Clinical Vignette Case Study

Mr James Walker is a 64 year old male, widower who lives in Brompton. He has one adult child, who lives an hour away by train. Mr Walker was found around midday by his neighbour, after falling from the top of a 3.6 metre ladder whilst cleaning the gutters. The neighbour, who witnessed the incident, informed the paramedics that Mr Walker was conscious and had reported that he had felt dizzy, so had tried to come down the ladder, but missed a rung. As he fell, Mr Walker tried to twist so he that would not land on his back. Instead he landed on his left side with his left arm underneath his body and hit his left temple area very hard on a rock in the garden bed.

[hbupro_banner id=”6299″]

Mr Walker has a previous medical history of osteoarthritis, secondary to Pagets disease and he has a significant bilateral hearing impediment, but frequently does not wear his hearing aides. His current medication regime is; Fosamax (Alendronate) 70 mg tablet once weekly and Meloxicam Capsule 10 mg once a day.

Mr Walker arrived in the emergency department (ED) by ambulance at 1230 hours. Left upper arm out of alignment, swollen, vacuum immobiliser insitu and elevated on a pillow. He has abrasions to his face, both hands and abdomen; having fallen onto the gardening and flowers below. The lacerations to his hands are soiled with dirt and debris from the gutters and gardening this morning but appear superficial. He complains of pain in his left upper quadrant of his abdomen. Paramedics handed over that he was initially drowsy and disorientated, and opened his eyes to voice. Currently his neurological observations have improved. His GCS is currently 15. Spinal precautions remain insitu.

ED Summary

Observations on admission to ED (presented in no particular order)

Temp 36.5C, Heart rate 94 and regular, respiratory rate 24, BP 86/60 and administered 500mL N/ Saline, then 250mL Albumex-4 followed by 100mL/hr/N/Saline. Sp02 initially 96% on 10 L via non rebreather mask and then deteriorated to 87%, haemoptysis, rapid shallow breathing (32 bpm) and asymmetrical chest movement. On auscultation diminished breath sounds on left side. Chest X-ray showed left-sided pneumothorax with blunted costaphrenic angle indicating blood. No evidence of rib fractures – Diagnosed with left haemopneumothorax. Chest tube inserted at 1315 hours attached to Atrium Ocean drain – Suction to be titrated so that the fluid in suction chamber is gently bubbling. Obs 15minutely (HR, Sp02, BP, RR, Respiratory Effort and temperature plus patency of UWSD) for 1hr post insertion then hrly for 4 hrs. ECG (Sinus rhythm).

Reviewed by Surgical team

Investigations: FBE, EUC, COAGs, Cultures, BAL; LFT; G&XM, Cardiac enzymes.

Trauma Radiology Series/ FAST/ CT:

C-Spine: head and spine – Spine cleared; Small left-sided subdural haematoma;

X-ray Chest (post chest tube insertion), abdomen, pelvis;

Limbs – left colles fracture (realigned and Plaster of Paris insitu);

[hbupro_banner id=”6296″]

Surgical registrar Notes:

Previous history noted. Plan: Strict monitoring of GCS and vital signs, nursing management of chest tube. IVT @ 100 mls/hr, IDC insertion and strict fluid balance. Transfer to high acuity ward, POP care, analgesia as charted. To remain NBM until gastro team review abdo X-Ray and check bowel sounds. Keep Spo2 above 96% 2-6L 02 via N/S or HM. Will review following gastro team recommendations.

Medications ordered:

Medication	dose	frequency
Ampicillin	1 g IV	QID
Tet tox	IM	stat
Morphine	1-5 mg IV or SC	4/24 prn
metoclopramide	10mg IV/O	8/24 prn
Clexane	20mg SC	daily
Paracetamol	1000mg O/IV	4-6/24 prn
tropisetron	5 mg IV	Daily
prochlorperazine	10 mg O	TDS prn
Endone	5 mg O	6/24 prm

