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No past medical history
a-e Primary assessment
Secondary assessment

pain assessment - PQRST
- Wound assessment: can indicate what kind of trauma or what kind of surface he fell onto (given he cant remember).

cardiac assessment

physical assessment

GSC

AVPU
CT brain
blood tests - troponin
ECG
postural BP
possible UTI?
what medications is he on?

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Possible stroke or myocardial infarction
Fracture?
Dislocation?

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69 year old man
fall
cant remember how he fell
no allergies
no medical history
contact family members, next of kin or people at the site of the fall
interpreter if NESB
small abrasion to the head
left arm pain (could be a symptom of radiating heart pain)

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possible delirium

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Is an ECG required?
Are the vital signs BTF?
Consider pain management?
Consider wound management
is cardiac monitoring required?

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Pain Relief
Social worker

imaging (CT, Brain, limbs)

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manage pain
improve mobility

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PT and OT
Medication review

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Has his pain subsided? Or does he need long-term medication for the pain

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Possible care plan or assess for mobility aids - discharge planning

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head injury

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has his mobility improved?

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is he still confused?

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Bob the builder, YES WE DID!

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IV access - basic electrolytes, troponin