A Fracture from a Fall: What's Going on Here?

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!

Updated: Feb 23, 2023

This article was reviewed and fact-checked by our Editorial Team.

A Fracture from a Fall: What's Going on Here?

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 98.9^oF
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!

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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About SafetyNurse1968, BSN, MSN, PhD

Patient Safety Columnist / Educator

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com.

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