Chapter 28
Emergency Department Medical Record
(Translated from original Polish documentation)
Szpital Uniwersytecki w Krakowie (University Hospital in Kraków)
Emergency Department - Medical Record
Patient Name: Unknown
PESEL: Unknown
Age: 4 years
Sex: Male
Mode of Arrival: EMS (ZRM - priority 1, with full emergency signals)
Accompanied by: EMS personnel only
Pre-Hospital Report (EMS)
Child found in residential setting. No responsible caregiver present at scene at time of EMS arrival. Patient was conscious, crying continuously, covered in blood and dirt. Report of possible domestic violence. Transport initiated under emergency conditions.
Triage (Category: RED – Immediate)
Patient admitted in extreme distress, continuously screaming, unable to be verbally soothed.
Vital Signs on Admission
Heart Rate: 178 bpm (severe tachycardia; normal range ~80–120 bpm)
Blood Pressure: 138/92 mmHg (markedly elevated for age)
Respiratory Rate: 42/min (tachypnea)
SpO?: 97% (room air)
Temperature: 36.1°C
General Condition
Child presents in poor general condition. Marked signs of chronic neglect and malnutrition. Body weight visibly below expected for age. Prominent ribs, reduced muscle mass. Clothing heavily soiled, partially blood-stained. Strong odor of poor hygiene.
Behavioral and Psychological State
Patient exhibits extreme fear response:
Continuous, high-pitched screaming without pause
No response to verbal reassurance
Attempts to physically withdraw from all staff
Flinching and shielding head/body during approach
Clinging reflex to stretcher, resisting touch
Episodes of gasping between cries
Patient appears severely traumatized, with behavior consistent with prolonged exposure to violence.
Physical Examination
Skin and Soft Tissue:
Multiple contusions and hematomas across torso, upper and lower extremities
Injuries present in various stages of healing (fresh, subacute, and older discolorations)
Patterned bruising noted on back and thighs
Numerous circular burn lesions (approx. 0.5–1 cm diameter), consistent with cigarette burns: At least 12 visible lesions, including both healed scars and recent wounds
Several open abrasions and superficial lacerations, some with dried blood
No signs of appropriate prior wound care
Head and Face:
Periorbital swelling (left side)
Small lacerations
Dried blood around nasal area
Extremities:
No obvious deformities suggesting acute fracture (further imaging required)
Guarding noted during palpation
Clinical Impression
Findings are highly indicative of prolonged, repeated physical abuse and severe neglect.
Combination of:
Multi-stage injuries
Burn patterns
Malnutrition
Extreme psychological distress
strongly suggests chronic non-accidental trauma within caregiving environment.
Interventions Initiated
Continuous cardiac and respiratory monitoring
IV access established (left forearm)
Blood samples collected (CBC, electrolytes, CRP)
Fluid therapy initiated (0.9% NaCl)
Analgesia administered (weight-adjusted)
Sedation administered due to inability to safely examine patient otherwise
Wounds cleaned and dressed
Legal and Protective Actions
Due to suspected severe abuse:
Policja (Police) notified at 18:55
S?d Rodzinny (Family Court) informed for urgent protective proceedings
O?rodek Pomocy Spo?ecznej (Social Welfare / Child Protection Services)
Patient placed under hospital protective custody pending investigation.
Additional Notes
No parent or legal guardian has presented as of time of documentation.
Patient identity not verified.
Case classified as high-risk child abuse.
Attending Physician: Dr. Joanna Kowalczyk
Attending Nurse: Katarzyna Nowak, RN
EMS Documentation: Attached