History Data Panel Presenting Complaint Altered mental status s/p MVC Person Giving Information EMS History of Present Illness 28 year old woman, 35 weeks pregnant per report of her husband the passenger. Was restrained driver of a vehicle that was T-boned by another vehicle traveling at high rate of speed. Hit on patient s side. + airbag deployment (no side curtain airbags), approximately 30 minute extrication time. Past Medical History Surgical: Unavailable Medical: 35 weeks pregnant. Other history unknown Injuries: Unavailable Medications: Unavailable Allergies: None Obstetrics: Unavailable Other: Unavailable Habits Smoking: Unavailable Drugs: Unavailable Alcohol: EMS does not believe alcohol was involved Other: NA Family Medical History Father: Unavailable Mother: Unavailable Siblings: Unavailable Other: Unavailable Social Married: Married Children: Unavailable Occupation: Unavailable Education: Unavailable Other: - 2019 American Board of Emergency Medicine 1 of 5
Physical Data Panel Gender: 28-year old Female Patient Name: Jenna Jones Weight: 80.0 kg ( 176.37 lbs) General Appearance: Pale, unresponsive Airway: Patient has sonorous respirations, no obvious airway trauma. Does not respond when spoken to. Breathing: Breath sounds auscultated on the right chest. No breath sounds on left. Circulation: Thready peripheral pulses, symmetric in all extremities. HEENT Head: Large hematoma to the left temporal area. Multiple abrasions around the face but no facial deformity or stepoffs. Eyes: Pupils are reactive bilaterally 5 to 3 mm Ears: L side hemotympanum Nose: Scant dried blood in nares bilaterally. No septal hematoma or gross deformity. Throat: No gag reflex. No apparent broken teeth or blood in the oropharynx. Other: Neck C-collar in place. If this portion of the exam is performed before decompression of the pneumothorax, patient will have JVD and mild tracheal deviation to the right. If after chest tube placement, Trachea midline. No JVD. Skin Multiple small lacerations and abrasions over body. 5 cm laceration to L forearm. Bleeding controlled. Chest Patient is moderately tachypneic. Normal breath sounds R lung, No audible breath sounds on the L. (If this portion of the physical exam is repeated after chest tube placement, patient is mechanically ventilated with bilateral breath sounds. ) Heart Tachycardic. No murmurs, rubs, or gallops. Abdomen Gravid. Bruising extending along the lower abdomen. Patient grimaces with palpation of the abdomen. Genitalia No gross bleeding Pelvic Examination NA Rectal Normal rectal tone, no blood. Extremities Abrasions to b/l legs, but no deformity, passive ROM is intact. L arm laceration. Vascular Radial and dp pulses are thready but palpable. Neurologic GCS: 6 Consciousness: Groans to painful stimuli. Does not open eyes. Cranial Nerves: Grossly intact. Unable to assess fully due to mental status. Motor : Withdraws all 4 extremities to pain. Sensory: Withdraws all 4 extremities to pain. Gait and Station: N/A 2019 American Board of Emergency Medicine 2 of 5
Verbal Reports Vital Signs Initial - on nonrebreather BP 82/45 P 114 R 28 O₂ Sat 92% NO ETI BP 82/45 P 114 R 22 O₂ Sat 82% Post intubation BP 78/46 P 125 O₂ Sat 90% PTX Decomp #1 BP 70/38 P 135 O₂ Sat 82% PTX Decomp #2 BP 65/34 P 145 O₂ Sat 72% Post Chest tube/ncd BP 84/58 P 110 T 36.6 C / 97.9 F 2019 American Board of Emergency Medicine 3 of 5
Send if "Identify and treat tension pneumothorax" is met Post uterus displacement BP 88/60 P 110 Send if "Appropriate positioning of hypotensive, gravid patient" is met Post PRBCs BP 92/62 P 106 T 36.5 C / 97.7 F Worsening shock BP 74/46 P 134 T 36.5 C / 97.7 F O₂ Sat 95% Send if "FAST Exam AND Surgical consult" is met Cardiac Arrest BP 0/0 P 0 O₂ Sat 0% Post C Section BP 82/64 P 122 O₂ Sat 96% 2019 American Board of Emergency Medicine 4 of 5
General Guidelines General Scoring Guidelines Extra points if candidate asks whether the patient s husband is present and updates him regarding status of patient. Score up if quickly recognizing pathology and performing correct diagnostics / management steps (DA, PS, PM) Score down if requiring prompts or seems unsure of diagnostics / management (DA, PS, PM) Score down if diagnostics / management steps are excessively delayed (DA, PM, PS) General Play of Case Guidelines Patient presents hypotensive and tachycardic. Minimal history is obtained from EMS if requested. The patient should be intubated during the primary survey because of a low GCS and should subsequently be diagnosed with a tension pneumothorax (was a simple PTX until PPV, then became a tension PTX) which should also be addressed during the primary survey. Resuscitation with IV fluids, then blood products should be initiated as well. Each of these interventions will result in small, transient improvements in vital signs. Time should be allowed afterwards for performance of a secondary survey with the above critical actions. If resident is able to evaluate fetus before cardiac arrest, they will see + fetal cardiac activity on ultrasound or fetal Doppler. After this, patient will decompensate and suffer cardiac arrest requiring performance of perimortem c-section. When the infant (wellappearing) is delivered (and handed off to NICU team), patient obtains ROSC and trauma surgery/ob arrive to transfer patient to the operating room. 2019 American Board of Emergency Medicine 5 of 5