Incident Details: 67 year old (Female) who had a fall; ankle injury.Case study one: Appraisal of Ankle Injury Assessments in Pre-hospital setting.PCFall – Right Ankle injuryHxPCThe patient was walking up 5 stairs to her home when she tripped and fell up the stairs landing on her right ankle awkwardly. The patient fell on the concrete floor, the patient sat for a minute and then with help from her husband was able to get up. The pain then limbed to the front room and put her foot up on the sofa. The concrete ground was dry. The patient was wearing sandals on her feet at the time. The patient has had no previous injuries to right ankle or foot. The patient states she has not hurt or injured herself anywhere else, no pain or discomfort anywhere apart from her right ankle. The husband was right behind her and witness everything. The patient did not hit her head, no LOC. No c-spine tenderness on palpation or movement.  The patient states that the ankle swelled straight away and bruising appeared soon after. The patient has not taken any analgesia for the pain.PMHxAsthmaFMHxNo family history of osteoporosis.MHxVentolin inhaler – maximum of 4 times a day or PRN.AllergiesKnown None.SHxLives with husband in a house. Patient believed not to be under the influence of any alcohol or drugs. Non-smoker.O/APatient sat on sofa with her leg raised with no shoe on the right foot. Patient talking in full sentences, alert and GCS 15/15.Site: All around the ankle and on the patient’s big toeOnset: 11:40am (10 minutes before the ambulance arrived)Radiation: NoneAssociated symptoms: Swelling, bruising and struggling to weight bearTiming: Since the fall at 11:40am that morning.Exacerbating symptoms: Tender on palpation, movement and weight bearing.Score: 7/10 pain when weight bearing. 3/10 when foot is elevated and resting.O/E RSSlight increased RR at 24. SP02 96% (Air). Equal air entry. Equal rise and fall.Trachea central.Equal resonance throughout.Chest sounds: clear.(Health References, 2012). CVSHR 78. BP 130/82. Cap Refill <2. CNSTemp 36.7 ABDONAD LMSPatient states she did not hurt or injury herself anywhere else apart from her right ankle. No pain of discomfort in left leg, both arms, neck and back.Look: Swelling to right ankle. No gross deformity.Palpate: Well perfused cap refill <2 Peripherals. Warm to touch. Good pedal pulse. No pain, discomfort or swelling over the patella, or over the head of the fibula. Ligaments appear intact. No loss of sensation. No pain, discomfort or swelling down the tibia, fibula and calf. No loss of sensation. Simmons test NAD. Painful on palpation of base of 5th metatarsal. Bruising to and 5th metatarsal.Movement: Unable to do more than 2 steps without being in severe pain.Active:Dorsiflexion/plantarflexion – Able to do but painful.Inversion – Able to but painfulEversion – Not painful.Resistance:Patient seemed in too much pain to be able to resistance movement and as Ottawa Positive I didn’t want to cause any more damage.(Docpods, 2017)IMP/DD? # Base of 5th metatarsal and/or ? soft tissue injury (Sprain/Strain)RxEnsure scene safety and PPEIntroduce myselfReassure patient and husband.Gained consentGained a history of event and relevant past medical history.Observations taken and physical examination completeOttawa positive right ankle – x-ray required.Wheelchair collected from ambulance by crewmatePain management – Entonox, 1g Paracetamol and vacuum Splint in accordance to JRCALC guidelines (2016) with no contraindications.Reassess patient in ambulanceConvey to A&EComplete EPCR.PLAN Conveyed patient to A&E.The most common lower limb fracture is the ankle, accounting for 9% of all fractures(Bugler, White & Thordarson, 2015). Subtle fractures are commonly misdiagnosed as sprained ankle due to clinical presentation similarities (Judd & Kim2002), a thorough initial examination is vital for treatment and positive patient outcome.  