The following excerpts have been taking from a patient – Maisie Wilson’s, electronic medical...

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The following excerpts have been taking from a patient – Maisie Wilson’s, electronic medical record.
Maisie Wilson
DOB: 14/10/1948
Sex: F UR: XXXXXXXXXX
Ambulance Notes:
1620 hrs A
ived to find pt lying at bottom of the stairs on her left side. Facial laceration to left
eye
ow approx. 3 cm. Pt reporting pain in L) hip and unable to get up. States she “tripped
on the rug” just after 8am and has been on the floor since, denies falling down the stairs or
LOC. Her husband found her about 1600 when he returned home. GCS 14 – (E4, V4, M6),
orientated to place and person but confused to time. PEARL 2+, BP 150/83mmHg, PR 98
pm, RR 16, SpO2 95% RA, Temp 36.3, Pain 7/10. Pt has been incontinent of urine and
faeces.
1623 hrs IVC inserted and IV morphine 5mg given. C-spine collar placed.
1624 hrs Left leg externally rotated and shorter than right
1628 hrs PR 91 bpm regular, BP 145/75mmHg, RR 14, SpO2 95% RA IV morphine 5mg
1635 hrs Transfe
ed to stretcher with spinal precautions, legs splinted for transport
ED Notes:
1650 hrs, Nursing Notes: New patient Maisie Wilson, 74, admitted to ED via ambulance after a fall at
home. Pt reports being “stuck on the floor” for about 8 hours until her husband found her and called
the ambulance. Pt was found at bottom of staircase from upstairs bedroom but denies falling down
the stairs, stated “I tripped on the rug and hit my head on the banister as I fell”. Pt unsure if LOC
occu
ed but doesn’t think so. Incontinent of urine and faeces while on floor. Pt states hasn’t eaten
or drunk anything today. History of HTN, osteoporosis, osteoarthritis, and a hysterectomy in 2009.
Normally takes atenolol, Panadol osteo and alendronate but pt doesn’t think she had any tablets
today. CNS: Pt alert but confused to place and time, orientated to person. GCS 14 – (E4, V4, M6) and
PEARL 2+. Reports 6/10 pain to L) hip and 4/10 pain to head. Pt given IV morphine 5mg. Spinal
precautions and collar insitu due to fall and head strike. Pt encouraged to lie still but attempting to
get up or move around in the bed. Spinal precautions explained but little change to behaviour, pt
unable to explain why she wants to get up. Pt can move all 4 limbs with normal strength except left
leg which is weaker and painful on movement. No abnormal sensation reported. CVS: PR 100, BP
148/96, pulses palpable in all 4 limbs. Cool to touch centrally and peripherally, temp 36.4. Capillary
efill <3 seconds to all limbs and colour normal. R)cubital fossa IVC inserted by ambulance, no signs
of infection and dressing intact. Resp: RR 19 and SpO2 96% on RA. Chest sounds clear. GIT: Pt c/o
thirst. Given mouth care but NBM at this time. Abdo soft and non tender, bowel sounds present.
Incontinent of faeces while on floor, pt denies normally having any problems with incontinence.
Renal: Denies needing to void now, incontinent of urine earlier. Endo: BGL 3.5mmol/L, no history of
diabetes according to patient. Skin: Laceration to left forehead just above pt’s eye
ow, approx. 3cm
long, awaiting Dr review. Dry blood to face and cut, oozing still when cleaned. Bruising to L) side of
face and L) hip noted. L) leg externally rotated and shorter than R) leg. Grazes to arms noted but
superficial and no dressings required. No other skin
eakdown noted although awaiting log roll to
check pt’s back. Social: Pt’s husband John, in attendance, bought in by ambulance. John stated he
was out playing golf with friends today and found Maisie on his return home. John is very teary and
apologetic to patient, stating “I’m so so
y” and “This is my fault”. Attempted to reassure John he did
nothing wrong. John and Maisie have a son, Michael who lives in Geelong. John has contacted
Michael who is coming in. They also have a daughter Kathy who lives in Canbe
a, she is waiting to
hear from the doctors before she flies down as she is caring for her grandchildren this week. Plan:
Log roll and complete wash and skin assessment of patient once morphine has reduced pain. For Dr
eview and further tests. N.Stewart (RN)
1700 hrs Nursing notes: Pt c/o nausea. IV ondansetron given as per Dr. Bed tilted head up while
maintaining spinal precautions. Further mouth care given as tongue and lips very dry and
cracked. N.Stewart (RN)
1720 hrs ED Dr Nguyen
Admitted post fall at home, on floor 8 hours.
Alert and restless. Confused to time and place, orientated to person. Head strike during fall.
Laceration to face – will need gluing together.
Chest clear, abdo soft
Fasting all day
Pain to L) hip, leg externally rotated and shortened
Plan: L) hip and pelvis xray
Head and spine CT
IV fluid as charted
Glue to face laceration.
NBM till results
Dr K. Nguyen
1830 hrs Addit: CT clear and no spinal tenderness on palpation, remove collar and cease spinal
precautions. Xray shows fracture to left NOF.
Refer to ortho. Pt will need open reduction and internal fixation.
Admit to ward, RIB till post-surgery.
Still c/o significant hip pain despite regular morphine – refer to anaesthetics for fascia iliac nerve
lock.
Dr K. Nguyen
1930 hrs Anaesthetics Dr Kyle
L) leg fascia iliac nerve block given. Pt reports no allergies or previous surgery to area. Ultrasound
guided insertion of ropivacaine 0.375% 35ml completed using sterile technique. Pt now reports pain
3/10. Will need 15-minute monitoring for 2 hours then 4 hourly. Report increased pain to on call
anaesthetist overnight. Dr Kyle

