Hello everyone, today I am going to present a case study of a paramedic report. The report includes the patient’s personal information, his condition, complaints, and medical history. Based on that information, the analysis of the patient’s health conditions regarding every organ system of the body is going to be presented.
In the end, a summary of the patient’s condition with a recommendation for further treatment is going to be made.
General information about the patient and the accident
General information tells us that the patient’s gender is male. Also, he is thirty-five years old. Fortunately, the patient did not lose consciousness and feel no dizziness. However, he has several complaints regarding his abdomen, arm, leg, and head.
Patient’s condition
The patient’s blood pressure shows hypertension of the second stage, indicating that there is a need for a medical treatment right away.
The pulse is out of normal range, which is 60-100 bpm, hence it is another indication of the patient’s critical health condition.
Breath rate can be a better indication of the patient’s physical condition. 24 is higher breath rate, indicating very serious physical condition.
Temperature of the patient is within the normal range. Pulse oximeter shows normal oxygen saturation.
Obviously, his left leg, left arm, and head were severely damaged.
Patient’s medical history
The patient’s medical history will be considered in further analysis of his condition.
The presence of type 1 diabetes indicates that the patient has problems with the endocrine system, particularly with insulin generation.
The excess of sugar in the blood might be a reason for high blood pressure as well. The reason is that the elasticity of blood vessels is decreased, which causes their narrowing. It results in oxygen deficiency, which causes high blood pressure.
Initial observation of the patient
Initial observation of the patient shows that he has damaged his forehead, having a cut and bump of two centimeters. Also, there is a significant injury in the elbow area, which can be identified by black and blue color, and a bone pushing the skin. The patient’s abdomen is decolorized as well as enlargement in his knee area. According to initial observation, the patient is in critical condition, which requires a full-body immediate medical check-up.
Integumentary system
In the patient’s case, his integumentary system was locally damaged.
Forehead cut, a bump, black and blue elbow area, discoloration of abdomen and knee indicates a damage in integumentary system of the patient.
The integumentary system is responsible for the protection of the body from various infections. Hence, immediate disinfection of the damaged parts of the skin is required to prevent the potential wound infection.
Musculoskeletal system
The initial observation of the patient showed that there is a sign of bone pushing out on the skin in the elbow area.
It clearly indicates that the musculoskeletal system of that area is damaged and in need of medical treatment.
Also, discoloration of the abdomen and knee means that the muscles of the area are significantly damaged.
Cardiovascular system
The patient has increased breath rate and pulse, meaning that the body is in need of oxygen. In order to sufficiently deliver the oxygen to the whole body, the heart starts working harder and faster. It obviously puts a lot of pressure on the cardiovascular system of the patient.
Respiratory system
The respiratory system provides the whole body with the required amount of oxygen. Any damage to the system might lead to oxygen shortage, which will affect the patient’s breath rate. Hence, the respiratory system should be checked for any damage.
Digestive system
The digestive system is located in the abdominal area of the body.
Patient’s complains about pain in his abdomen is an indication of the potential damage to the digestive system.
Reproductive system
Since the patient did not report any discomfort in the area of the reproductive system, there is no direct indication of any damage.
However, it is better to double-check and ask a patient if he feels any discomfort in that area.
Endocrine system
The patient has diabetes type 1, which means that his endocrine system is not generating enough insulin. The accident is a stressful situation for the body, which results in a release of epinephrine by adrenal glands. The release of epinephrine makes the pancreas generate glucagon, which increases blood glucose level. For a patient with type 1 diabetes, such a condition is very serious and requires immediate medical assistance.
Nervous system
Such a car accident will obviously result in the stress of any individual. For the patient who already has depression and anxiety, the accident puts extra pressure on the nervous system. Psychological assistance is required to decrease the stress and pressure on the nervous system.
Summary
- Considering the severity of the patient’s physical injuries, the pain in the lower quadrant of the abdomen might be an indication of internal injury or bleeding (potentially digestive system).
- Increased breath rate indicates the body’s critical condition, even though it can be explained by the patient’s asthma.
- Since the patient has type 1 diabetes, immediate medical treatment is required (insulin injection)
- Further treatment of the patient includes an Ultrasound or CT scan for check of internal bleeding along with psychological assistance.
References
Martini, F., Timmons, M. J., Tallitsch, R. B., Ober, W. C., Garrison, C. W., Welch, K. B., & Hutchings, R. T. (2006). Human anatomy (p. 904). San Francisco, CA: Pearson/Benjamin Cummings.
Respiratory System: Functions, Facts, Organs & Anatomy. Cleveland Clinic. (2020). Web.
Taylor, T. (2020). Integumentary System. Innerbody research. Web.