Common symptoms of a sprained and fractured ankle are sudden pain, swelling, bruising and an inability to walk (Kenny, 2015). The Ionising Radiation (Medical Exposure) Regulations 2000 legislation provides patients and employers protection from the dangers of exposure to unnecessary radiation (Department of Health, 2000), because of this the Ottawa Ankle Rules (OAR) (Stiell, 2016) was implemented.Implementing the OAR into a pre-hospital setting will enable paramedics to complete a thorough assessment and avoid unnecessary hospital admissions (Simpson, 2010) and radiation exposure (Bachmann et al, 2003).In 1992, the OAR (Appendix 1) was first introduced, the original rules recommended that an ankle X-ray is only required if the patient is: 55 years of age or older, unable to weight bear or walk more than 4 steps, experiencing bony tenderness on the posterior edge or inferior tip of the lateral malleolus and the posterior edge or inferior tip of the medial malleolus (Wright, 2016).The OAR has a high sensitivity ranging from 96.4% to 99.0%, a negative test finding is an acceptable measurement that there is no fracture present; however, the Buffalo Rule, a modification of the OAR has an even higher sensitivity of 100%, all patients who had malleolar pain had fractures (Jenkin, Sitler & Kelly, 2010). The Buffalo Rule increases accuracy by the tender point measured from the crest or mid-portion of the malleoli, distal 6cm of the fibula and tibia; reducing palpating over ligament injuries (Jonckheer et al., 2015).Both assessments can potentially decrease the number of patients exposed to unnecessary radiation and reduce the costs associated with ankle injuries. Bachmann’s (2003a) found the OAR could reduce this by 19% to 39%, whereas the Buffalo Rule could reduce this by 54% (Leddy et al, 1998). Although the OAR reduces the need for X-ray without misdiagnosing fractures and soft tissue damage, the Buffalo modifications improve malleolar fracture specificity without sacrificing sensitivity (Miller, Svoboda & Gerber, 2012).The National Institute for Health and Care Excellence (2016) recommends the OAR as part of the assessment and management in non-complicated factures in patients over 5 years old to determine if an X-ray is required. The Health and Care Professions Council’s (2012, p.3) “you must act in the best interests of service users” (1) and also “act within the limits of you knowledge, skills and experience and, if necessary, refer the matter to another practitioner” (6). This protects patients against unnecessary hazards such as radiation from X-rays or if a paramedic feels deems it necessary from a thorough assessment using the OAR, referring them to another practitioner.My patient matched one of the criteria of the current OAR and therefore guided our clinical decision to convey the patient to accident and emergency for an X-ray.ReferencesBachmann, L, Kollo, E, Koller, M, Steurer, J, Riet, G. (2003). Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and mid-foot: systematic review. British Medical Journal. Vol. 326:417.Bugler, K.E., White, T.O and Thordarson, D.B. (2015) Ankle fractures. Available at: http://www.boneandjoint.org.uk/content/focus/ankle-fractures (Accessed: 12 December 2016).Department of Health (2000). The Ionising Radiation (Medical Exposure) Regulations 2000. London: The Stationery Office, 2000.Docpods (2017). Metatarsal Anatomy. Available at: http://www.docpods.com/metatarsal-anatomy (Accessed: 12 December 2017).Health and Care Professions Council (2012) ‘Standards of Conduct Performance and Ethics’. Available at: http://www.hcpc-uk.org/assets/documents/10003B6EStandardsofconduct,performanceandethics.pdf (Accessed: 12 December 2016)Health References (2012). Lungs. Available at: http://www.healthsanaz.com/lungs-drawing-for-kids-ldk08.html (Accessed: 12 December 2016).Jenkin, M., Sitler, M.R. and Kelly, J.D. (2010) ‘Clinical usefulness of the Ottawa ankle rules for detecting fractures of the ankle and Midfoot’, National Centre