Encounter ER-26-0501
Disposition Pending
Chief Complaint
Polytrauma — Road Traffic Accident
Priority
Level 2 — Emergency
Zone
Critical Care / Orange Zone
Doctor
Dr. Nasima Chowdhury
Nurse
Rezaul Karim
Arrival & Identification
Arrival Mode
Ambulance
Source
RTA scene, Uttara
Arrival Time
08:10
Identification
Confirmed at Registration
Triage Assessment
- Chief Complaint
- Polytrauma following RTA (motorcycle vs. car)
- Mechanism of Injury
- High-speed motorcycle collision, thrown from vehicle
- Airway
- Patent
- Breathing
- 22/min, mild distress
- Circulation
- BP 100/68, HR 108 (tachycardic)
- Disability
- GCS 14, alert but drowsy
- Exposure
- Multiple abrasions, suspected left femur fracture
- Pain Score
- 7 / 10
- Oxygen Saturation
- 95% on room air
- Blood Glucose
- 5.8 mmol/L
- Allergies
- NKDA (No Known Drug Allergies)
- Existing Conditions
- None known
Vital Signs
| Time | Temp | Pulse | RR | BP | SpO2 | Glucose | Pain | GCS |
|---|---|---|---|---|---|---|---|---|
| 08:12 | 36.8°C | 112 | 24 | 96/64 | 94% | 5.8 | 8/10 | 14 |
| 08:30 | 36.9°C | 108 | 22 | 98/66 | 95% | — | 7/10 | 14 |
| 09:00 | 36.9°C | 104 | 20 | 100/68 | 96% | — | 6/10 | 14 |
| 09:20 (latest) | 36.9°C | 102 | 20 | 102/70 | 96% | — | 4/10 | 14 |
GCS
Eye
4 — Spontaneous
Verbal
4 — Confused
Motor
6 — Obeys commands
Total
GCS 14 (E4 V4 M6)
Triage Reassessment History
| Time | Priority | Note |
|---|---|---|
| 08:12 | Level 2 — Emergency | Initial triage |
| 08:45 | Level 2 — Emergency | Reassessed — stable, no change |
Chief Complaint
- Onset
- Sudden — RTA at 07:55
- Duration
- ~15 min pre-hospital
- Severity
- Severe
- Location
- Multiple — head, chest, left leg
- Associated Symptoms
- Left leg pain/deformity, mild headache, no reported loss of consciousness
History
- Present Illness
- Motorcycle collision, thrown approximately 5 meters
- Past Medical History
- Hypertension (on Amlodipine)
- Surgical History
- Appendectomy, 2015
- Medication History
- Amlodipine 5mg OD
- Allergy
- NKDA
- Family History
- Non-contributory
- Social History
- Non-smoker
- Trauma History
- None prior
Physical Examination
- General
- Alert, distressed, GCS 14
- Airway
- Patent
- Respiratory
- Bilateral air entry, mild tachypnea
- Cardiovascular
- Tachycardic, no murmurs
- Neurological
- GCS 14, pupils equal and reactive
- Abdomen
- Soft, mild tenderness left upper quadrant, no rigidity
- Musculoskeletal
- Deformity left mid-thigh, distal pulses intact
- Skin
- Multiple abrasions, no active bleeding
- ENT
- Within normal limits
- Eye
- PERRLA
- Genitourinary
- Not examined — not indicated
Diagnosis
- Provisional Diagnosis
- Closed fracture, left femur; multiple abrasions; suspected mild traumatic brain injury
- Differential Diagnosis
- Intra-abdominal injury (rule out), pelvic fracture (rule out)
- Final Diagnosis
- Pending imaging review
- ICD Code
- S72.3 (femur fracture) — provisional
- Injury / Trauma Diagnosis
- Blunt polytrauma, road traffic accident
Resuscitation / Code Record
N/A — not a resuscitation/code case.
