ROYAL HOBART HOSPITAL

EMERGENCY DEPARTMENT PHYSICIAN ASSESSMENT

Patient Name: LAHEY, Sarah Jane
UR Number: 2018-ED-07291830
Date of Birth: 13/03/1989
Age: 29 years
Sex: Female
Date of Assessment: 29 July 2018
Assessing Physician: Dr. Finn Montgomery, MBBS, FACEM
Position: Head of Emergency Department

PATIENT IDENTIFICATION AND PRESENTATION

Time of Assessment: 19:38
Location: Emergency Department, Bay 4
Referral Source: RN Jackson Roberts (post hand laceration repair)

Chief Complaint: Head injury with concussive symptoms following reported fall during police operational duties

Current Status: Patient alert, oriented x3, cooperative with examination. Right hand freshly sutured (6 interrupted sutures, mid-palm laceration), dressed appropriately. Patient reports persistent headache, nausea, light sensitivity following head impact approximately 2.5 hours prior to presentation.

HISTORY OF PRESENTING COMPLAINT

Mechanism of Injury (as reported by patient):

Patient states she sustained injuries during search of residential premises at Berriedale Road, Glenorchy whilst performing detective duties approximately 17:00-17:15 today. Reports losing footing whilst moving through dimly lit room, falling forward. States she caught right hand on broken glass from window during fall, simultaneously striking left side of head against wall.

Immediate Post-Injury:

• No loss of consciousness (patient emphatic on this point)
• Immediate awareness of both injuries
• Self-applied pressure bandaging to hand using shirt sleeve
• Remained at scene briefly before self-driving to hospital
• Partner (Detective Karl Murphy) present at scene but uninjured

Current Symptoms:

• Headache: Severe (8/10), left temporal-parietal region, constant, throbbing quality, exacerbated by movement and light
• Nausea: Moderate, persistent, improved slightly with antiemetic
• Light Sensitivity: Significant, patient squinting against overhead lighting throughout examination
• Dizziness: Mild, primarily with position changes or rapid head movement
• Concentration: Patient reports difficulty maintaining focus, thoughts "feel slow"

Symptoms Denied:

• Loss of consciousness at any point
• Amnesia (retrograde or anterograde)
• Vision changes beyond light sensitivity (no diplopia, scotomas, or blurring)
• Vomiting (nausea only)
• Seizure activity
• Weakness or numbness in extremities
• Clear fluid from nose or ears
• Neck pain or stiffness

PAST MEDICAL HISTORY

• No significant chronic medical conditions
• No previous head injuries requiring medical attention
• No history of seizures or neurological disorders
• No history of bleeding disorders

Medications: None regular
Allergies: NKDA
Tetanus Status: Current (2015)

Social History:

• Occupation: Detective, Tasmania Police (active duty)
• Non-smoker
• Alcohol: Social, occasional
• Lives independently

VITAL SIGNS

Time: 19:38

• Blood Pressure: 136/84 mmHg
• Heart Rate: 82 bpm (regular)
• Respiratory Rate: 16 breaths/min
• Temperature: 37.2°C
• SpO2: 99% on room air
• Pain Score: 8/10 (headache), 4/10 (hand post-suturing)

PHYSICAL EXAMINATION

General Appearance:Alert, oriented x3. Patient appears fatigued, maintaining controlled professional demeanor throughout examination. Slight pallor noted. Patient consistently squints against examination room lighting, requests dimmer environment.

Head and Scalp Examination:

Careful palpation of entire scalp performed. Significant finding:

• Left temporal-parietal region: Large, boggy haematoma, approximately 6cm x 4cm, tender to palpation
• Location: Positioned just superior and posterior to left ear
• No open wounds, lacerations, or abrasions to scalp
• No palpable skull deformity or crepitus
• No step-offs or depression
• Scalp otherwise intact, no other areas of tenderness

Neurological Examination:

Glasgow Coma Scale: 15/15

• Eyes: 4 (spontaneous)
• Verbal: 5 (oriented)
• Motor: 6 (obeys commands)

Cranial Nerves:

• CN I (Olfactory): Not formally tested
• CN II (Optic): Visual acuity grossly intact, reads wall chart appropriately despite light sensitivity. Visual fields full to confrontation.
• CN III, IV, VI (Oculomotor, Trochlear, Abducens):
  • Pupils equal (4mm), round, reactive to light bilaterally
  • Extraocular movements intact all directions
  • No nystagmus noted
  • Mild discomfort with rapid eye movements (patient reports increased headache)
• CN V (Trigeminal): Facial sensation intact bilaterally, jaw strength symmetric
• CN VII (Facial): Facial movements symmetric, no weakness or asymmetry
• CN VIII (Vestibulocochlear): Hearing grossly intact bilaterally, Rinne and Weber tests not formally performed
• CN IX, X (Glossopharyngeal, Vagus): Palate elevates symmetrically, gag reflex present
• CN XI (Accessory): Shoulder shrug and head turn strength symmetric
• CN XII (Hypoglossal): Tongue protrudes midline, movements normal

Motor Examination:

• Tone: Normal throughout
• Power: 5/5 all major muscle groups bilaterally (upper and lower extremities)
• Right hand: Limited assessment due to fresh injury and sutures, but patient able to flex fingers with moderate discomfort
• No drift with eyes closed, arms extended

Sensory Examination:

• Light touch intact bilaterally upper and lower extremities
• Pain/temperature: Grossly intact
• Right hand: Decreased sensation immediate to wound (expected post-injury and local anaesthetic)

Reflexes:

• Biceps, triceps, brachioradialis: 2+ bilaterally and symmetric
• Patellar, Achilles: 2+ bilaterally and symmetric
• Plantar: Downgoing bilaterally
• No pathological reflexes elicited

Coordination:

• Finger-to-nose: Intact bilaterally (limited right hand due to injury)
• Heel-to-shin: Intact bilaterally
• Rapid alternating movements: Intact, though patient reports increased headache with sustained testing

Gait and Station:

• Patient able to stand without support
• Romberg: Negative
• Gait: Steady, appropriate, no ataxia noted
• Tandem walk: Accomplished with mild unsteadiness, patient reports increased dizziness

Neck Examination:

• Full range of motion without pain
• No midline cervical tenderness
• No posterior cervical muscle spasm
• Kernig's sign: Negative
• Brudzinski's sign: Negative

COGNITIVE ASSESSMENT

Orientation:

• Person: "Sarah Jane Lahey"
• Place: "Royal Hobart Hospital, Emergency Department"
• Time: Correctly identifies day (Sunday), date (29 July), year (2018), approximate time

Memory:

Immediate Recall:

Words given: Apple, Table, Penny

Immediate repetition: Correct

Short-term Memory:

After 5-minute interval with other testing: "Apple, Table, Penny" - all correct

Long-term Memory:

Patient able to recall personal history, recent events, details of investigation work appropriately

Attention and Concentration:

• Serial 7s: 100, 93, 86, 79, 72, 65 - completed accurately but more slowly than expected for someone of patient's education/intelligence
• Spell "WORLD" backwards: D-L-R-O-W - correct but required visible concentration
• Patient notes difficulty maintaining focus, describes thoughts as "slightly foggy"

Higher Cognitive Function:

• Speech: Fluent, appropriate, no dysarthria or word-finding difficulty
• Comprehension: Intact
• Judgment: Appropriate responses to hypothetical scenarios

ASSESSMENT AND DIAGNOSTIC IMPRESSION

Primary Diagnosis: Moderate Concussion (Post-Concussive Syndrome)

Evidence Supporting Diagnosis:

1. Significant head impact with immediate onset of symptoms
2. Persistent headache (8/10 severity) refractory to standard analgesia
3. Nausea and light sensitivity
4. Cognitive symptoms (difficulty concentrating, "foggy" thinking)
5. Large haematoma at impact site confirming significant force
6. Neurological examination otherwise normal - no focal deficits

Severity Assessment: Moderate

• Glasgow Coma Scale maintained at 15
• No loss of consciousness reported
• No amnesia
• However: Significant symptom burden, persistent headache, cognitive complaints, substantial haematoma

Secondary Diagnosis: Right palm laceration (treated, sutured)

MECHANISM OF INJURY ANALYSIS

Patient's Reported Mechanism:Forward fall whilst moving through room, catching hand on broken glass, striking head against wall.

CRITICAL OBSERVATION - INCONSISTENCY NOTED:

The injury pattern observed does NOT fully align with the reported mechanism of injury. Specific concerns:

1. Head Impact Location:
   • Patient reports falling forward and hitting wall
   • Impact site is LEFT TEMPORAL-PARIETAL (side of head)
   • Forward fall mechanics would typically produce FRONTAL impact (forehead, face)
   • Lateral head impact suggests DIFFERENT PHYSICS:
     • Person was pushed/struck from side, OR
     • Person's head struck something while moving laterally, OR
     • Fall occurred with rotational component not described
2. Hand Injury Pattern:
   • Single, clean palm laceration
   • Consistent with hand PRESSED AGAINST or PUSHED INTO glass rather than catching oneself during fall
   • Typical fall reflex produces:
     • Multiple contact points (palm AND heel of hand, possibly forearm)
     • Defensive wounds on multiple surfaces
     • Associated bruising from impact force
   • Observed injury: Isolated palm laceration, no associated defensive injuries
3. Absence of Other Expected Injuries:
   • No facial injuries or bruising (would expect if falling forward toward wall)
   • No knee, hip, or shoulder injuries (would expect from fall to ground)
   • No scrapes or abrasions anywhere (would expect from uncontrolled fall)
   • ONLY injuries: Side-of-head haematoma and single palm laceration

Alternative Mechanism Consideration:

The injury pattern is MORE CONSISTENT with:

• Lateral force to head (pushed, shoved, or struck from side)
• Hand pressed into glass during struggle or restraint
• Possibly during physical altercation or confrontation
• NOT consistent with simple forward fall as reported

Documentation Note:

This discrepancy between reported mechanism and observed injury pattern is MEDICALLY SIGNIFICANT and is being documented in this assessment. The injuries observed suggest different circumstances than those reported by patient.

Patient was given opportunity during examination to clarify or expand on mechanism - patient maintained original account without elaboration. When gently questioned about discrepancies, patient became slightly defensive, reiterated fall narrative.

Recommendation: This inconsistency should be noted for administrative/supervisory review. Medical treatment proceeds based on injuries present regardless of mechanism, but the documented concern may be relevant for workplace safety review or other administrative purposes.

IMAGING AND INVESTIGATIONS

CT Head: NOT indicated at this time

Rationale:

• GCS maintained at 15
• No loss of consciousness
• No focal neurological deficits
• No signs of skull fracture
• Patient alert, oriented, appropriate
• Haematoma is superficial (scalp), no signs of underlying skull injury

Canadian CT Head Rule Applied: Low risk for neurosurgical intervention

• GCS 15 at 2 hours post-injury ✓
• No suspected skull fracture ✗
• No vomiting (nausea only) ✗
• Age <65 years ✓
• No amnesia ✗
• No dangerous mechanism (by reported account) ✗

Patient does not meet criteria requiring mandatory CT imaging. Clinical observation appropriate.

Other Investigations:

• None required at this time
• Hand laceration: No radiograph needed, no concern for retained foreign body

MANAGEMENT AND TREATMENT PLAN

Immediate Management:

1. Analgesia:
   • Paracetamol 1g PO administered at 19:55
   • May repeat every 6 hours as needed
   • AVOID: Aspirin, NSAIDs (bleeding risk with head injury)
2. Antiemetic:
   • Metoclopramide 10mg PO (already given during triage)
   • May repeat if nausea persists
3. Observation Period:
   • MINIMUM 4 hours observation in Emergency Department
   • Hourly vital signs and neurological observations
   • Assessment for symptom progression
   • Specifically monitoring for:
     • Worsening headache
     • Onset of vomiting
     • Vision changes
     • Altered level of consciousness
     • Any new neurological symptoms

Discharge Criteria (to be met before release):

• Stable vital signs x2 consecutive observations
• No worsening of symptoms during observation
• Patient able to tolerate oral fluids
• Responsible adult available for monitoring
• Patient/escort understand warning signs requiring return

ACTIVITY RESTRICTIONS AND PRECAUTIONS

Strict Instructions (explained verbally and provided in writing):

REST REQUIREMENTS:

• Cognitive rest essential for recovery
• Dark, quiet environment
• NO work for MINIMUM 72 hours (3 days)
• NO driving for MINIMUM 48 hours (2 days)
• NO screens (computer, phone, television) for 24 hours minimum
• NO reading for 24 hours minimum
• Light physical activity only - no exercise, heavy lifting, or strenuous activity

PROHIBITED Activities:

• Alcohol consumption (minimum 48 hours, preferably until full recovery)
• Operating machinery or vehicles
• Making important decisions
• Return to work or operational police duties
• Contact sports or activities with fall risk
• Swimming or water immersion (also contraindicated for hand wound)

Permitted Activities:

• Light walking in controlled environment
• Listening to quiet music or audiobooks
• Light conversation
• Rest and sleep (patient should be wakeable but doesn't need to be woken routinely)

RED FLAG WARNING SIGNS

Patient and responsible adult instructed to call 000 and return immediately if ANY of the following occur:

• Severe headache that is worsening or not responding to paracetamol
• Repeated vomiting (more than twice)
• Vision changes: Blurred vision, double vision, loss of visual field
• Confusion or disorientation: Not knowing where you are, who people are, what day it is
• Difficulty waking or staying awake: Excessive drowsiness beyond normal tiredness
• Seizure activity of any kind
• Weakness or numbness in arms, legs, or face
• Slurred speech or difficulty speaking
• Clear fluid leaking from nose or ears
• Severe dizziness or loss of balance preventing walking
• Unusual behavior or personality changes
• Loss of consciousness even briefly

These symptoms require IMMEDIATE emergency assessment - do NOT wait to see if they improve.

