Case Presentation
Molly Mc Donald is a 74-year old grandmother who lives alone in a home unit in a city suburb. At 11.00am one morning, Molly is discovered by her daughter, Clara, collapsed at the bottom of concrete steps leading out to her clothesline. Molly has sustained a gash to her forehead on the right side and blood pools around her face as she lies prone. Clara notes that although Molly answers to her name, she is confused as to where she is and what day it is. Molly is complaining of “pain in my head”. Clara does not want to shift Molly and anyway, she thinks she would not be able to stand. She calls Emergency Services (ES) who arrive within 10 minutes.
Question 1 (15 minutes)
(a) Describe the steps ES paramedics should take to assess Molly. For each step, provide a brief rationale.
Molly should be assessed for breathing, BP, bleeding, heart rate, as well as keep hear airways clear and stable. it is important nothing kills her and monitoring these and possibly providing care when needed is important.
Additionally try to get more information from Clara, as well as possibly putting on a neck brace, as possibly spinal injury could have occurred
Getting a GCS done is important, as well as monitoring any changes in vitals, or LOC.
also doing a blood glucose test could be needed, as there could by hypoglycaemia
(b) What information could be obtained by paramedics from Clara that would help them begin to form an idea as to the reason for Molly’s collapse and why is this important?
medication, past medical history, recent complaints, anthing molly has noticed. additionally how long she estimates she has been there. its important to ask all these to get more information and context to make decisions with
Clinical Update
During handover to medical and nursing staff in ED at 11.40am, the following information is conveyed: 74-year old female with traumatic head injury found lying face-down at the base of 3 steps onto concrete pathway. 5cm gash to right forehead, approximately 100mL blood loss from wound. GCS last taken at 11.20 and was 12 (E3V4M5). Compression bandage applied and has been reinforced due to wound continuing to ooze. Significant grazing to right forearm and a large amount of bruising but no overt signs of limb fractures. Neck brace in place. Time of collapse estimated to be somewhere between 8.30am and 10.45am, since patient’s daughter says mother likes to get her washing on the line sometime after 8.30 and she arrived to see mother at 11.00am. En route to hospital, patient experienced a single tonic clonic seizure. Daughter has accompanied the mother to ED.
On examination by the House Surgeon: Patient rousable but provides inappropriate replies to questions. GCS 11 (E3V3M5). Breath possibly smells of alcohol or some sort of volatile solvent. Complaints of severe headache right side. Head wound continues to ooze, forehead oedema beginning to extend to right eye. Grazing to right forearm. Large amount of bruising becoming apparent.
Neurological:
- Left pupil 3mm and reacts to light
- Right pupil 4mm and reacts sluggishly to light
- No facial asymmetry
- Motor: some weakness left leg. Right leg and arm normal power.
- Sensation localising to pain.
- Deep tendon reflexes increased on the left.
- Fundoscopy reveals no papilloedema
- No further seizure activity
Vital Signs:
- BP: 166/70
- Pulse: 62 b/min and regular
- Respirations: 16/min and laboured
- O2 saturation: 96% on room air
- Blood glucose level (finger prick): 6.8 mmol/L (normal)
Patient has a four-year history of hypertension, not well controlled (on metoprolol). Recently diagnosed with heart failure and atrial fibrillation, for which she is also taking dabigatran. Patient’s daughter reports patient is additionally self-medicating with daily aspirin (100mg) because she was told it would help her avoid bowel cancer. Daughter reports her mother has also been drinking alcoholic beverages heavily since losing her husband and she thinks that isolation and loneliness have a large part to play in this.
Question 2 (15 minutes)
(a) With reference to the information the House Officer has above, formulate a list of differential diagnoses for Molly’s presentation. Beside each possible diagnosis, provide a rationale for your thinking.
acute subdural bleed
epidural haemorrhage
subarachnoid bleed
intoxication precipitatinfg tbi
(b) State one (1) laboratory test or investigation that is not CT or MRI whose results could be used to support your diagnostic hypotheses.
alcohol blood test.
(c) Which diagnosis do you think is the most likely and why?
(d) Using the principles you have learnt regarding the systematic approach to interpreting head CT, list two (2) features you would expect to see on Molly’s CT head scan.
Clinical Update
Over the ensuing hours following CT a conservative management approach is taken, since surgical intervention carries too great a risk. Unfortunately, in the early hours of the next morning Molly’s status rapidly deteriorates. Molly becomes unresponsive, both pupils are fixed and dilated and she demonstrates decerebrate posturing. At 0600 hours, Molly, who during this time had been treated in the Intensive Care Unit, is pronounced dead by the registrar.
