Name: Sparkle, Twilight
Age: 22
Sex: Female
Race: Unicorn
Date of Admission: 31/12 - 8:24 PM
Doctor in charge of the examination: Dr. Tender Care M.D.
Assisting nurses: Quick Patch, Mending Balm
Chief Complaint: Patient was unconscious, brought in by elite detachment of the EUP
History of Present Illness: The patient is a light purple unicorn mare in comatose state. The accompanying guards were not able to give an accurate account of the events precipitating the mare’s arrival at the emergency room. Per testimony of the Royal Guards, the patient was found amongst the rubble of her living quarters in the Canterlot Castle and upon checking her vitals, was immediately transferred to Canterlot General Hospital alongside her familiar. The patient was worked up back to stable levels here in the emergency room, but could not be awoken from her coma.
Past Medical History: Minor past admissions for exhaustion and severe fatigue during her stay at Princess Celestia’s School for Gifted Unicorns. Subject is slightly out of shape in part due to low-activity lifestyle.
Current Medications: 60mg Strottera (atomoxetine) per day.
Allergies: No known drug allergies, lactose intolerance.
Family History: Noncontributory
Social History: No history of tobacco, alcohol, recreational poison joke, or illicit drug use.
Review of Systems: Unable to review due to the patient’s status.
Physical Examination:
Vital Signs: Blood pressure 89/54, heart rate 52 bpm, respiratory rate 10, temperature 35 °C.
Skin: On physical examination, skin is pale, dry and warm. Several bruises of varying degrees of severity were found alongside minor lacerations correlating with the Royal Guard description of the circumstances of Miss Sparkle’s accident.
Coat: Slight singing of the fur in the left side of the face and neck, part of the chest and front limbs correspondent with the powerful release of a thaumaturgic energy.
HEENT: Intracranial pressure at 22mm Hg. Pupils were fixed and non-reactive to light. No eye discharge. No epistaxis.
Neck: Mild JVD. Supple. Respiratory effort is normal.
Chest: Clear with good breath sounds but below the safe range. Eighth and ninth left rib show signs of fracture, causing pressure in the lungs and heart.
Cardiac: Irregular rate and rhythm, arrived at the emergency room below safe levels and dropping.
Back: No CVA tenderness found.
Abdomen: Soft. Minimal tenderness in the suprapubic area. Bowel sounds are normoactive in all quadrants. No mass, guarding, rigidity or rebound tenderness.
Limbs: Front limbs show the same bruising and singing of the fur correspondent with the rest of the body. Back legs do not show the same damage to the fur, but the abundance of tender spots lead to believe patient was flung backwards, landing on her backside with force.
Neurological: There is reflex reaction in limbs to pain stimulus, but the patient does not respond to other kind of stimuli. She had no signs of basal skull fracture, but there was an abrasion with an ecchymosis to the left forehead and a smaller abrasion over the chin. Scalp, skull and facial bones appear to be intact. Brainstem reflexes, such as corneal and gag were intact.
Intervention: The patient was brought to stable condition in the Emergency Room and proceeded to be admitted to the hospital for long-term stay. Further analyses are required to fully determine the neurological damages the patient suffered due to her accident, as well as their extent. Additional clinical plans on hold pending those results.
Diagnoses:
Additional Observations:
We've done what we can to stabilise her. External wounds were treated, but all internal damage caused by the explosion must be await further exams before we proceed with treatment. Until then, she will be closely monitored and for any change in her condition.