AN ACCIDENT AND EMERGENCY TRIAGE FORM
DATE: 14 October
TIME: 14:16
NAME: Leonard Dunlow
AGE: 18
PRESENTING COMPLAINT: Assault and hit by van – torso pain and facial laceration
HISTORY OF PRESENTING COMPLAINT: Patient reports he was assaulted by a young man in the street at 13:00 on 14 October. He was beaten with fists and thrown to the ground. He was then kicked repeatedly in the chest, back and stomach. When he made an attempt to escape, he was hit by a van. Patient was self-mobile when paramedics arrived and treated at the scene. There did not seem to be any significant head injuries. The patient was breathing shallowly and guarding his chest.
ON EXAMINATION: The patient can stand unaided. There is blood on his face from a cut of about two inches on his right cheek. He is breathing shallowly and guarding his chest. The patient is alert and has multiple contusions across his chest and upper back. He has minor cuts and bruising on his knuckles.
PAST MEDICAL HISTORY: Anxiety
MEDICATION: Sertraline
SOCIAL AND FAMILY HISTORY: None
REPORT COMPLIED BY: Senior Staff Nurse Consuelo Day