Clara is at Molly’s side as she passes. Staff provide Clara with a hot cup of tea while she contemplates the huge loss her mother is in her and her children’s life. Clara has three children, two teenage girls and a four-year old boy to her second husband. She wonders how she is going to deliver the bad news to her little boy.
Question 3 (5 minutes)
(a) Using your knowledge of the cognitive, social, moral and emotional development of a child of this age, discuss what you think might be the young boy’s ability to understand the concept of dying.
Answers
Case Presentation
Molly Mc Donald is a 74-year old grandmother who lives alone in a home unit in a city suburb. At 11.00am one morning, Molly is discovered by her daughter, Clara, collapsed at the bottom of concrete steps leading out to her clothesline. Molly has sustained a gash to her forehead on the right side and blood pools around her face as she lies prone. Clara notes that although Molly answers to her name, she is confused as to where she is and what day it is. Molly is complaining of “pain in my head”. Clara does not want to shift Molly and anyway, she thinks she would not be able to stand. She calls Emergency Services (ES) who arrive within 10 minutes.
Question 1 (15 minutes)
(a) Describe the steps ES paramedics should take to assess Molly. For each step, provide a brief rationale.
(b) What information could be obtained by paramedics from Clara that would help them begin to form an idea as to the reason for Molly’s collapse and why is this important?
Clinical Update
During handover to medical and nursing staff in ED at 11.40am, the following information is conveyed: 74-year old female with traumatic head injury found lying face-down at the base of 3 steps onto concrete pathway. 5cm gash to right forehead, approximately 100mL blood loss from wound. GCS last taken at 11.20 and was 12 (E3V4M5). Compression bandage applied and has been reinforced due to wound continuing to ooze. Significant grazing to right forearm and a large amount of bruising but no overt signs of limb fractures. Neck brace in place. Time of collapse estimated to be somewhere between 8.30am and 10.45am, since patient’s daughter says mother likes to get her washing on the line sometime after 8.30 and she arrived to see mother at 11.00am. En route to hospital, patient experienced a single tonic clonic seizure. Daughter has accompanied the mother to ED.
On examination by the House Surgeon: Patient rousable but provides inappropriate replies to questions. GCS 11 (E3V3M5). Breath possibly smells of alcohol or some sort of volatile solvent. Complaints of severe headache right side. Head wound continues to ooze, forehead oedema beginning to extend to right eye. Grazing to right forearm. Large amount of bruising becoming apparent.
Neurological:
- Left pupil 3mm and reacts to light
- Right pupil 4mm and reacts sluggishly to light
- No facial asymmetry
- Motor: some weakness left leg. Right leg and arm normal power.
- Sensation localising to pain.
- Deep tendon reflexes increased on the left.
- Fundoscopy reveals no papilloedema
- No further seizure activity
Vital Signs:
- BP: 166/70
- Pulse: 62 b/min and regular
- Respirations: 16/min and laboured
- O2 saturation: 96% on room air
- Blood glucose level (finger prick): 6.8 mmol/L (normal)
Patient has a four-year history of hypertension, not well controlled (on metoprolol). Recently diagnosed with heart failure and atrial fibrillation, for which she is also taking dabigatran. Patient’s daughter reports patient is additionally self-medicating with daily aspirin (100mg) because she was told it would help her avoid bowel cancer. Daughter reports her mother has also been drinking alcoholic beverages heavily since losing her husband and she thinks that isolation and loneliness have a large part to play in this.
Question 2 (15 minutes)
(a) With reference to the information the House Officer has above, formulate a list of differential diagnoses for Molly’s presentation. Beside each possible diagnosis, provide a rationale for your thinking.
(b) State one (1) laboratory test or investigation that is not CT or MRI whose results could be used to support your diagnostic hypotheses.
(c) Which diagnosis do you think is the most likely and why?
(d) Using the principles you have learnt regarding the systematic approach to interpreting head CT, list two (2) features you would expect to see on Molly’s CT head scan.
Clinical Update
Over the ensuing hours following CT a conservative management approach is taken, since surgical intervention carries too great a risk. Unfortunately, in the early hours of the next morning Molly’s status rapidly deteriorates. Molly becomes unresponsive, both pupils are fixed and dilated and she demonstrates decerebrate posturing. At 0600 hours, Molly, who during this time had been treated in the Intensive Care Unit, is pronounced dead by the registrar.
Clara is at Molly’s side as she passes. Staff provide Clara with a hot cup of tea while she contemplates the huge loss her mother is in her and her children’s life. Clara has three children, two teenage girls and a four-year old boy to her second husband. She wonders how she is going to deliver the bad news to her little boy.
Question 3 (5 minutes)
(a) Using your knowledge of the cognitive, social, moral and emotional development of a child of this age, discuss what you think might be the young boy’s ability to understand the concept of dying.