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Na místě 30letá žena stěžující si na úporné bolesti hlavy nejvíce v oblasti týlu. S ničím se neléčí. Bolesti trvají již třetí den a dnes již nereagují ani na analgetika. Žena je při vědomí, bledá, opocená, nevzracela. Během vyšetření upadá do bezvědomí. Zornice jsou anizokorické, mydriáza vpravo nereaguje na osvit, vlevo zornice menší, reagující na osvit. TK 110/60, P 82, SPO2 98%, D 12, jiné info nelze získat. Pracovní diagnoza, léčba a směřování.
Řešení:
Syndrom intrakraniální hypertenze (diferenciální diagnostika bez zobrazovacích metod a dalších vyšetření v PNP nelze). Bolest hlavy nereagující na analgetika. Neurologická klinická symptomatologie (lateralizace, meningeální syndrom) a porucha vědomí může být známkou kraniokaudální deteriorace- nutno sledovat dynamiku! V popisu postrádám hodnotu tělesné teploty a popis případných kožních změn. Zajištění vitálních funkcí, drenážní poloha, monitorace během transportu. Směrování: UP (zařízení s neurochirurgií a nejlépe i infekčním oddělením) – nejsem autorem modelovky, ale díky za ni!

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