Short Case A
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Dispatch details
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Called to an unknown situation at a beach (located adjacent to
tropical waters)
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Time of Day
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1530 hours
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Time to scene
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35 mins
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Time to hospital
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1 hour
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Partner
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Single Officer
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Scene
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Pt located under a tree in the park beside the beach
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General appearance
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Conscious, alert, in obvious pain, nauseated and vomiting.
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Presenting history
**please note student has to ask specific questions to attain this
information.
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Patient had been swimming and felt something brush against their lower
leg when in the water. Initially felt
itchy. Within 30 minutes began to
experience pain to lower back, and abdomen, diaphoretic, nauseated, vomited
multiple times.
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Primary Survey
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Danger - Nil
Response – Alert
Airway – Clear
Breathing - adequate to
sustain life
Circulation – adequate to sustain life
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Observations
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Temperature
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37.1
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Pulse
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130
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Respirations
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32
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Blood Pressure
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180/110
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SpO2
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99% room air
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BSL
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8.0 mmol
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Chest auscultation
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Coarse Crackles basal lung fields
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End tidal CO2
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33 mmHg
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GCS
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Eyes open
Verbal orientated
Motor reluctantly obeys commands
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Pupils
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PEARL size 2
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Skin
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Colour – pale but flushed face
Temperature - warm
Moisture – diaphoretic
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ECG
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Sinus tachycardia occasional VEB
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Assessment Task
1. Complete
a primary survey.
2. Gather
a history which will enable you to make a provisional diagnosis.
3. Complete
a head to toe assessment which will assist you to make a provisional
diagnosis.
4. Provide
a single specific provisional diagnosis for this patient.
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PMSC 13006 Short Case A
Marking rubric
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Student Name
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Student Number
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Assessor Name
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Student Mark and Feedback
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Total
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/
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Comments/Feedback for Students
**Assessors
please note feedback should note what segments the student performed well and
any points for improvement. Any
feedback should be delivered in as supportive manner as possible.
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Assessment Item
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Completed
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Not completed
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1. Primary Survey
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Verbalises assessing danger or actions
indicate student has assessed danger to satisfaction of assessor
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Checks patient response or verbalises
patient is alert because of patient presentation
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Checks patient’s airway is clear or
verbalises clear because of patient presentation
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Checks patient’s breathing is adequate to
sustain life or verbalises same because of patient presentation
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Checks patient’s circulation is adequate to
sustain life or verbalises same because of pulse check or patient
presentation
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Undertake Assessment required to make a
provisional diagnosis
If required student may be prompted to go
straight from primary survey to assessing the head to toe
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2. Head to Toe Assessment
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Completed
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Not completed
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Assesses head and neck – visual examination
only is acceptable.
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Assesses chest – auscultation of chest and
visual examination only is acceptable.
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Assesses abdomen – palpation of abdomen and
visual examination only is acceptable.
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Assesses pelvis – either visual examination
or gentle palpation is acceptable
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Investigates Lower Limbs for sting pattern –
reddened area by moulage.
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Checks arms for further sting patterns
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Checks back for further sting patterns
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3. History taking to assist with making
a Provisional Diagnosis
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S -Investigates Signs and Symptoms including Pain Assessment (OPQRST)
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A -Asks if patient has any Allergies AND investigates what
reaction they suffer
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M -Asks if patient is taking any Medication
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P -Asks patient or bystander/family member if patient has any
past medical history
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L – List of lasts including Last ate and last drank, last menses
if female patient, last seen Dr.
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E -Investigates events leading up to patient/bystanders calling
an ambulance
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4. Provides a provisional diagnosis
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Provisional diagnosis of Irrukandji syndrome
should be formed for this patient
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