48-year-old female client admitted to the emergency department via ambulance following a motor vehicle accident. The client was riding a bike and collided with a car, resulting in a fall. Client noted to be wearing a helmet at the time of the accident. History of asthma, irritable bowel syndrome, arthroscopy on L knee, and meniscus repair ten years ago. No known allergies. Last tetanus immunization two years ago. Current medications: Albuterol rescue inhaler two puffs prn asthma, Multivitamin 1 tablet orally daily, Docusate sodium 1 cap daily for constipation.
0900: Client alert, oriented x4, crying, reports that she doesnt remember exactly what happened. Client reports sharp stabbing pain in right lower leg, pain rated 8/10. Right tibial area slightly edematous and ecchymotic. Limited range of motion noted. Peripheral pulses in affected extremity 2+, remaining peripheral pulses +3, toes mobile and slightly edematous, capillary refill 2 seconds. Multiple abrasions noted on bilateral extremities, a 2 cm x 2 cm full-thickness laceration noted on the right knee. T-97.6, P-88, R-20, BP 124/76, Pulse Oximetry-98% on room air.
0915: Client transferred to radiology via stretcher for stat x-ray of the right leg and computed tomography scan of the head.
0945: Verbal report from Radiologist, Right tibial transverse closed fracture. CT Head-negative. On-call orthopedist notified of radiology report, treatment plan, closed reduction, and cast application.
