AN ACCIDENT AND EMERGENCY TRIAGE FORM
DATE: 17 October
TIME: 12:15
NAME: Terence Dunlow
AGE: 24
PRESENTING COMPLAINT: Assault – torso and head pain, leg and hand laceration
HISTORY OF PRESENTING COMPLAINT: Patient reports he was assaulted by a masked person in the Southampton Harbour Hotel car park at around 10:50 on 17 October. He was kicked and punched until he fell to the ground. He was then kicked in the head and chest until he lost consciousness. Patient was unconscious when paramedics arrived but was treated at the scene. He was self-mobile and able to walk to the ambulance. There did not seem to be any significant head injuries. There is a laceration on the patient’s left thigh and left palm.
ON EXAMINATION: The patient can stand aided but is unstable when unaided due to leg laceration. There is blood on their hand from a cut of about one inch and blood on their thigh from a cut of about three inches. The patient is alert and has multiple contusions across their face, chest, arms, legs and back.
PAST MEDICAL HISTORY: None.
MEDICATION: None.
SOCIAL AND FAMILY HISTORY: None.
REPORT COMPLIED BY: Senior Staff Nurse Consuelo Day