1540: A 59-year-old male who was doing home repairs fell from the top of an 8-foot stepladder. He experienced a brief loss of consciousness, which he regained once his wife checked on him. The client's wife drove him to the ED to get further care. A large laceration over the right parietal area with a large amount of bloody drainage. The client endorses a headache rated 6 on a scale of 0 (no pain) to 10 (severe pain). The client reports right lower arm pain, rated 2 on a scale of 0 (no pain) to 10 (severe pain). A full range of motion was noted in the right arm, with slight bruising and discomfort with movement.

Past medical history:

• Hyperlipidemia

• Hypothyroidism

• Benign prostatic hyperplasia

• Coronary artery disease

• Venous thromboembolism

Current medications -

• Apixaban

• Tamsulosin

• Multivitamin

• Levothyroxine

• Atorvastatin

• Gemfibrozil

1540: Oral temperature 97.7° F (36.5° C), P 98, RR 18, BP 130/85, pulse oximetry 95% on room air

1619: The client's wife alerted RN to the bedside, where she stated, 'he is getting confused.' The client was assessed and is not oriented to person, place, or situation. The client kept repeating, "Where am I"? Reoriented the client. The pupillary assessment showed the right pupil at 4 mm and the left at 2 mm. Both were sluggish to light. Notified the physician of the condition change at this time.

1655: Head CT scan

• Axial head computed tomography scan shows a frontoparietal large subdural hematoma

1655: Radiograph (x-ray) of the right radius and ulna

• No evidence of fracture, significant soft tissue swelling