Assignment Task
SITUATION
Miss Hermione Granger, a 5-year old girl, was brought in by ambulance accompanied by her mother following a collision with a car whilst riding her bicycle. The collision was at low speed. The injuries she sustained include a suspected fracture of her left tibia and fibula, multiple grazes across her legs and feet, left hip, and shoulder. She has a 5cm laceration on her left elbow. Hermione was wearing her helmet but has sustained a small graze above her left eyebrow.
BACKGROUND
Miss Hermione Granger has no past medical and surgical histories. She lives at home with her parents and a younger brother. Miss Hermione Granger was born at 38 weeks gestation with no neonatal complications. Her immunisation is up to date.
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Her Glasgow Coma Scale (GCS) is 15, moving right upper and lower limbs with mild weakness, mild weakness in left upper limb and severe weakness in left lower limb. Both her pupils equal and reactive to light. Her vital signs are as follows: Heart Rate 130 bpm Respiration 30 bpm Blood Pressure 120/60 mmHg SaO2 99%. She was crying due to the injuries she sustained. All blood investigations were done, and results were unremarkable. CT Trauma done and was normal (Fig 1) including her left tibia and fibula
RECOMMENDATION
Continue neurological observations. Miss Hermione Granger will be kept Nil by Mouth (NBM) until she is awake. She has had IN Fentanyl STAT administered prior to CT Trauma and a second dose during the procedure. Miss Hermione Granger has analgesia prescribed as well as intravenous therapy
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