- Arrest Time
- —
- Recognition Time
- —
- CPR Start / Cycles
- —
- Rhythm
- —
- Defibrillation
- —
- ROSC / Death
- —
Airway Management
Oxygen
Nasal cannula, 4 L/min
Advanced Airway
Not required — no intubation needed
Primary Survey — ABCDE
- A — Airway
- Patent; cervical collar applied prehospital, cleared clinically
- B — Breathing
- RR 22, SpO2 95% on NC, chest movement symmetric, breath sounds clear bilaterally, mild distress
- C — Circulation
- Pulse 108 thready, BP 100/68, no external bleeding, capillary refill 3s, 2× large-bore IV access established
- D — Disability
- GCS 14 (E4 V4 M6), pupils PERRLA, blood glucose 5.8
- E — Exposure
- Left thigh deformity/swelling, multiple abrasions torso and limbs, temp 36.9°C, full-body log-roll exam done
Secondary Survey
- Head
- Small scalp laceration, no depressed fracture
- Face
- Abrasions, no fracture
- Neck
- No tenderness, collar removed after clinical clearance
- Chest
- No crepitus, breath sounds equal
- Abdomen
- Mild left upper quadrant tenderness, no guarding
- Pelvis
- Stable, no tenderness
- Spine
- No midline tenderness
- Upper Limbs
- Abrasions, full range of motion
- Lower Limbs
- Left femur deformity, distal pulses/sensation intact
- Skin
- Multiple abrasions cleaned and dressed
- Neurological
- GCS 14, no focal deficit
Injury Documentation
| Type | Location | Side | Mechanism | Severity | Time | Description |
|---|---|---|---|---|---|---|
| Fracture | Left Femur (mid-shaft) | Left | Blunt trauma / RTA | Severe | 07:55 | Closed displaced fracture, splinted at scene |
| Abrasion | Torso / Limbs (multiple) | Bilateral | Road surface friction | Minor | 07:55 | Multiple superficial abrasions, cleaned and dressed |
| Laceration | Scalp | N/A | Blunt trauma | Minor | 07:55 | 2cm laceration, sutured |
Orders
| Investigation | Priority | Status | Result |
|---|---|---|---|
| X-ray — Left Femur | Stat | Reported | Displaced mid-shaft fracture confirmed |
| CT Head | Stat | Reported | No acute intracranial findings |
| Chest X-ray | Urgent | Reported | Clear, no rib fracture |
| FBC / Renal / Coagulation | Stat | Result Available | See LIS for full panel |
| Blood Group & Crossmatch | Urgent | Result Available | O+, 2 units crossmatched (reserved) |
Critical Result Alert
| Result | Alert Time | Recipient | Acknowledgement | Action Documented |
|---|---|---|---|---|
| Potassium 5.6 mmol/L (mildly elevated) | 09:05 | Dr. Nasima Chowdhury | Acknowledged 09:08 | Repeat U&E in 2 hours, monitor |
| Troponin I elevated (0.8 ng/mL) — cardiac workup | 09:32 | Dr. Nasima Chowdhury | Pending |
1 critical result pending acknowledgement for this encounter.
Medication Orders
| Drug | Dose | Route | Type | Start Time |
|---|---|---|---|---|
| Paracetamol | 1 g IV | IV | Stat | 08:20 |
| Normal Saline | 1 L | IV | Stat | 08:15 |
| Ceftriaxone | 1 g IV | IV | Stat | 08:25 |
| Tetanus Toxoid | 0.5 mL | IM | Routine | 08:30 |
Medication Administration Record
| Drug | Ordered | Verified | Dispensed | Administered | Documented |
|---|---|---|---|---|---|
| Paracetamol 1g IV | Administered 08:22 — Rezaul Karim | ||||
| Normal Saline 1L | Running — Rezaul Karim | ||||
| Ceftriaxone 1g IV | Administered 08:28 — Rezaul Karim | ||||
| Tetanus Toxoid 0.5mL | Pending | ||||
Emergency Drug Tray Reference
Analgesics and IV fluids drawn from Critical Care / Orange Zone crash cart CC-02. See Crash Carts for the full master.
This encounter has not entered formal Observation status — currently under active treatment in Critical Care / Orange Zone. Vitals below are from active-treatment monitoring, not a dedicated observation stay.
Monitoring
| Time | BP | HR | SpO2 | RR | Temp | Pain | GCS | Glucose |
|---|---|---|---|---|---|---|---|---|
| 08:12 | 96/64 | 112 | 94% | 24 | 36.8°C | 8/10 | 14 | 5.8 |
| 08:45 | 98/66 | 108 | 95% | 22 | 36.9°C | 7/10 | 14 | — |
| 09:20 (latest) | 102/70 | 102 | 96% | 20 | 36.9°C | 4/10 | 14 | — |
Nursing Documentation
- Nursing Assessment
- Patient responding well to analgesia, pain trending down, remains alert and cooperative
- Intake / Output
- IV fluids running 1L NS, no urinary catheter, no output recorded yet
- Medication Administration
- See Medication tab MAR
- Procedures
- Wound cleaning and dressing performed 08:40
- Wound Care
- Abrasions cleaned and dressed, scalp laceration sutured
- Patient Response
- Tolerating treatment well, pain improved from 8/10 to 4/10
- Handover
- Handed over to day-shift nurse Rezaul Karim at 09:00
Disposition Pending: Awaiting orthopedic consultation from Dr. Tom Alexander before the final Admission-vs-OT decision.
Disposition Actions
Medico-Legal Case (MLC)
Access logged — Medical Records / Police liaison only.
- Case Type
- Road Traffic Accident
- Police Station
- Uttara Police Station
- Officer
- SI Rafiqul Islam
- Case / Reference No.
- MLC-26-0087
- Notification Time
- 08:20
Billing Summary
| Charge | Amount |
|---|---|
| Emergency Registration | $20.00 |
| Emergency Consultation | $80.00 |
| Procedures (wound care / suturing) | $120.00 |
| Doctor Fee | $150.00 |
| Nursing | $60.00 |
| Investigation & Imaging (CT, X-ray, labs) | $420.00 |
| Medication | $85.00 |
| Consumables | $45.00 |
| Ambulance | $100.00 |
| Total (running) | $1,080.00 |
Final invoice generated at disposition.
View Invoice