for Biotechnology Information, 45(5), pp. 480–482.Jonckheer, P., Willems, T.M., De Ridder, R. and Roosen, P. (2015) Evaluating fracture risk in acute ankle sprains: Any news since the Ottawa Ankle Rules? A systematic review. Available at: https://www.researchgate.net/publication/287958805_Evaluating_fracture_risk_in_acute_ankle_sprains_Any_news_since_the_Ottawa_Ankle_Rules_A_systematic_review (Accessed: 12 December 2016).JRCALC (2016). Clinical practice guidelines: Entonox, Paracetamol and Morphine. (4th ed). Bridgewater: Class Professional PublishingJudd, D. and Kim, D. (2002) Foot fractures frequently Misdiagnosed as ankle sprains. Available at: http://www.aafp.org/afp/2002/0901/p785.html (Accessed: 12 December 2016).Kenny, T. (2015) Ankle Injuries. Available at: http://patient.info/health/ankle-injuries-leaflet (Accessed: 12 February 2017).Leddy JJ, Smolinski RJ, Lawrence J, Snyder JL and Priore RL. (1998) Prospective evaluation of the Ottawa Ankle Rules in a university sports medicine center: with a modification to increase specificity for identifying malleolar fractures. Am J Sports Med. 26(2): 158–165.Miller, J.M., Svoboda, S.J. and Gerber, P.J. (2012) ‘Diagnosis of an isolated posterior malleolar fracture in a young female military cadet: a resident case report’, National Centre for Biotechnology Information, 7(2), pp. 167–172.National Institute for Health and Care Excellence (2016) Fractures (non-complex): Assessment and management. Available at: https://www.nice.org.uk/guidance/ng38 (Accessed: 12 December 2016).Simpson, P.M. (2014) ‘Use of the Ottawa ankle rule by paramedics in the out-of-hospital setting’, Journal of Emergency Primary Health Care, 8(2), pp. 1–7.Stiell, I. (2016) Ottawa ankle rule. Available at: https://www.mdcalc.com/ottawa-ankle-rule (Accessed: 12 December 2016).Wright, M. (2016) Ankle fractures. Information about broken ankle. Patient. Available at: http://patient.info/doctor/ankle-fractures (Accessed: 12 December 2016).AppendixAppendix 1: Ottawa Ankle RulesCASE STUDY TWO  Incident Details: 4 year old boy with mild croupCase study two – Evaluation of Dexamethasone in croupPCBreathing difficultiesHxPCThe patient had cold symptoms for 4 days. The patient woke up around 2am with a barking cough and stridor at rest. The last episode of croup that the patient had was 12 months ago. The patient has not been abroad recently and not been in contact with anyone who has been poorly recently. Slightly off food but has been drinking a lot more than usual. No diarrhoea or vomiting. Patient is still opening his bowels as normal and passing urine as normal.PMHxHas had croup every year since birth. This was his 4th episode.Vaccinations up to date:  Measles, mumps and rubella.FMHxMum used to suffer with croup when she was young. Otherwise no family history of respiratory problems.MHxNone. Normally fit and well.SHxPatient lives with mum, dad and his little brother in their house. The patient goes their local nursey. The house is a smoke free house.O/APatient sat on sofa with dad watching television. Patient able to answer nodding his head or answering yes or no (seemed shy at first), alert and GCS 15/15. Using the patient triangle assessment tool the patient had rosy cheeks, normal neurological response and increased respiratory rate on initial look.O/E RSIncreased RR at 38. SP02 97% (Air). Patient was using accessory muscles. No tracheal tug present. No respiratory recession. Not cyanosed. Patient had a barking cough.Chest sounds were clear.Equal rise and fall.Trachea central.Equal resonance throughout.(Health References, 2012). RSUsing the modified Taussig Croup Score the patient scored 1 (Only on exertion).