Who you are:
You are FY2 in A&E.Who is the patient:
Randy smith, 46-year-old, brought to the hospital by the ambulance after having a fall.What you should do:
Take history, assess the patient and discuss your initial plan of management with the patient.
Criteria for performing a CT scan for adults:
- CT head scan should be performed within 1 hour.
- GCS less than 13 on initial assessment in A&E.
- GCS less than 15 at 2 hours after head injury on assessment in A&E.
- Suspected open or depressed skull fracture.
- Any sign of basal skull fracture (hemotympanum, panda eyes, cerebrospinal fluid leak from ears or nose, battle sign.)
- Post-traumatic seizure.
- Focal neurological deficit
- More than 1 episode of vomiting.
For patients who have sustained a head injury and the following risk factors.
CT head scan should be performed within 8 hours of the risk factors being identified.
- Patient on warfarin.
- LOC or amnesia and any of the following:
- Age more than 65.
- Any history of bleeding and clotting disorder.
- Dangerous mechanism of injury e.g., Fall of more than 1 meter or 5 steps, RTA either is:
– Pedestrian or Cyclist or vehicle occupant.
– More than 30 min retrograde amnesia of event "immediately before the injury”.
Build rapport
Doctor: I can see from my notes that you had a fall, how are you right now? Patient: I am fine now doctor thank you.
P1
D: I’d like to have chat with you about what happened, can you tell me more about it?
P: I was out with my friends at a restaurant when I had a fall and then I fainted D: Sorry to hear that. How long did you remain unconscious?
P: I don’t know but I regained my consciousness in the ambulance.
BEFORE – DURING - AFTER
D: Any fits before? (Epilepsy)
P: No.
D: Any heart racing? (AF)
P: No.
D: Did you have your meal as usual? (hypoglycemia)
P: Yes, and also, I was drinking alcohol.
D: How much did you drink?
P: Around 3-4 glasses of wine.
D: Any balance problem while walking? (ataxia)
P: No.
D: Did you feel like the room was spinning? (Meniere’s)
P: No.
D: Any trauma to your head?
P: I think when I fell, I hit my head (+ve finding)
D: Any fever/flu-like symptoms? (Confusion)
P: No.
D: Any vomiting?
P: I vomited twice. (+ve finding)
D: Sorry I have to ask you….by any chance did you bite your tongue or wet yourself after the fall?
P: No.
D: Apart from this, is there anything else?
P: No
FLAWS +Ask about CT criteria
P2 (PAST HX)
D: Has this ever happened to you before?
P: No.
D: Do you have any medical condition?
P: No.
D: Are you taking any medications?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
DESA
D: Tell me about your diet?
P: I try to eat healthy.
D: Do you smoke?
P: No.
D: Do you do physical exercise?
P: Not really.
D: Do you have any kind of stress?
P: No.
ICE
Examination:
Observations: Measuring BP while lying down & standing.
Chest: (examine heart).
Head: small bruise on forehead (+ve finding)
Provisional Diagnosis
From the chat we had (mention the positive findings) you told me that you had a head injury and you fainted. After that you vomited twice, so I suspect that the head injury is the cause for your loss of consciousness.
Management:
- Senior
- Keep you under observation to monitor you
- Investigations: you told me that you vomited twice so we will do CT scan to make sure everything is OK with you. According to the result we will decide if we will admit you or discharge you
- Safety netting: if you notice any vomiting, LOC, dizziness or fit call 999.