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St Thomas' Hospital - Majors: Bay 1

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Patient Chart

Patient Name:	Robert Peel		Date of Birth:	04/03/1973	Gender:	Male
Address:	10 Downing Street		Allergies:	NKDA	Presenting Complaint:	Trauma
Vitals			GP:	West London Clinic
Time:	08:00	08:05	08:10	08:15	08:20	08:25	08:30	08:35	08:40
Heart Rate:	110	115	101	105	110	115	115	120	125
Respiratory Rate:	24	26	24	22	24	20	20	18	18
SPO2:	98%(RA)	96%(RA)	96%(RA)	92%(RA)	92%(RA)	94%(O2)	96%(O2)	95%(O2)	96%(O2)
Blood Pressure:	135/90	135/90	130/90	125/80	115/75	116/72	110/70	112/72	115/75
Temperature:	36.9				36.5				35.9
Capillary Refill [P\|C]:	[2s\|2s]	[2s\|2s]	[2s\|2s]	[4s\|2s]	[4s\|2s]	[4s\|2s]	[6s\|4s]	[6s\|4s]	[6s\|4s]
Peak Flow:	N/A
AVPU:	Alert	Alert	Alert	Alert	Voice	Voice	Voice	Pain	Pain
GCS:	15/15 (E4\|V5\|M6)				14/15 (E3\|V5\|M6)			11/15 (E2\|V4\|M5)	9/15 (E2\|V3\|M4)
Blood Glucose:	4.3
Pupil Size (L\|R):	4\|4	4\|4	4\|4	3\|3	2\|2			2\|2	2\|2
ECG:	Sinus Tachycardia
Pain Score:	9/10	9/10	9/10	6/10	6/10	4/10	2/10	2/10	NN/10

History of Presenting Complaint

PT was thrown from his horse while riding in Green Park this morning (approx. 07:30).

Horse then trampled him.

07:30
<c> - No pain C1-5 (C6/7 pain++)
A- CLR
B - Increased WOB.
C - CAP REFILL OKAY. BP ↑.
D - PEARRLA. GCS 15/15.
E - Bruising to trunk around (L) clavicle.

ECG: Sinus Tachycardia | PR: 101 | BP: 139/90 | RR: 28 | SPO2: 99% (A)

Immobilised and transported to ED.

Past Medical History

Fractured wrist playing polo 15 years ago.

Medication & Drug History

PDx: Nil

08:10 - Methoxyflurane: PO | Batch Number;AT0M1C
08:12 - 20mg Morphine: IV | Batch Number; AT0M1C

Family History

DNACPR In place. Date: 01/03/2020-Indefinite - Reason: PT requested with GP.

Social History

Lives with wife Julia Floyd and 7 children.

Examination Findings

A - Airway
Airway clear and patent, no signs of obstruction or trauma to the airway structures.

B - Breathing
Bilateral air entry present but reduced on the left side, breath sounds diminished in left lower quadrant, ?pneumothorax. Normal percussion note right side, dullness on percussion on the left lower quadrant.

C - Circulation
No visible heaves or thrills, heart sounds are regular but rapid; no peripheral oedema.
ECG shows sinus tachycardia at 110 bpm, normal cardiac axis, PR interval and QRS duration within normal limits; diffuse ST depressions noted across the anterior leads. CRT - <2s central.

D - Disability
~~GCS 15 (E4 V5 M6)~~ @ 08:00
~~GCS 14 (E3 V5 M6)~~ @ 08:20
~~GCS 11 (E2 V4 M5)~~ @ 08:30
GCS 9 (E2 V3 M4) @ 08:40
Pupils equal but sluggish in response. FAST negative.

E - Exposure/Environmental Control
Abdomen tense and tender on palpation, marked guarding present. No external bleeding noted; extremities cool to touch, CRT - >2s peripherally.

ABG / VBG

08:00

Arterial Blood Gas (ABG):

pH: 7.40 - (within optimal range)
PaCO2: 38 mmHg - (within optimal range)
PaO2: 80 mmHg - (lower end of normal, no significant hypoxemia)
HCO3-: 24 mEq/L - (within optimal range)
Base Excess: 0 mEq/L - (no base deficit, within normal limits)
Lactate: 2.2 mmol/L ↑ (slightly elevated, early indicator of stress)

Venous Blood Gas (VBG):

pH: 7.37 - (slightly lower than arterial, within normal range)
PvCO2: 42 mmHg - (within normal range)
PvO2: 45 mmHg ↓ (slightly reduced, indicating some tissue oxygen extraction)
HCO3-: 23 mEq/L - (similar to arterial)
Base Excess: -1 mEq/L ↓ (mild base deficit)
Lactate: 2.5 mmol/L ↑ (indicates mild hypoperfusion)