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A Fracture from a Fall: What’s Going on Here? | Case Study

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A new case study in which a 77 yo white female arrives to the emergency room by taxi with a suspected skull fracture. This topic was suggested by a reader – thank you so much for your ideas – keep them coming!

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

"I fell, hit my head, and can't stop bleeding": What's happening to this woman?

A Fracture from a Fall: What’s Going on Here? | Case Study

Disclaimer: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.

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DO NOT POST ANSWER HERE.

Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below.

Chief Complaint

“I was working in the garden, and I tripped and fell and hit my head. It was so stupid of me to leave my rake lying on the grass. I’m sorry to bother you, but I couldn’t get it to stop bleeding. I hope it’s not too bad.”

General Appearance

Patient is thin and appears her stated age. She is wearing clothing with frayed edges and there is a stain on her shirt. Her socks are mismatched. She moves slowly and carefully. She holds a bloodstained washcloth to her right temple. She doesn’t make eye contact and is restless – she fidgets and keeps folding and unfolding the sheet on the gurney.

Past Medical History

  • Occasional constipation
  • Arthritis in hands and feet
  • Depression

Family History

  • Both parents deceased, father died from CVA at age 77, Mother developed Alzheimer disease in late 70s and died when she was 83.
  • Brother died from heart disease at age 72

Social History

  • Lives with only daughter, age 53
  • Has been widowed for 15 years (husband died of cancer)
  • Does not smoke or drink alcohol

Medications

  • Ibuprofen 200 mg q 4h PRN
  • Docusate sodium 100 mg po BID
  • Citalopram 20 mg PO qday

Allergies

Co-tromoxazole = rash

Review of Systems: (only abnormal values presented)

Skin

Skin is pale and dry with senile lentigines, poor skin turgor

HEENT

Dentures present, small abrasion to right upper lip, patient states, “I can’t find my glasses.”

Lungs/Thorax

Mildly increased chest AP diameter with mild kyphosis

Musculoskeletal

Healing bruise noted on left upper arm

Pain is rated at 7/10 in right temple and 5/10 in her hands and knees. “My arthritis is paining me today.” Upon examination, there appears to be a laceration to the right frontal lobe above the right eye, with a hairline fracture and a small amount of continuous bleeding.

Vital Signs

  • BP 141/93 sitting, RA 138/88 standing LA
  • HR 90 (60-90) seated, 95 standing
  • RR 20 (12-14)
  • T 98.9oF
  • HT 5’ 2”
  • WT 95 lbs
  • BMI 17.4

Laboratory Test Results (normal values)

  • Na 146 meg/L (135-145)
  • K 4.8 meq/L (3.5-5)
  • Cl 111 (101-112)
  • Mg 2.8 mg/dL (1.8-3)
  • PO4 4.2 mg/dL (2.5-4.5)
  • BUN 21 mg/dL (8-20)
  • Cr 1.2 mg/dL (0.6-1.2)
  • Ca 9.0 mh/dL (8.5-10.5)
  • Hb 12.8 g/dL females (12-15.5)
  • Hct 36.2% females (35-45%)
  • Plt 290,000 cu/mm (150,000-450,000)
  • WBC 8,000 x 103/mm3 (4,800- 10,800)
  • Glu fasting 62 mg/dL (60-110)
  • Total Protein 6.0 g/dL (6-8.3)
  • Albumin 2.7 g/dL (3.4-4.7)
  • Prealbumin 10 mg/dL (15-36)

Urinalysis

  • pH 6.2 (5-6.5)
  • Specific gravity 1.035 (1.016-1.022)
  • Negative for white/red blood cells, proteins, ketones,bacteria or glucose
  • Urine is dark yellow with strong odor

What is going on with this patient besides a fracture?

What labs do you want?

What other diagnostic tests should we run?

Ask me some questions!

REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com.

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26 Comment(s)

TriciaJ, RN

Specializes in Psych, Corrections, Med-Surg, Ambulatory. Has 40 years experience.

My first questions are what did she strike her head against, does she remember how she got the bruise on her arm, and has her daughter been contacted?  Is she on her way?

nursej22, MSN, RN

Specializes in Public Health, TB. Has 36 years experience.

