x8973468 Jules Street, Temora, NSWJasmine23/8/199418/02 210019/02/20 043519/02 065519/02 0715Jasmine has been admitted to medical ward. Brought to ED hours with headache andvomiting and agitation. History of migraines. Did have trip and fall three days ago resulting inright temporal laceration requiring sutures. Jasmine thinks her headaches and vomiting aremigraine-related. Her husband reports a period of agitation … Continue reading “right temporal laceration requiring sutures | My Assignment Tutor”
x8973468 Jules Street, Temora, NSWJasmine23/8/199418/02 210019/02/20 043519/02 065519/02 0715Jasmine has been admitted to medical ward. Brought to ED hours with headache andvomiting and agitation. History of migraines. Did have trip and fall three days ago resulting inright temporal laceration requiring sutures. Jasmine thinks her headaches and vomiting aremigraine-related. Her husband reports a period of agitation this evening at home (very unlikeJasmine)EXWKDVEHHQUHOD[HGVLQFHDWWHQGLQJKRVSLWDO. In ED Jasmine has been given 5mgMorphine IVI and 10mg Maxalon with some relief of pain and nausea- nil further vomiting. RIVCin situ dorsum of hand.Observations within normal limits. Neuro Obs- GCS 15 PEARL. At present Jasmine is slightlydrowsy, her frontal headache is constant/throbbing worse with movement/associated withphotophobia rated at 4/10. Jasmine states that her headache is very similar to usual occasionalmigraines and wants to go home asap as she has an upcoming clinical exam she needs tostudy for (she is a medical student). CT performed but results not available. Husband Peter hasgone home. Plan for hourly neuro obs overnight. Jane Brock RNMedical Note: CMO Susan James – RN asked for Clinical Review re GCS decease to 14DQGDJLWDWLRQZKHQZRNHQ I admitted Jasmine last night following 3 day history of ongoingheadaches and vomiting post trip/fall and head injury right temple (laceration required 6sutures).No LOC. Her husband stated she had a period of agitation yesterday pm whichconcerned him. Jasmine stated her headaches/vomiting are like her migraines. Assessment lastevening neurologically intact. Pain/vomiting treated with Morphine and Maxalon. Awaiting CTresults.$VVHVVPHQW$LUZDSDWHQW%UHDWKLQJ1$’6D2DLU55&LUFXODWLRQODVWREV%3VOLJKWOHOHYDWHG+5110 ST (in pain)&DSUHILOOVHFV‘ *&6 3($5/ 2ULHQWHG WR SHUVRQQRW WR SODFH LQLWLDOO EXW RQFH ZRNHQ XS 2. QRWRULHQWHG WR WLPHGDWH QHHGHG UHPLQGLQJ &RRSHUDWLYH )XOO SRZHU DOO OLPEV &UDQLDO QHUYHDVVHVVPHQWJURVVOLQWDFW1RVLJQVRIDJLWDWLRQDWSUHVHQW%6/(DIHEULOH6WLOOKDVIURQWDOKHDGDFKHVWDWHVQRZDQGYRPLWHGDIWHUH[DPLQDWLRQIRUIXUWKHUPRUSKLQHDGGRQGDQVHWURQImpression:?migraine secondary to concussion /?concussionPlan: Continue with hourly neuro obsChase up CT results in am Susan James CMO345162 Nursing note: Clinical review as above after decrease in GCS and some agitation whenJasmine was woken at 0400. Plan noted as above, given 5mg s/c morphine and IV ondansetronand will review. Jane Brock RNNursing note: Jasmine’s condition has deteriorated since 0430 and was found having ageneralised seizure at 0610. Rapid response called and in progress.Unfortunately due to a deterioration of another patient Jasmine did not have neurologicalobservations or nursing care attended at 0500 or 0600. CMO and Nurse Manager in attendancewith Jasmine currently. Her husband Peter has been informed of her deterioration and is inattendance.Jane Brock RNMedical Note: CMO Susan James. Jasmine found having generalised seizure at 0610. Nonursing observation of Jasmine attended after 0430 review and administration of Morphine andOndansetron due to serious deterioration of another patient in the ward and nursing availability.Unknown length of time of seizure activity. Note Right pupil enlargement (7 and fixed). CT Scanresults have just been sent through. Full rapid response notes to follow. Susan James CMO345162Kain19/02 0415
