//------------------------------//
// Supplemental: Patient Notes 1 
// Story: Trust Once Lost 
// by Greenhorne 
//------------------------------//

*GREEN* (F)
MRN: 132719
Admitted: 12/5/04
Red Cross, M.D.

12/5/04 19:52
Unicorn Filly, name ukn, age ukn, assumed 8-10y/o, presenting to emergency with reduced LOC (GCS:9), lower RFL hematoma; gross deformity ?#, superficial cuts and bruises.

V: 
Febrile 100.7F
HR 102
BP 97/42
sats 98% on RA
BGL: 4.3
Ht: 2’3”
Wt: 52lb

N:
Rousable to pain
Speech slurred and incoherent
Pupils 30mm, equal and reactive
Non-compliant with hoof grip assessment
Nil facial droop, good strength in all limbs

C:
EKG no anomalies
Peripheral pulses strong
Severe hematoma lower RFL
Capillary refill <1s
IVC in situ lower LFL; 80mL/hr NS; patent and secure

R:
RR 22
98% on RA
Regular and unlaboured
Lung sounds clear

GI:
All teeth intact
Bowel sounds normal
Nil distension or masses on abdo palpation
BNO
NBM

GU:
Has not voided
Bladder not distended on palpation
Nil external signs of sexual trauma

M:
Gross deformity ?# lower RFL
Muscle strength normal

I:
Multiple superficial lesions (see body chart)
Coat appears healthy
Nil signs of healed injuries
Skin hot and sweaty

P:
Ukn

Hx: witnesses report Green was found injured and unconscious in the Everfree Forest. Witnesses report Green became confused and disoriented upon waking. Witness states “she thought we were timberwolves” and reports that Green was initially resistant until she could be reoriented. Witness states that Green “limped about ten miles” before collapsing. Nil Medical Hx as patient is unidentified.



CTB for urgent review

CXR, RFLXR, Dental XR for age estimation

CRP, CBC, EUC, LFT, Tox Screen, INR, XM

Cath for Urine Sample, UA, UDS, UCx

Place tracking spell for absconsion risk

NBM for surgery

For Ortho review

For Neuro review

For Social Worker review


Dr Red Cross, M.D.