Assume there was some imaging done to diagnose hairline fx, but if not already done I would get a head CT. Need further investigation about why she is bleeding so would get PT, PTT. Get guiac to assess for GI bleed.  Mini-mental state exam to assess for dementia. 

And yes, is the daughter there? Or someone who can give a more complete history? Can you check with PCP, or whoever prescribed the citalopram? Has she been taking it as prescribed? 

I agree with all the above but I’m also really concerned with her home situation. The patient’s clothing and appearance are concerning, she is definitely underweight,  unexplained bruising and she has lost her glasses.  These observations added with poor eye contact bother me. These things are not emergent but need to explored after medical issues are found and resolved. 

nursej22, MSN, RN

Specializes in Public Health, TB. Has 36 years experience.

2 hours ago, Ninaof8 said:

I agree with all the above but I’m also really concerned with her home situation. The patient’s clothing and appearance are concerning, she is definitely underweight,  unexplained bruising and she has lost her glasses.  These observations added with poor eye contact bother me. These things are not emergent but need to explored after medical issues are found and resolved. 

Which is why at least 2 of us want to speak to the daughter, whom we were told lives with the patient. The patient seems to be a vague historian, so I wouldn't be surprised if the daughter is out of the picture. 

 

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

When the patient is asked about contacting her daughter she says, "Oh dear me no, I don't want to bother her." She refuses to give any contact information for her daughter. Patient states, "I must have hit my head on a rock in the garden. The bruise is from running into a doorknob - I am so clumsy."

Scans and more info coming...

Thanks so much for all the questions and input.

lde

Specializes in Student.

First ever participation in one of these and I'm still in nursing school (Q6 of 10 - Medusrg 2) so I'm hopefully not too off the mark :) but I wanted to try and participate and learn:

- I would also ask her about her appearance a little more; maybe she has financial difficulties? Maybe its just dementia but who knows.
- Are there any neighbors or friends she talks to? If its not the daughter then maybe its someone else she might be talking to?
- Specific gravity, color and odor of urine are concerning but UTI scan appears to be clear? So my question is does it make sense to do a urine culture at all? Could there be other kidney or GU infections that are present but don't show up in the urine scan?
- BUN & Creatinine is high too which makes me wonder if kidneys are fine at all. Can we do tests that check urea, uric acid levels in the blood?
- CT scans would help for sure, maybe ICP check to see if there is a hematoma?

Just some things I thought about :). Do let me know if my thought processes are off. Thanks.

VivaLasViejas, ASN, RN

Specializes in LTC, assisted living, med-surg, psych. Has 20 years experience.

I noted that her blood glucose was a little low, which could have contributed to the fall. I’m also concerned about the possibility of neglect or abuse due to the condition of her clothing, probable dehydration and unexplained bruising. Her albumin and prealbumin are low indicating malnutrition and her kidney function is borderline abnormal. How is her cognition? When was her last physical? Does she see a psychiatrist or therapist for her depression? 
 

Tests I’d ask for:

1) MMSE or SLUMS to assess cognition

2) A1C

3) LFTs

 

 

 

August Saunders, ADN, CNA, LPN

Specializes in MedSURG nurse.

Dehydration. Start fluids. But she might need some albumin as well. Values are low. Need LFT. Head and AP CT and ECG.  She is Malnourished, her bmi is low. Last bm?? 

August Saunders, ADN, CNA, LPN

Specializes in MedSURG nurse.

3 hours ago, August Saunders said:

Dehydration. Start fluids. But she might need some albumin as well. Values are low. Need LFT. Head and AP CT and ECG.  She is Malnourished, her bmi is low. Last bm?? 

Also pt inr 

sirI, MSN, APRN, NP

Specializes in Education, FP, LNC, Forensics, ED, OB. Has 30 years experience.

Just a reminder whenever anyone is ready to register a "guess" at the diagnosis.

Go to the Help Desk and start a ticket. Then tell Admins what you think the diagnosis is. You can include rationales, too.

Then ... later ... if you need to amend and/or add to your guess/rationale, just return to the same ticket for an update.

Get yours in soon.

Ioreth, ADN, RN

Specializes in Ortho-Neuro. Has 2 years experience.

