K.B. is a 21-year-old man with a past medical history (PMH) of seizure disorder controlled with carba

Question

mazepine (Tegretol). He was accidentally struck in the head by a pitched baseball while batting in a
baseball game.

He was unconscious for about 5 seconds, then awakened and was alert and respon
sive. After a few hours, K.B. returned home with complaints of a "splitting" headache, drowsiness, slight
confusion, and some nausea. K.B. was taken to the local hospital emergency department (ED), where a
computed tomography (CT) scan revealed a left subdural hematoma. He was been transferred to your
medical center 70 miles away, which has a neurosurgeon on call, and is being admitted from the ED to
the medical unit.
The ED nurse gives you the previous information during a phoned report. What other
information do you need to prepare for K.B.?

Answer 1

Any significant health history, such as allergies and existing health problems; any continuous
medications; any changes in his neurologic status since the initial assessment; his current neurologic
status, including level of consciousness (LOC), pupillary function, and eye movement; motor
function; vital signs (VS) and pulse oximetry values; respiratory patterns; any tubes and lines that
were inserted, such as intravenous (IV) lines; urine output; laboratory tests or diagnostic tests
ordered other than the CT scan; treatments and medications received, including pain medications
or narcotics; the presence of any family members; and whether he has been evaluated by a
neurosurgeon