PACTS SP-LLM Trial Case
Setting: Outpatient clinic during regular office hours
You are covering for another resident in the clinic today. The patient is a 40-year-old who was in a rollover MVA about 10 days ago. The patient was in Trauma hold for 24 hours to R/O concussion and evaluate injuries. Initial workup included CT of head, abdomen, chest and extremities. Patient concussion protocol was negative. Patient suffered contusion to right side of head, mild concussion, temporary loss of consciousness at scene, impaled metal object in right forearm requiring bedside irrigation and several staples. No antibiotics ordered. Right wrist sprain (sent home with splint) and right knee contusion with effusion. Had limited ROM of right knee and discharged without PT or assistive devices for ambulation.
Over the past few days the patient has called the trauma service several times for complaints of pain, headache, and generalized discomfort and have requested additional pain medication. An additional 2 days of oxycodone was given. This follow up visit was rescheduled 5 days earlier than planned. No Physical Exam is required by you.
Patient Information:
Patient Name: D. Chang
Age: 40 years old
PMH: Headache, eczema, difficulty sleeping
PSH: Car accident 10 days ago where vehicle flipped – impaled metal object in right forearm requiring several staples, right wrist sprain (no fracture)
Medications: The only prescribed medication was oxycodone x 7 days and re-ordered oxycodone 5mg x 4 doses (2 days ago)
Vital Signs: HR 72 RR 18 BP 149/82 Temp 37.4
Lab Results: N/A
Image Results: