Case Study

Mr Willie Jungala is a 71-year-old gentleman

that has been admitted to hospital post fall
with soft tissue injury to right hip.

Assessment data
History
Patient profile Willie Jungala, 71-year-old man from Alice Springs
Chief complaint Pain to right hip following fall
Was going to kitchen to make a sandwich and tripped on
kids tonka truck. Landed on the floor on his right side.
Following fall, Willie was experiencing pain on movement
History of complaint
and difficulty weight bearing. Two teenage grandchildren
tried to help him up but too painful, so they called an
ambulance.
Phx Hypertension, Type 2 Diabetes, Unstable Angina
Allergies Nil known allergies.
• Aspirin 100mg mane
• Perindopril 2mg mane
Medications • Metformin 1000mg TDS
• GTN 600mcg tablets S/L prn

Alcohol use Social - 2 to 3 beers (mid-strength), 2 to 3 times per week.

Non-smoker. Regular exposure to campfire smoke. Most
Tobacco use nights have a campfire burning - sit by campfire and enjoy
the night 'yarning' or listening to music.
Drug use Nil.
Lives in town camp in house with extended family.
Approximately 12 family members staying at house: wife;
Home environment
daughter and her 4 teenage boys; daughter and her two
toddlers; son's two adult boys.
Work environment Was a station hand. Retired 5 years ago.
Sometimes. At the moment, youngest daughter that lives at
home there with her two toddlers, has recently been
Stress
diagnosed with cancer. A few drinks and a few laughs help
ease the stress.
Education Year 9 schooling.
Economic status Own land and house out bush but staying in town for a

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 while.
Aboriginal. Speaks Waramungu, Walpiri, Eastern and
Ethnic background
Central Arrente, Western Arrentre and English.
Baptised Catholic by missionaries when young. Only goes
Religion/ spirituality to church for funerals. Willie's spirit is strengthened by
family and country.
Married. Been with wife for 51 years. Have one son and two
Sexual practice
daughters.
ADLs Independent.
Does not drive any more due to decreased vision (diabetic
IADLs retinopathy). Starting to get cataracts. Had glasses a few
years ago but they don't work so well any more.
Cognitive function No worries.
Diet Diabetic diet
Sleep 7-8 hours a night.
Regular check-ups every few months with diabetic doctors/
Health check ups
clinics. Go to medical service if need to. Moves between
medical services depending on where he is staying at.

Physical
Assessment data
assessment
Temp 36.0, Pulse 100, Resps 20, SpO2 94% RA, BP 150/95,
Vital signs
BGL 3.9mmols/L, Pain 6 out of 10
• GCS 13
• Pupils equal and reactive to light
• Lethargic, eyes open when spoken to, follows
CNS commands, orientated to place and person; not time.
• Difficult to test muscle strength due to pain from injury to
right side

• Both feet pale in colour

• No sacral or ankle oedema
• Bilateral cool skin temperature in feet; hands warm
CVS
• Peripheral pulses present but dorsalis weak bilaterally
• Capillary refill feet and hands > 3 seconds

• Shallow and regular breathing

• No reports of pain on palpation
• Chest expansion symmetrical
Resp
• Percussion- bilateral resonance in all areas
• Auscultation - no abnormal breath sounds noted

• Blue/red coloured haematoma to right hip and extends to

right buttock
• Swelling evident
MSK
• Skin intact
• Decreased range of movement around hip
• Tender on palpation of right hip area

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 • Reluctant to attempt walking due to pain

• Loss of appetite and nausea last few days

• No vomiting
• Regular bowel movements. Little bit constipated last two
days.
GIT
• Generalised distention
• Bowel sounds in all 4 quadrants
• Mild tenderness lower abdominal area

• No pain on passing urine

• 2-3 days of increased urinary frequency and urgency/
Urinary
wanting to go bad
• Passed cloudy, malodorous urine approx 1 hour before
fall

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