(South Western Ambulance Service Trust, 2014) CVSHR 150. Cap Refill <2. CNSTemp 37.4. BM 4.2 PEARL 3mm ABDONAD LMSNAD OTHERNo mottled skin, or rashes. Peripheries warm to touch. Throat: Moist mouth and tongue, throat not inflamed, red or sore. Straight uvela and tonsils not raised, red and no pits or puss.IMP/DDMild CroupRxEnsure scene safety and PPEIntroduce myselfReassured the parents and patientGained consentGained a history of event and relevant past medical history.Observations taken and physical examination complete and monitoredMum administered his own Calpol as he was due his next dose.Dexamethasone 3.8mg dose was administered (JRCALC, 2016)Completed the documentation and monitored the patient’s observation.Patient’s observations improved:SP02 98% RR 30 HR 136 TEMP 36.8 No stridor present and the barking cough improved. The patient was happy chatting with us and watching television.PLAN Non-convey. Safety netting put into place: worsening advice given, patient left in care of parents. A croup leaflet left with parents.Croup is a viral respiratory tract illness affecting children between 6 months and 3 years; however, it can affect children up to the age of 15 (SWAST, 2014). It causes swelling to the vocal cords causing the barking cough, any swelling narrows the airway and can obstruct breathing in severe cases (Sears, 2013). Some children may have cold-like symptoms a few days before developing croup symptoms (NHS, 2014). Using the modified Taussig Croup Score, croup is split into severity categories; mild (scoring 1-2), moderate (scoring 3-4) or severe (scoring 5-6). The case study patient scored as mild (JRCALC 2013). The National Institute for Health and Care Excellence (2012) states that mild croup symptoms are; “occasional barking cough and no audible stridor at rest, no or mild suprasternal and/or intercostal recession and the child is happy, eating, drinking and playing”. Mild croup with no signs of moderate or severe/life-threating croup can be managed at home with administration of Dexamethasone (Dex) (SWAST, 2014)Mild croup is generally self-limiting but a single dose of a corticosteroid is beneficial (British National Formulary for Children, 2017). A single dose of Dex should be administered to all children with mild, moderate or severe croup (NICE, 2012). One of the benefits of using corticosteroid is that its biological half-life is between 36 – 72 hours (SWAST, 2014).The benefits of giving this drug to moderate or severe croup is well established but not for mild croup (McMorran, 2016). Bjornson et al’s (2004) randomised trial of a single dose for mild croup found that Dex is an effective treatment; quicker resolution of symptoms, less lost sleep and less stress for the parents. However, the long-term effects in mild croup is unknown (Kermode-Scott, 2004). O’Mara (2005) also supports the use of Dex as it reduces loss of sleep for the child and the chances of returning to medical care. Corticosteroids can have immunosuppressive effects which can lead to infectious complications, although this is rare it is still a concern when administering to children with mild croup (James, 2008). The advantage of Dex is that it works quickly within 30 minutes if the child is having a single dose (Dobrovoljac, 2011). A disadvantage is that child may find it unpleasant to taste and can cause vomiting in some cases, therefore the child may not get the correct dose needed to resolve the croup symptoms (Solemiani et al, 2013).The long-term effect of Dex is unknown; however, Bjornson et al’s (2004) study supports the use in children with croup. Dex is an effective treatment for children with mild croup, it is an easy and low-cost therapy which relieves symptoms and has social and economic benefits (Evidence-Based Healthcare & Public Health, 2005). Children who receive oral Dex are less likely to need medical care later (Luria, 2001).Research suggests the use of Dexamethasone in children is vastly beneficial and effective in mild, moderate and severe croup clinically for the patient and emotionally for the parent/guardian(s); these benefits outweigh the potential and rare risks.ReferencesBjornson, C.L., Klassen, T.P., Williamson, J., Brant, R., Mitton, C., Plint, A., Bulloch, B., Evered, L. and