The Summer Sun Incident

by Zaid ValRoa

Canterlot General Hospital - Emergency Room Report 28-013/S

Name: The Dragon, Spike
Age: 12
Sex: Male
Race: Dragon

Date of Admission: 31/12 - 8:26 PM

Doctor in charge of the examination: Dr. Bonesaw M.D.
Assisting nurses: Sweetheart

Chief Complaint: Dizziness and minor bruising.

History of Present Illness: The patient is a young dragon presenting signs of confusion and lightheadedness. As stated by the Royal Guard upon arrival, the patient was found amongst the rubble of the Southern Tower of the Royal Castle.

Past Medical History: Previous admission for onset symptoms of carpal tunnel syndrome due to his work as a scribe.
Current Medications: None.
Allergies: No known drug allergies.
Family History: Noncontributory
Social History: No history of tobacco, alcohol, recreational poison joke, or illicit drug use.
Review of Systems: The patient denies any discomfort beyond his bruises. Reaction time slow due to lightheadedness. Otherwise, as stated above in in HPI.

Physical Examination: Discrepancies must be reviewed due to patient's draconic nature

Vital Signs: Blood pressure 135/87, heart rate 120 bpm, respiratory rate 16, temperature 42 °C.
Skin: On physical examination, scales prevent an accurate analysis of the skin. A few bruises of varying degrees of severity were found, but the scales appear to have prevented any major laceration or puncturing.
Coat: Nonapplicable
HEENT: Intracranial pressure at 12mm Hg. Minor bruising on the lower left side of the head. No eye pain. No eye discharge. No epistaxis. No sinus pain. No sore throat. No odynophagia. No ear pain. No congestion.
Neck: Denies any neck pain.
Chest: Clear with good breath sounds within the safe range.
Cardiac: Regular rate and rhythm.
Back: No CVA tenderness found.
Abdomen: Soft. Bowel sounds are normoactive in all quadrants. No mass, guarding, rigidity or rebound tenderness. No GI upsets.
Limbs: Arms show the most damage, the abundance of tender spots and scorch marks led to believe patient raised arms to protect himself from the explosion.
Neurological: He had an episode of mild confusion. Minor headache corresponding to head bruising. No syncope or seizure. There is reflex reaction in limbs to pain stimulus. No signs of basal skull fracture. Scalp, skull and facial bones appear to be intact. Brainstem reflexes, such as corneal and gag were intact.

Intervention: The patient was admitted for the night, and will be discharged to home once he is stabilised. Further analyses are required to determine any neurological damages not discovered on initial examination.

Diagnoses:

• Minor head trauma and bruising.
• Lightheadedness produced by aforementioned head trauma.

Additional Observations:
He is a lucky one. I don't know what should be thanked for him getting out of the explosion with just a mild concussion, if him being a dragon or what, but he is in good shape, all things considered. Specially when compared to how Miss Sparkle fared. Let him rest for the night, nurse Sweetheart will keep an eye on him to make sure he heals well.

Comments

[circs]

As a former transcriptionist, bravo!