Abnormal narrative bank — focused / at-risk
Six focused abnormal narratives carrying the full necessity chain — finding, severity, comparison, risk, action, notification, and reassessment.
A1 Delayed intracranial bleed after a fall | Skilled post-fall surveillance in a patient on warfarin who now reports a new dull unilateral headache with one episode of vomiting and mild drowsiness two days after an unwitnessed fall — new findings from the prior reassuring checks and concerning for a delayed intracranial bleed. EMS was activated for emergent evaluation and no further anticoagulant dose was given pending direction; the provider was notified at 16:05. Pupil size, mentation, and vital signs were monitored pending transport, and routine teaching was deferred until the patient was cleared (cross-reference Anticoagulation, Neurological). |
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A2 Thunderclap headache | Skilled assessment of a sudden “worst-ever” headache that peaked within seconds, with photophobia and vomiting — a thunderclap onset concerning for subarachnoid hemorrhage. EMS was activated immediately and the time of onset documented; the provider was notified at 10:20. The patient was kept calm and still, neurologic status and pupils monitored, and no oral intake given pending transport (cross-reference Neurological). |
A3 Suspected meningitis | Skilled assessment of a new severe headache with fever, neck stiffness, and photophobia — findings concerning for meningitis. EMS was activated for emergent evaluation given the risk of rapid deterioration; the provider was notified at 13:35. Vital signs and mentation were monitored pending transport, the patient kept in a low-stimulation environment, and the onset and progression documented. |
A4 Giant-cell arteritis | Skilled assessment of an older adult with a new temporal headache, tenderness over a prominent temporal artery, jaw claudication with chewing, and transient blurring of vision in one eye — findings concerning for giant-cell arteritis, which threatens vision. The provider was notified urgently at 11:10; orders for urgent evaluation and laboratory studies were received and the importance of prompt treatment to prevent vision loss conveyed. The visual symptoms and headache will be reassessed, and the patient instructed to seek emergency care for any vision loss (cross-reference Eyes/Vision). |
A5 Scalp wound infection | Skilled assessment of a scalp laceration with new surrounding erythema extending 1.5 cm, warmth, purulent drainage, and tenderness, with a low-grade fever — new from the prior visit and concerning for a wound infection. The wound was cleansed and dressed per order and the provider notified at 14:40; orders for an oral antibiotic and a wound check were received. The patient and caregiver were taught the signs of spreading infection and when to seek care; the wound and temperature will be reassessed next visit (cross-reference Wounds). |
A6 New scalp mass / non-healing lesion | Skilled assessment identifying a new firm scalp nodule that has enlarged over several weeks and a separate lesion that has not healed and bleeds with minor contact — findings requiring evaluation to exclude malignancy. The provider was notified at 09:45 and a referral for evaluation requested; the lesions were measured for tracking and protected. The patient was educated on the reason for evaluation and to avoid trauma to the area; the lesions will be reassessed next visit (cross-reference Integumentary). |