Melclin
Forum Deputy Chief
- 1,796
- 4
- 0
15:30 on a nice sunny day and you are drawn away from watching Australia demolishing the English in the first test for a...
CODE:1 - 82 yrs female - Traumatic injuries (Possible dangerous body area).
O/A: You are directed to a smiling older woman sitting on the ground in the garage of an expensive looking house with a bloody towel wrapped around her ankle. She says that she tripped after having caught her leg on something, and fell hitting her head on the edge of the car bonnet on the way down. She is quite sorry to be such a bother, and if you could just help her up, her son will take her to the doctor.
O/E:
-a small lac above her right eye with a mid sized developing haematoma.
-a 10cm lac on her left calf of medium depth, no spontaneously bleeding.
-estimated blood loss of about 20-40mls.
Nil LOC.
Nil C-Spine tenderness or back pain (spontaneously and on palpation).
Nil apparent neuromuscular deficit.
No dizziness before falling (she is quite adamant that she fell because she caught her leg on what turns out to be a pretty nasty jagged piece of metal protruding from the hot water service).
No chest pain, SOB, current dizziness, diaphoresis.
No headache or blurred vision.
No allergies.
3/10 pain for the lac on her leg. 1/10 pain for lac on her head.
Vitals
Her skin is warm and pink. BP: 200/100, Pulse: 48 (strong, regular), RR: 18 (regular, no distress), Temp: 36.9 (98.4), GCS:15, Pupils : Left pupil is 3mm larger than the right pupil (it is unclear if that is normal for her).
Meds
Warfarin, Candesartan.
Hx
Hypertension, cataract surgery, osteoarthritis, stroke (two years previous, is unclear about any lasting deficits).
She is generally in good health and is relatively fit.
Pt is unhappy about going to hospital and is insistent on going to the toilet first and collecting a few bits and pieces from her dresser.
So, a few questions:
-What are you concerned about, why, and what are you going to do about it?
-Spinal precautions?
-Can she go to the toilet and potter about?
-Transport choice (just your thoughts in general about what kind of hospital you think she needs)?
-Level of transport urgency?
-Any medications?
CODE:1 - 82 yrs female - Traumatic injuries (Possible dangerous body area).
O/A: You are directed to a smiling older woman sitting on the ground in the garage of an expensive looking house with a bloody towel wrapped around her ankle. She says that she tripped after having caught her leg on something, and fell hitting her head on the edge of the car bonnet on the way down. She is quite sorry to be such a bother, and if you could just help her up, her son will take her to the doctor.
O/E:
-a small lac above her right eye with a mid sized developing haematoma.
-a 10cm lac on her left calf of medium depth, no spontaneously bleeding.
-estimated blood loss of about 20-40mls.
Nil LOC.
Nil C-Spine tenderness or back pain (spontaneously and on palpation).
Nil apparent neuromuscular deficit.
No dizziness before falling (she is quite adamant that she fell because she caught her leg on what turns out to be a pretty nasty jagged piece of metal protruding from the hot water service).
No chest pain, SOB, current dizziness, diaphoresis.
No headache or blurred vision.
No allergies.
3/10 pain for the lac on her leg. 1/10 pain for lac on her head.
Vitals
Her skin is warm and pink. BP: 200/100, Pulse: 48 (strong, regular), RR: 18 (regular, no distress), Temp: 36.9 (98.4), GCS:15, Pupils : Left pupil is 3mm larger than the right pupil (it is unclear if that is normal for her).
Meds
Warfarin, Candesartan.
Hx
Hypertension, cataract surgery, osteoarthritis, stroke (two years previous, is unclear about any lasting deficits).
She is generally in good health and is relatively fit.
Pt is unhappy about going to hospital and is insistent on going to the toilet first and collecting a few bits and pieces from her dresser.
So, a few questions:
-What are you concerned about, why, and what are you going to do about it?
-Spinal precautions?
-Can she go to the toilet and potter about?
-Transport choice (just your thoughts in general about what kind of hospital you think she needs)?
-Level of transport urgency?
-Any medications?