This is a case study involving a 35 year old male called P.D., who was brought to the emergency department complaining of a sore shoulder. He states that he forced off the road while riding his motorcycle, and he sideswiped a telephone pole. He did not lose consciousness. A urine specimen reveals gross hematuria. P.D. also states that a tape player in the right pocket of a leather jacket is shattered.
Subjective Data- Patient states, “he has a sore shoulder”. Patient also states “ he was forced off his motorcycle and sideswiped a telephone pole”. Patient denies losing consciousness and states “a tape player in the right pocket of a leather jacket is shattered”.
Objective Data: Urinalysis reveals gross hematuria.
Initial …show more content…
The most reliable signs and symptoms in alert patients like P.D. are pain, tenderness, gastrointestinal hemorrhage, hypovolemia and evidence of peritoneal irritation. Priorities for the patient with actual or suspected trauma taken from abdominal trauma: Dealing with the damage (Blank-Reid 2007). Maintain ABCs – Patient is speaking, so airway is patent. No evidence of breathing difficulty, but could develop later, so monitor breathing. Circulation is important, since the urinalysis revealed gross hematuria, there could be bleeding at multiple locations. Monitoring for signs of internal bleeding is priority. Rapid neurological exam should be performed. The patient denies loss of consciousness, but he could have lost consciousness and doesn’t remember it. Brief focused medical history – previous trauma, medications, allergies, and preexisting medical conditions. Assess the abdomen comparing left side to right side: Inspection, Auscultation, Percussion, and Palpation. Assess the chest for broken ribs; assess the liver since the damaged tape player is on the right side. Assess the kidneys, comparing the left to the right. Make sure the patient has venous access in case of need to start IV or take blood for labs. Labs- CBC, H&H, ABGs, BUN, PT, PTT, Electrolytes, BUN, Creatinine, type and cross match in preparation for blood replacement. Serum amylase and lipase levels. Diagnostic exams may be ordered – CT,
Subjective Data- Patient states, “he has a sore shoulder”. Patient also states “ he was forced off his motorcycle and sideswiped a telephone pole”. Patient denies losing consciousness and states “a tape player in the right pocket of a leather jacket is shattered”.
Objective Data: Urinalysis reveals gross hematuria.
Initial …show more content…
The most reliable signs and symptoms in alert patients like P.D. are pain, tenderness, gastrointestinal hemorrhage, hypovolemia and evidence of peritoneal irritation. Priorities for the patient with actual or suspected trauma taken from abdominal trauma: Dealing with the damage (Blank-Reid 2007). Maintain ABCs – Patient is speaking, so airway is patent. No evidence of breathing difficulty, but could develop later, so monitor breathing. Circulation is important, since the urinalysis revealed gross hematuria, there could be bleeding at multiple locations. Monitoring for signs of internal bleeding is priority. Rapid neurological exam should be performed. The patient denies loss of consciousness, but he could have lost consciousness and doesn’t remember it. Brief focused medical history – previous trauma, medications, allergies, and preexisting medical conditions. Assess the abdomen comparing left side to right side: Inspection, Auscultation, Percussion, and Palpation. Assess the chest for broken ribs; assess the liver since the damaged tape player is on the right side. Assess the kidneys, comparing the left to the right. Make sure the patient has venous access in case of need to start IV or take blood for labs. Labs- CBC, H&H, ABGs, BUN, PT, PTT, Electrolytes, BUN, Creatinine, type and cross match in preparation for blood replacement. Serum amylase and lipase levels. Diagnostic exams may be ordered – CT,