maisie-wilson-anaesthetic-chart-k44ji1em.pdf maisie-wilson-general-observation-chart-t3u3wmat.pdf maisie-wilson-ivt-orders-55v3x45g.pdf maisie-wilson-medication-chart-5k4v1uip.pdf maisie-wilson-progress-notes-brcfmd33.pdf

Dr. Sulabh · Accepted Answer

1
Anesthetic chart analysis:
	The female patient in this case study is named Maisie Wilson who is suffering from hip and face injuries after falling from stairs. Further injections of anesthetic medicines like fentanyl, midazolam and propofol medicines were given to this patient to decrease the conscious state and the pain suffering in this patient. The condition of this elderly female patient is being monitored in a hospital setting. The parameters which are being measured include an analysis of respiration rate, partial pressure of oxygen, carbon dioxide, cardiac rhythm and tidal volume. Further laryngoscopy was performed to analyze and monitor the condition of this patient. This patient was kept on a ventilator inhalation system with monitoring. A urinary catheter was used for draining the urine from the urinary bladder and the volume of the urine excreted from the body was also measured. The respiration rate of this patient is normal with a value of 14 breaths per minute. The tidal volume of this patient is high with a value of 550ml in comparison to the normal value of 400ml. Further blood pressure monitoring and electrocardiography monitoring was performed for this patient (Magazine et al., 2017). 
General observation chart:
	In the general observation chart, the respiration rate of this patient is normal in the range of 15-20 as depicted in the chart. The oxygen saturation levels in the range of 95%-100% are considered normal. As observed in the observation chart the oxygen saturation levels are in the range of 95%-97% which is considered normal. The normal systolic blood pressure is 120mmHg and the normal diastolic blood pressure is 80mmHg. Thus the levels of blood pressure in mmHg are elevated in this patient in the range of 90mmHg-160mmHg. The heart rate of this patient is in the range of 90-100 beats per minute which is high in comparison to the normal heart beat rate range of 60-100 beats per minute. In the general observation chart, the body temperature is less in the range of 36 degrees -37 degree centigrade. Further, this patient is being monitored and kept on the intravenous therapy of 5% dextrose solution and Hartmann solution with constant monitoring by a nurse and physician. 
Medicine chart observations:
	This patient was given a dose of painkiller medicines like paracetamol and morphine. The medicine ondansetron was given to lessen the intensity of the occurrence of nausea in this patient. Ropivacaine was given in the form of a general anesthetic agent. Atenolol medicine was given to the patient to decrease the increased levels of blood pressure and hypertension in the patient. This patient is also suffering from the disease thromboembolism in the veins for which the medicine warfarin was given to this patient. There is an occlusion in the veins of this patient with abnormal blood clotting which is being treated with an anticoagulant medicine warfarin. The time duration and intervals of prescribing a medicine were also noted and reported in the medical report. 
History of this patient:
The case study of this elderly patient reveals that she is suffering from osteoarthritis, osteoporosis and hysterectomy. The doctor prescribed an X-ray imaging of the hip region, spinal region, and head to analyze the intensity of bone trauma and fracture. This patient is in agony and she is suffering from serious pain for which painkillers were prescribed to this patient. Initially, the pain level decreased from an intensity scaling of 7/10 to 3/10 after the prescription of the painkiller medicines. After falling from stairs there is an increase in the chance of the formation of blood clots and hemorrhages. Further bone fracturing takes place and there is an occurrence of spinal-related and brain-related injuries which may deteriorate the condition of this patient. The intensity and trauma of injury after a fall depend upon the height, width and length of the stairs from which the fall has taken place.
General perspectives:
 	If the height from which the fall has taken place is more, then the intensity of the formation of the wounds and injury is also more. Further intensity injury scale,

The following excerpts have been taking from a patient – Maisie Wilson’s, electronic medical record. Maisie Wilson DOB: 14/10/1948 Sex: F UR: XXXXXXXXXX Ambulance Notes: 1620 hrs Arrived to...

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