Emergency Room Patient’s Health History and Care Case Study

Emergency Room Patient’s Health History and Care Case Study

Demographics

The patient is a 32-years-old male. He was admitted to Emergency Room (ER) 2 weeks ago. The patient was referred to the hospital by a general practitioner (GP).

Presenting Complaint

The patient was in good condition and did not have any critical healthcare issues before he got injured. He appeared in the ER because he had his finger amputated accidentally. It happened to him when he started splitting firewood. He cut his hand accidentally, injured his thumb finger, and amputated his index finger so that there was a necessity to consult a doctor. His case got worse over the course of time until he received the needed care.

History of Presenting Complaint

The patient claimed that he noticed the problem immediately and it got worse before he received treatment. He suffered from severe (10) pain in his hand until it was released with painkillers. The patient wanted his finger to be put in its place but was afraid that it would not be possible. He also thought that he could have had some infection in the wound.

Past Medical/Surgical History

In 2015, the patient had surgery, which dealt with his knee replacement. In addition to that, he had cleft palate surgery. What is more, the patient had 3 surgeries performed on the eye. Still, none of them have any relation to the current case and problems with his finger. The patient has no history of current and inactive medical conditions.

Drug History

The patient is taking painkillers to reduce the pain because of his injury: Bi Morphine is used to relieve pain 3 times a day and paracetamol is used 4 times a day (1000 mg).

Intravenous therapy is used to keep his blood pressure up as he has atrial fibrillation and his heart rhythm is irregular.

The patient has no allergies. No side-effects are noticed.

He has all obligatory vaccinations, including Flu, Td/Tdap, MMR, and Chickenpox (CDC 2016).

Family History

No diseases run in the family. Both parents are alive and have only age-related health issues, such as high blood pressure and farsightedness.

Social History

He has never smoked, drunk alcohol, or taking drugs.

The patient is a farmer so that he works outside the home a lot. He did not travel much and was at home recently. He has a dog.

The patient is divorced and has two male children, but he lives alone in a large one-story house. Being independent, he is able to take care of himself, walk and drive without any assistance.

Review of systems

  • Gastroenterology: no mouth ulcers, indigestion, nausea, vomiting, diarrhea, abdominal pain, constipation, or bleeding.
  • Genitourinary: no problems with passing urine.
  • Rheumatology: no weakness, stiffness, and joint pain. Swelling, pain, and limited mobility due to the injury but it is getting better.
  • Skin: no rash, lumps, itch, or hair changes.

Brief Summary of the Case

A 32-years-old male was admitted to the ER 2 weeks ago. He is a farmer with a work injury (finger amputation). Before the accident, he had several surgeries but was in a normal general condition. Now he is receiving painkillers and intravenous therapy.

Reflection/Discussion

I from this case that it is easier to treat a patient and reach positive outcomes if one did not have related health issues in the past. I also got to know that treatment with painkillers may be the best option in case of amputation.

On the wards, I noticed that the patient lacks his family’s attention and support. I believe that nurses and other members of the medical staff should be more attentive to him.

After the report, my views changed and I started to pay more attention, not to the problem that the patient has but to him as an individual.

Reference List

CDC 2016, 2016 recommended immunizations for adults: by age, Web.

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