Johnson, D.W. (2004) ‘A Randomized trial of a single dose of oral dexamethasone for mild Croup’, New England Journal of Medicine, 351(13), pp. 1306–1313. Doi: 10.1056/nejmoa033534.British National Formulary for Children (2017) Croup. Available at: https://www.evidence.nhs.uk/formulary/bnfc/current/3-respiratory-system/31-bronchodilators/croup (Accessed: 2 February 2017).Dobrovoljac, M. and Geelhoed, G.C. (2011) ‘How fast does oral dexamethasone work in mild to moderately severe croup? A randomized double-blinded clinical trial’, Emergency Medicine Australasia, 24(1), pp. 79–85. Doi: 10.1111/j.1742-6723.2011.01475.x.Evidence-Based Healthcare & Public Health (2005) ‘Oral dexamethasone is effective for mild croup in children’, Evidence-based Healthcare and Public Health, 9(2), pp. 167–168. Doi: 10.1016/j.ehbc.2005.01.029.Health References (2012). Lungs. Available at: http://www.healthsanaz.com/lungs-drawing-for-kids-ldk08.html (Accessed: 2 February 2017).James, D. and Cherry, M.D. (2008) ‘Croup’, New England Journal of Medicine, 358(4), pp. 384–391. Doi: 10.1056/nejmcp072022.JRCALC (2013). Clinical practice guidelines: Respiratory illness in children. 4th ed. Bridgewater: Class Professional Publishing. P110-111JRCALC (2016). Clinical practice guidelines: Page for age. (4th ed). Bridgewater: Class Professional Publishing. P283Kermode-Scott, B. (2004) ‘Corticosteroids may be effective for most cases of croup, study shows’, BMJ, 329(7469), pp. 762–0. Doi: 10.1136/bmj.329.7469.762-c.Luria, J., Gonzalez-del-Rey, J., DiGiulio, G., McAneney, C., Olson, J. and Ruddy, R. (2001) ‘Effectiveness of oral or nebulized dexamethasone for children with mild croup’, Archives of paediatrics & adolescent medicine. 155(12), pp. 1340–5.McMorran, J., Crowther, D., McMorran, S., Youngmin, S., Wacogne, I., Pleat, J. and Prince, C. (2016) Steroids in croup – general practice notebook. Available at: http://www.gpnotebook.co.uk/simplepage.cfm?ID=-536477621 (Accessed: 3 February 2017).National Institute for Health and Care Excellence (2012) Clinical Knowledge Summaries. Available at: https://cks.nice.org.uk/croup#!scenario (Accessed: 2 February 2017).O’Mara, L. (2005) ‘Dexamethasone reduced the incidence of children with mild croup who returned for medical care’, Evidence-Based Nursing, 8(2), pp. 41–41. Doi: 10.1136/ebn.8.2.41.Sears, W. (2013) Croup symptoms and treatment. Available at: http://www.askdrsears.com/topics/health-concerns/childhood-illnesses/croup (Accessed: 2 February 2017).Soleimani, G., Daryadel, A., Ansari Moghadam, A. and Sharif, M.R. (2013) ‘The comparison of oral and IM dexamethasone efficacy in Croup treatment’, Journal of Comprehensive Pediatrics, 4(4), pp. 175–8. Doi: 10.17795/compreped-4528.South Western Ambulance Service Trust (2014) Management of Croup. Available at: http://www.swast.nhs.uk/Downloads/Clinical%20Guidelines%20SWASFT%20staff/CG26_Croup.pdf (Accessed: 2 February 2017).South Western Ambulance Service Trust (2015) Medicines Protocol: Dexamethasone. Available at: http://www.swast.nhs.uk/Downloads/Clinical%20Guidelines%20SWASFT%20staff/SWASFTMedicinesProtocol_Dexamethasone.pdf (Accessed: 2 February 2017).CASE STUDY THREE  Student ID: 10191190Word count: 514Submission date: Monday 8th May 2017Module code: Para 301Module title: Refining practitioner skills for patient careIncident Details: Elderly woman fall non-injury, query urine tract infection in pre-hospital setting.Case study three – Evaluation of urine dip analysis (Catheterised and non-catheterised patients).PCNon-injury fallHxPCThe patient had an unwitnessed mechanical non-injury fall at her own home in the carpeted living room. The patient was only wearing socks at the time. The patient had no chest pain and did not feel dizzy before the fall. No recent headaches. The patient feels well in herself. Patient remembers the whole event, the patient did not bang her head and no