Neurological observations And CT Report Case Study - Medical Science Assignment Help

Assignment Task

TRIAGE:

• 18 year old male, brought in by ambulance following an alleged altercation where patient struck head on road curb at 2300 hrs.
• Patient is denies loss of consciousness but unable to recall all events. Patient
• appears alert but teary and takes a couple of moments to answer questions.
• On examination, 4cm laceration noted with slow ooze from wound. Dressing insitu. Vital signs and GCS recorded at 2325 hrs as per chart. No other obvious injuries.
• Patient denies drug use, states has had approximately ‘five beers since 7pm’. Breath alcohol taken at 2330 hours 0.06%.
• Patient reports pain to be 5/10 at occipital region, no analgesia taken prior to presentation.
• Patient states is usually fit and well.

PAST MEDICAL HISTORY:

Childhood asthma, up-to-date with immunisations (last tetanus 12 months ago). Not on any medications and no known allergies.

Vital signs

Blood Pressure: 141/88 mmHg
Heart Rate 90 beats/minute
Respiratory Rate 17 breaths/minute
SpO2 99% on room air
Temperature 36.0 c (tympanic)

Neurological observations

GCS
Eyes 4
Verbal 4
Motor 6

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