rupture.
3. Pleuritis.

Question 11

Things to ask (forget):

Answer 11

1. Convulsions.
2. Change in vision.
3. Confusion, memory loss, change in personality.
4. Weakness/numbness.
5. Heart symptoms (palpitations).
6. Last meal/drink.
7. Were you under the influence of drugs/alcohol?
8. Pain on urination?

Question 12

Forget in PEx:

Answer 12

1. VS: fever, RR.
2. HEENT: No JVD, no bruises, PERRLA, EOMI, no pharyngeal edema or exudates.
3. Chest: 2 large bruises on left chest, left rib tenderness, decreased breath sounds over left lung field. Right lung fields clear.
4. Workup: Sputum and blood Gram stain and culture.