LOC.PMHxAsthmaHypertensionAFFMHxUnknown.MHxVentolin Salbutamol InhalerRamiprilAtenololAllergiesMushrooms. No medication allergies known.SHxPatient lives home alone, has carers in 3 times a day. The patient does have a pendant alarm in place which she push to make contact with the ambulance service.O/APatient was sitting on the floor leaning against the sofa. Patient was conscious and breathing. The patient states she was walking with her frame to the kitchen from the living room when she felt her sock slip on her television magazine which was on the floor and fell to the floor. The patient was unable to get back up due to mobility.O/E RSRR 24. Equal rise and fall. SP02 94% (Air) Patient is a heavy smoker and has been all her life. Patient is able to talk in full sentences. GCS 15, (A) VPU. No cough or colds recently. Chest sounds clear.Good lateral air entry.Equal rise and fall.Trachea central.Equal resonance throughout.(Health References, 2012). CVSHR 66. Cap Refill <2. ECG Normal Sinus Rhythm. Patient denies any chest pain or discomfort. CNSTemp 38.4. BM 4.4 ABDONo pain or discomfort on palpation, soft abdominal. No guarding or masses. Normal bowel sounds. Eating and drinking as normal for the patient. Patient states her urine has looked dark in colour recently. Patient has been going more often and stings when passing urine. Bowels open as normal. No nausea or vomiting. No scars seen. Patient denies any abdominal pain or discomfort. LMSPatient stated she has not hurt or injured herself and no complaint of any pain or discomfort. No C-spine tenderness on movement or palpation. No red marks or bruises. Patient did not bang her head. Usually uses a frame to mobilise around the flat.IMP/DD? UTIRxEnsure scene safety and PPEIntroduce myselfReassure patientGained consentGained a history of event and relevant past medical history.Observations taken and monitoredPatient LMS assessed.Patient assisted back to feet and saw patient mobilise with frame as normal for her safety.Urine was dipped and analysed.Patient was given a course of antibiotics by the Emergency Care Practitioner on scene.Patient was reassured and carers were coming in the next hour.Completed the documentation including falls referral.Urine Analysis found:LeucocytesBloodProteinNitratesPLAN Non-convey. Safety netting put into place: worsening advice given, patient’s carers coming in within the hour. Antibiotics given.Urinary tract infections (UTIs) are common in women and the elderly (WebMD, 2015). The infection can occur in the bladder, kidneys or the connecting tubes (NHS, 2016). This is the second most common bacterial infection seen in the elderly (Ho, 2016); up to 30% of the elderly have a UTI with a mortality rate as high as 33% (Cove-Smith and Almond, 2007). Patients with a catheter are at higher risk of getting a UTI, with 90-100% of patients with long-term catheterization developing a bacterial infection (Brusch, 2015).UTI symptoms are; burning or stinging feeling when passing urine, increased frequency and urge, pain or pressure in the back or lower abdomen, fever, chills, tiredness, strange smell to urine, dark and cloudy or blood in urine (Smith, 2017). Symptoms of a UTI in a patient with a long-term catheter include; new onset of a fever, altered mental state, tiredness, flank pain and decreased urine output (Sign, 2013).UTIs are commonly caused by the bacteria infection, Escherichia coli which is easily corrected with antibiotics (British National Formulary, 2014). Non-complicated UTIs are treated with a short course of antibiotics however, men and pregnant women may be given longer courses of antibiotics (NHS, 2016). Patients with a catheter should only be treated if symptomatic (Jarvis, Chan and Gottlieb, 2014) and if symptoms are present a dipstick analysis of urine can be performed (Bates, 2013).Testing for a UTI using a dipstick is a common, quick and easy to use and low cost (Rehmani, 2004). Dipstick urinalysis is an accurate test to use