FOLLOW-UP CARE

Mandatory Follow-up:

1. GP Review - 3 Days (1 August 2018):
   • Concussion symptom assessment
   • Hand wound check
   • Clearance assessment for return to light duties
   • Further work restrictions if symptoms persist
2. Suture Removal - 10 Days (8 August 2018):
   • Can be performed by GP or return to RHH
   • Wound healing assessment
   • Final hand function check
3. Clearance for Full Duties:
   • Patient may NOT return to full operational duties until:
     • Complete resolution of concussion symptoms
     • Medical clearance from GP or specialist
     • Minimum 7 days post-injury even if symptom-free
   • Premature return to duty risks:
     • Second impact syndrome (potentially fatal)
     • Prolonged recovery time
     • Permanent cognitive effects

Return to Work Guidelines:

This patient works in high-risk operational role (police detective). Extra caution required:

• NO firearms use until medically cleared
• NO driving patrol vehicles until 48 hours minimum + symptom-free
• NO operational duties requiring split-second decisions until cleared
• Light administrative duties only after 72 hours IF symptoms resolved

Medical Certificate Issued:

• Unfit for all duties: 30-31 July 2018 (minimum)
• Review required 1 August 2018 for further certification

DISCHARGE PLAN

Patient will be discharged ONLY AFTER:

1. Completion of minimum 4-hour observation period
2. No deterioration in symptoms or neurological status
3. Vital signs stable
4. Patient able to tolerate oral intake
5. Responsible adult (Detective Sergeant Charlie Claiborne) available for transport and monitoring
6. Patient and escort demonstrate understanding of:
   • Activity restrictions
   • Warning signs requiring return
   • Follow-up requirements

Discharge Medications:

• Paracetamol 1g every 6 hours as needed (patient to purchase OTC)
• Metoclopramide 10mg three times daily as needed for nausea (3 days supply prescribed)

Discharge Documentation:

• Detailed written instructions for patient
• Medical certificate for employer
• Hand wound care instructions (already provided by RN Roberts)
• GP referral letter
• Emergency return criteria card

SUPERVISOR NOTIFICATION

Detective Sergeant Charlie Claiborne notified per protocol for injured police officer.

Briefing provided to DS Claiborne at 20:15 regarding:

• Nature and extent of injuries
• Required observation period
• Mandatory work restrictions
• Warning signs requiring return
• Follow-up requirements
• Documented concerns regarding mechanism of injury

DS Claiborne acknowledged understanding and confirmed availability to provide transport and monitoring post-discharge.

CLINICAL IMPRESSION AND CONCERNS

Summary:

29-year-old female police detective presenting with moderate concussion and sutured hand laceration. Neurologically intact with no focal deficits, but significant concussive symptom burden requiring observation and strict activity restriction.

Primary Concern - Medical:

Concussion with substantial haematoma indicates significant force of impact. Patient requires careful monitoring for potential delayed complications (intracranial bleeding, worsening oedema). Observation period and discharge warnings are ESSENTIAL.

Secondary Concern - Administrative:

DOCUMENTED DISCREPANCY between reported mechanism and observed injury pattern raises questions about circumstances of injury. While medical treatment is provided regardless of mechanism, this inconsistency is significant and should be noted for:

• Workplace safety review
• Incident investigation as appropriate
• Administrative follow-up

The injuries sustained are consistent with lateral impact to head and forced compression of hand against sharp object, rather than the reported forward fall. Patient has been given opportunity to clarify but maintains original account.

This observation is being formally documented in medical record and has been communicated to supervising officer (DS Claiborne) for appropriate administrative action.

PROGNOSIS

Short-term (1-2 weeks):

• Concussion symptoms expected to gradually improve over 7-14 days
• Most patients fully recover within 2 weeks
• Hand wound expected to heal without complication if care instructions followed

Return to Work:

• Light administrative duties: Possible after 3-5 days if symptoms resolved
• Full operational duties: Minimum 7-10 days, requires medical clearance

Complications to Monitor:

• Post-concussive syndrome (symptoms persisting beyond 2 weeks)
• Second impact syndrome if premature return to activities
• Hand wound infection (low risk given clean injury and appropriate closure)

Long-term:

• Full recovery expected without permanent sequelae if appropriate precautions followed
• Single concussion without complications generally does not increase risk of long-term problems
• Repeated concussions would be concerning - emphasize importance of full recovery before returning to operational duties

Assessment Completed: 20:18
Documentation Completed: 20:35

Assessing Physician:
Dr. Finn Montgomery, MBBS, FACEM
Head of Emergency Department
Signature: F. Montgomery
Date: 29 July 2018
Time: 20:35

Form Authorization: ED-PHYSICIAN-ASSESSMENT-001
Distribution: Medical Record (Original), Discharge Summary (Copy), Supervisor Notification (Copy), GP Referral (Copy)

CONFIDENTIAL MEDICAL DOCUMENT