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!
"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?
