Case

The case is used in the analysis, documentation, and validation of the developed profiles. The case is a specefic example of data which should be standardized in the profiles.

Case description
A patient is cutting branches of a large tree in the garden, where he falls 2 meters down from a ladder. When the ambulance arrives, the patient is conscious but complains of pain in the right arm and at the right hip (VAS: eight out of ten). The patient has no known allergies, but has well-treated type 2 diabetes. After the anamnesis is recorded, the ambulance rescuers triage the patient. The patient's vital parameters are: Temp. 36.8 ° C, HR: 111 / min, RF: 31 / min, BT: 150/100 mmHg, SpO2: 89 % and GCS: 14. The patient has free airways but has moderate shortness of breath. Due to the height of the fall, the patient is placed on a spineboard with a collar to ensure stability. When he enters the ambulance, the ambulance rescuers treat the patient with morphine (10 mg, given intravenously). The patient is examined where the ambulance rescuers suspect a fracture of the hip and a fracture of the right forearm, which is entered as a note to AKM. The ambulance rescuers therefore drive him to AKM.