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!

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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 98.9oF
  • 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!

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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SafetyNurse1968

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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Specializes in Psych, Corrections, Med-Surg, Ambulatory.

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?

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Specializes in Public Health, TB.

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? 

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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. 

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Specializes in Public Health, TB.
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. 

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Specializes in Education, Informatics, Patient Safety.

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.

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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.

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Specializes in LTC, assisted living, med-surg, psych.

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

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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?? 

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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 

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Specializes in Ortho-Neuro.

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?

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Specializes in Ortho-Neuro.

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?

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