It is pretty typical for head lacerations to bleed profusely. Is the bleeding normal for a head laceration or does it continue after holding pressure and closing the laceration with sutures and/or skin adhesive?

Ioreth, ADN, RN

Specializes in Ortho-Neuro. Has 2 years experience.

Patient stated she lives with her daughter and no others, but won't provide contact information. Is there anyone else who visits frequently, or even infrequently but has seen her recently?

I would go through some safety screening, questions like: 
What is your support system?
Do you feel safe in your home?
Do you have concerns regarding personal safety, shelter, food, finances?
Have you been the victim of abuse of any kind within the last 5 years?

SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

Follow up information:

  • aPTT: 12 seconds (10-13)
  • INR: 0.9 (below 1)
  • RBC 4.3 million (4.2-5.4 million/mcL)

The bleeding stopped after direct pressure was applied and the wound was cleaned and sutured.

This patient is dehydrated and malnourished, so your first thought is that dementia may be involved, but her Folstein Mini-Mental score is 29/30. She says, “There’s nothing wrong with me that a little bandage won’t fix.”

While you are waiting for someone to take her to radiology for an X-ray, you ask her about her nutrition and mention that she is dehydrated. She says, “My daughter takes good care of me. I just forget to eat and drink. I’m stupid like that.” When you ask her about the bruise on her left arm she says, “I fall all the time, I’m just clumsy” You then ask her about her arthritis and mention that there are medications that can help with the pain. The patient becomes increasingly agitated. She says, “My daughter will be home from work soon and she will wonder where I am. How long is this going to take?”

You reassure the patient, but her agitation increases. Just as she says, “I’m going to have to leave.” The technicians arrive to take her for an X-ray.

X-ray: frontal bone fracture that extends to the roof of the left orbit. A nondisplaced isolated anterior table fracture is confirmed. There is no sign of subdural hematoma.

After the X-ray, the physician informs the patient that nondisplaced or minimally displaced (< 1-2 mm) isolated anterior table fractures can be managed conservatively with local wound care and analgesics. Patients should be closely observed for signs of frontal sinusitis, which may indicate fracture involvement in the nasofrontal duct.

The patient says, “Just bandage me up the best you can. I have to get home before my daughter does.”

What should you do?

 

August Saunders, ADN, CNA, LPN

Specializes in MedSURG nurse.

First try again to educate the patient on what’s going on and why she needs to be monitored. Offer to call her daughter for her and explain what is going on and the importance of why she needs to be monitored (to the daughter). Or if the patient is adamant on leaving, possibly her daughter should be listed as her emergency contact, so go ahead and call anyways ??? Educate her on s/s of what to look for. Offer her daughter some assistance on hooking her up with case management (if possible) so she could get some services to help with her mom while she’s at work. 

 

nursej22, MSN, RN

Specializes in Public Health, TB. Has 36 years experience.

Hmm, the patient seems to be fearful of her daughter...

Was a full body exam done to look for other injuries, besides the bruise on her arm. 

lde

Specializes in Student.

31 minutes ago, nursej22 said:

Hmm, the patient seems to be fearful of her daughter...

 Was a full body exam done to look for other injuries, besides the bruise on her arm. 

Yeah I agree. I would definitely probe that angle more as medically she seems reasonably stable apart from the poor nutrition and dehydration which hints at not having enough to eat and drink. The agitation each time the daughter is mentioned and the hurry to get home makes this more plausible.

I'd gently ask (and I don't know the best way) if she would like to speak to someone who is skilled with domestic violence cases. But that might get her more agitated. We can say we'll call the daughter and explain she is hurt and if she still resists there's definitely something up there. How does the patient react when we say its our duty to check for domestic violence issues?

Has she ever had similar injuries in the past? Who has helped out then? Also can we check for any other signs of Alzheimer's? (not sure that MMSE already covers this?)

Edited by lde

TriciaJ, RN

Specializes in Psych, Corrections, Med-Surg, Ambulatory. Has 40 years experience.

I would ask: "Beside your daughter, what other family do you have?  Do any of them live locally?" 

How did the patient get to the hospital?  Can Adult Protective Services be called?

I would be very loath to send the patient home on her own.  Ideally she would be admitted for rehydration and further evaluation.