High acuity ward charts and observations as follows

Fluid Balance Chart

Time		Input		Progressive input	Output		Progressive output
Time	Oral		IV	Progressive input	Urine (IDC)	Chest drain	Progressive output
ED			N/Saline 500 bolus Albumex-4 250	750	IDC inserted		250
1400			100	850		55	305
1500			100	950		30	390
1600			100	1050	280	10	680
1700			100	1150		20	700
1800			100	1250	100	10	810
1900	ice		100	1350		10	820
2000			100	1450	100	10	930
2100	ice		100	1550		0	930
2200			100	1650	100	10	1040

Nursing Note 2000hrs:

Observations and care provided as charted. IVT continues at 100mls/hr, IDC insitu draining around 50mL straw coloured urine. GCS 14/15. At times appears to be a little inappropriate to staff in what he says, appears jovial. L) arm elevated on pillow – PoP – NAD, observations satisfactory and minimal pain to this arm. Complaining of headache, abdo pain and pain to multiple lacerations to hands. Administered morphine and IV paracetamol. All wounds cleaned with a medisponge, primapore insitu. Remains NBM, bowel sounds noted. Albert Hendon RN

Nursing note 2225hrs:

MET call 2200hrs: GCS decreased to 12 in particular became confused to location and person, became erratic. Increased systolic BP and widened pulse pressures. Increasingly agitated then drowsy, inappropriate words and localising to pain, difficult to rouse and then GCS 10/15. Pupils size 5 and right eye slow to react. Chest tube swinging and bubbling – minimal drainage last 2 hours. MET team called and requested neuro team to urgently review patient. Possible emergency craniotomy. Graham Noah RN

CT information inserted for nurses interest

Patient taken to theatre for emergency craniotomy, then transferred to ICU for ICP monitoring and management.

Observations and facts on readmission to high acuity ward (in no particular order of importance

Observations	2000hrs	2200hrs
Pulse	106 bpm	80 bpm
BP	154/68	160/60
Temp	37.5’C	37.9
Sp02	96% 2L	95% 2L
Respiratory Rate	18 bpm	22 bpm irregular
GCS	14/15	13/15
Pupils R) eye L) eye	R) 4mm reactive L) 4mm sluggish	R) 4mm reactive L) 5mm sluggish
Power R/L	R=L	R=L
Neurovascular observations L) arm	Colour: pink Warmth:warm Movement: yes Sensation: full Pulses: present	C √ W √ M √ S √ P √
Pain	4/10	6/10 LUQ pain; R & L hand
GIT	Nausea Bowel sounds	Nausea borborygmus
UWSD Swinging Bubbling Draining	swinging: √ bubbling: √ draining: √ clean dry Opsite insitu	swinging: √ bubbling: √ draining: X
Wounds R & L hands		Wounds to hands cleaned with n/saline Primapore insitu;

Blood Results	ED	Day 1	Day 2
Hb	165g/L	138	110
Haematocrit	0.49	0.45	0.52
RCC	6.0 x10¹²/L	5.8	4.8
Neutrophils	7.0 X 10⁹/L	6.8	8.5
Lymphocytes	3.5 X 10⁹/L	3.8	4.2
Monocytes	0.6 X 10⁹/L	0.66	0.5
Eosinophils	0.09X10⁹/L	0.091	0.002
Basophils	<0.1×106 10 9/L	.09	.001
Platelets	327 X 10⁹/L	360	220
PT	11 seconds	10	12
sodium 135-145 mmol/L	140mmol/L	142	143
Potassium 3.5-5.4mmol/L	5.0mmol/L	5.7	5.4
Urea 5.0-15.0 mml/L	4.8mmol/L	6.0	6.2
Chloride 95–110mmol/L	106mmol/L	110	105
Creatinine 60-110µmol/L	44mmol/L	68	70
Anion Gap 15-31mmol/L	12mmol/L	14
Bilirubin Total 0-7_umol/L	8 umol/L	9	25
Albumin 25-38 g/L	41g/L	45	38
Calcium 2.10-2.60 mmol/L	2.64 mmol/L	2.4	2.38
Magnesium	0.9mmol/L	.87	.84
Alkaline phosphatase	85 U/L	86	85
Glucose	5.9mmol/L	4.5	6.1