and supports clinicians when diagnosing patients with a UTI (Sultaria et al, 2001). Bolann, Sandberg and Digranes (1990) found that once the dipstick results were complete, the microscopy did not give any additional information. Kayalp et al’s (2013) study showed urine dipstick and microscopy are accurate tools to use to rule out a UTI however, microscopy is the highest accuracy tool to use when looking for bacteriuria UTI. Similarly, Devillie et al (2004) found that a urine dipstick test is a valuable tool to rule out the presence of an infection with negative results. Therefore, in clinical assessment, dripping urine is an adequate method to diagnose a UTI (Sultana et al, 2001).When testing asymptomatic catheterized patients, the use of urinary dipsticks is a very effective and cheap diagnostic tool (Tissot et al, 2001). However, Southern Health (2017) suggest, when diagnosing a UTI in a patient with a catheter, dipstick testing is not an accurate tool and should not be used.In conclusion, when patients are symptomatic the use of dipstick urinalysis is a useful and reliable diagnostic method to support the clinician’s diagnosis of a UTI (Zamanazad, 2009). However, using dipsticks in catheterized patients is an unreliable diagnostic tool and should not be used to diagnose a UTI (Schwartz and Barone, 2006). Emergency Care Practitioners find that dipstick testing for leukocyte esterase and nitrites is a useful, cheap and safe diagnostic tool in the prehospital setting to diagnose certain groups of patients and it is as useful as microscopy and cultures (South Western Ambulance Service, 2014).ReferencesBates, B. (2013). Interpretation of Urinalysis and Urine Culture for UTI Treatment.  Uspharmacist.com. Available at: https://www.uspharmacist.com/article/interpretation-of-urinalysis-and-urine-culture-for-uti-treatment (Accessed 25 Apr. 2017).Bolann, B., Sandberg, S. and Digranes, A. (1990). Implications of probability analysis for interpreting results of leukocyte esterase and nitrite test strips. Clinchem.aaccjnls.org. Available at: http://clinchem.aaccjnls.org/content/35/8/1663.long (Accessed 25 Apr. 2017).British National Formulary(2014). 5.1.13 Urinary-tract infections:  NHS. Available at: https://www.evidence.nhs.uk/formulary/bnf/current/5-infections/51-antibacterial-drugs/5113-urinary-tract-infections (Accessed 25 Apr. 2017).Brusch, J. (2015). Catheter-Related Urinary Tract Infection: Transmission and Pathogens, Guidelines for Catheter Use, Diagnosis. Emedicine.medscape.com. Available at: http://emedicine.medscape.com/article/2040035-overview (Accessed 25 Apr. 2017).Cove-Smith, A and Almond, M. (2007). Management of urinary tract infections in the elderly. Trends in Urology, Gynaecology & Sexual Health, 12(4), pp.31-34. Available at: http://onlinelibrary.wiley.com/doi/10.1002/tre.33/pdf (Accessed 25 Apr. 2017).Devillé, W, Yzermans, J, van Duijn, N, Bezemer, P, van der Windt, D. and Bouter, L. (2004). The urine dipstick test useful to rule out infections. A meta-analysis of the accuracy. BMC Urology, 4(1). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC434513/ [Accessed 25 Apr. 2017].Health References (2012). Lungs. Available at: http://www.healthsanaz.com/lungs-drawing-for-kids-ldk08.html (Accessed: 25 Apr. 2017).Ho, J. (2017). Urinary Tract Infections in the Elderly.  Mercury Pharmacy Services. Available at: http://www.mercuryrx.com/single-post/2016/11/28/Urinary-Tract-Infections-in-the-Elderly (Accessed 25 Apr. 2017).Jarvis, T., Chan, L. and Gottlieb, T. (2014). Assessment and management of lower urinary tract infection in adults. Australian Prescriber, 37(1), pp.7-9. Available at: https://www.nps.org.au/australian-prescriber/articles/assessment-and-management-of-lower-urinary-tract-infection-in-adults (Accessed 25 Apr. 2017)].Kayalp, D., Dogan, K., Ceylan, G., Senes, M. and Yucel, D. (2013). Can routine automated urinalysis reduce culture requests? Clinical Biochemistry, [online] 46(13-14), pp.1285-1289. Available at: http://www.sciencedirect.com.plymouth.idm.oclc.org/science/article/pii/S0009912013002920 (Accessed 25 Apr. 2017).NHS (2016). Urinary tract infections (UTIs) in adults – NHS Choices.  