CHARLES PETERSON 72-YEAR-OLD MALE FALL WITH
SUSPECTED CLOSED HEAD INJURY PRESENTING TO
HOSPITAL UTI
Full Case Study: Charles Peterson
Patient Demographics
• Name: Charles Peterson
• Age: 72 years
• Gender: Male
, • Ethnicity: Caucasian
• Code Status: Full code
• Advance Directive: None on file
• Living Situation: Lives alone in a two-story home; wife deceased 3 years
ago
• Primary Care Provider: Yes, established
Chief Complaint
“I fell down at home and hit my head. Also, I’ve been feeling confused and
burning when I pee.”
History of Present Illness (HPI)
Mr. Peterson presents to the Emergency Department via EMS after a fall at home
approximately 2 hours ago. His neighbor called 911 after finding him on the
kitchen floor, disoriented, unable to get up. The patient reports that he “got dizzy
and the floor came up fast.” He struck the left side of his head on the tile floor. No
loss of consciousness reported by patient or neighbor, but neighbor states
patient was “not making sense” for about 10 minutes after the fall.
For the past 3 days, the patient has noted increasing urinary frequency, dysuria,
and suprapubic discomfort. Over the last 24 hours, his son (called by phone)
reports that Mr. Peterson has been more confused than usual — forgetting
medications, getting lost in his own home, and agitated at night.
No headache, vomiting, or seizure-like activity.
No previous falls in the past year.
Review of Systems (ROS)
• General: Fatigue, decreased appetite x2 days. No fever/chills at home
(tympanic 99.2°F by neighbor).
• HEENT: No vision changes, no diplopia. No ear pain.
• Neurologic: Intermittent confusion, worse at night. No dizziness currently.
No weakness or numbness.
SUSPECTED CLOSED HEAD INJURY PRESENTING TO
HOSPITAL UTI
Full Case Study: Charles Peterson
Patient Demographics
• Name: Charles Peterson
• Age: 72 years
• Gender: Male
, • Ethnicity: Caucasian
• Code Status: Full code
• Advance Directive: None on file
• Living Situation: Lives alone in a two-story home; wife deceased 3 years
ago
• Primary Care Provider: Yes, established
Chief Complaint
“I fell down at home and hit my head. Also, I’ve been feeling confused and
burning when I pee.”
History of Present Illness (HPI)
Mr. Peterson presents to the Emergency Department via EMS after a fall at home
approximately 2 hours ago. His neighbor called 911 after finding him on the
kitchen floor, disoriented, unable to get up. The patient reports that he “got dizzy
and the floor came up fast.” He struck the left side of his head on the tile floor. No
loss of consciousness reported by patient or neighbor, but neighbor states
patient was “not making sense” for about 10 minutes after the fall.
For the past 3 days, the patient has noted increasing urinary frequency, dysuria,
and suprapubic discomfort. Over the last 24 hours, his son (called by phone)
reports that Mr. Peterson has been more confused than usual — forgetting
medications, getting lost in his own home, and agitated at night.
No headache, vomiting, or seizure-like activity.
No previous falls in the past year.
Review of Systems (ROS)
• General: Fatigue, decreased appetite x2 days. No fever/chills at home
(tympanic 99.2°F by neighbor).
• HEENT: No vision changes, no diplopia. No ear pain.
• Neurologic: Intermittent confusion, worse at night. No dizziness currently.
No weakness or numbness.
