Head injury
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Assessment of Head Injury and Assault
Introduction to Patient Assessment
Introduction: I'm Mark, the triage nurse today. We'll quickly assess your condition to determine appropriate care.
Patient Identification
Patient Details: Name: Charles Dunnigan, Date of Birth: 16/05/64
Initial Assessment and History
Initial Assessment: We'll check your blood pressure and discuss your symptoms.
- Are you comfortable with me checking your blood pressure?
- Any particular arm you prefer?
History of Presenting Complaint: Charles reports being punched without provocation, resulting in headache and dizziness.
Assessment of Injury and Symptoms
Symptoms: Charles experienced dizziness, headache, and visual disturbances post-assault.
- Did you lose consciousness?
- Do you have any neck pain or stiffness?
- Any visual disturbances or sensitivity to light?
Physical Examination: No signs of significant head or neck injury noted, aside from jaw tenderness and headache.
Medical History and Medication
Medical History: No known medical conditions or current medications.
- Any drug allergies?
- Have you experienced similar symptoms before?
Clinical Decision and Next Steps
Clinical Decision: Considering the head injury and symptoms, Charles will be referred to an A&E doctor for further assessment and investigations.
- We'll check your blood sugar levels as a precaution.
- You may need imaging tests to assess for any internal injuries.
Final Instructions
Discharge: Charles will be directed to A&E for comprehensive evaluation and management.
- Would you prefer to walk or use a wheelchair?
- Head towards the waiting area by the TVs and wait to be called.
Thank you for your cooperation, Charles. We'll ensure you receive the necessary care promptly.