Available at: http://www.nhs.uk/conditions/Urinary-tract-infection-adults/Pages/Introduction.aspx (Accessed 25 Apr. 2017).Rehmani R (2004). Accuracy of urine dipstick to predict urinary tract infections in an emergency department. – PubMed – NCBI. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15125171 (Accessed 25 Apr. 2017).Schwartz DS, Barone JE. (2006) Correlation of urinalysis and dipstick results with catheter-associated urinary tract infections in surgical ICU patients. Intensive Care Med; 32:1797–1801.Sign.ac.uk. (2013). SIGN Guideline 88: Management of suspected bacterial urinary tract infection in adults – section 6. Available at: http://www.sign.ac.uk/guidelines/fulltext/88/section6.html (Accessed 25 Apr. 2017).Smith, M. (2017). A Guide to Urinary Tract Infections (UTIs).  WebMD. Available at: http://www.webmd.com/women/guide/your-guide-urinary-tract-infections#1 (Accessed 25 Apr. 2017).South Western Ambulance Service. (2014). Urinary tract infection in children: Diagnosis, treatment and long-term management. Available at: http://www.swast.nhs.uk/Downloads/SWASFT%20NICE%20action%20plans/ActionPlan_14-13UTIChild.pdf (Accessed 25 Apr. 2017).Southern Health (2017). Urinary Catheter Care Guidelines. Available at: http://www.southernhealth.nhs.uk/EasysiteWeb/getresource.axd?AssetID=70589&type=full&servicetype=Inline (Accessed 25 Apr. 2017).Sultana, R., Zalstein, S., Cameron, P. and Campbell, D. (2001). Dipstick urinalysis and the accuracy of the clinical diagnosis of urinary tract infection. The Journal of Emergency Medicine, [online] 20(1), pp.13-19. Available at: http://www.sciencedirect.com.plymouth.idm.oclc.org/science/article/pii/S0736467900002900 (Accessed 25 Apr. 2017).Tissot, E., Woronoff-Lemsi, M., Cornette, C., Plesiat, P., Jacquet, M. and Capellier, G. (2001). Cost-effectiveness of urinary dipsticks to screen asymptomatic catheter-associated urinary infections in an intensive care unit. Intensive Care Medicine, 27(12), pp.1842-1847. Available at: https://www.ncbi.nlm.nih.gov/pubmed/11797017?dopt=Abstract (Accessed 25 Apr. 2017).WebMD. (2015). Urinary Tract Infections (UTIs) in Older Adults-Topic Overview. Available at: http://www.webmd.com/women/tc/urinary-tract-infections-utis-in-older-adults-topic-overview (Accessed 25 Apr. 2017).Zamanzad, B. (2009). Accuracy of dipstick urinalysis as a screening method for detection of glucose, protein, nitrites and blood. Eastern Mediterranean Health Journal. Available at: http://applications.emro.who.int/emhj/1505/15_5_2009_1323_1328.pdf (Accessed 25 Apr. 2017).Plymouth UniversityFaculty of health and human sciencesSchool of health professionals   CASE STUDY FOUR Student ID: 10191190Word count: 537Submission date: Monday 8th May 2017Module code: Para 301Module title: Refining practitioner skills for patient careIncident Details: 72 year old, male dog bite to left thumb self-presented at the local minor injuries unit.      Case Study Four: Evaluation of cleaning Wounds; Saline Verses tap waterPCDog bite – two puncture wounds to left thumbHxPCThe patient owns three dogs, one of which is a new puppy; the dogs were fighting and the patient tried breaking them up. The dog bit the patient’s left thumb. Patient had wrapped kitchen tissue around the wound.PMHxDiabetic – diet controlledAcid reflexFMHxUnknownMHxOmeprazoleAllergiesKnown None.SHxRetired, lives with wife and three Jack Russell dogs. Currently staying in their holiday home.O/APatient drove himself in to the minor injuries unit (MIU) near his holiday home. Patient talking in full sentences, alert and GCS 15/15.Site: The Thenar area of the thumbOnset: When the dog let go, around 14:00Radiation: NoneAssociated symptoms: Swelling, two puncture wounds to the thenar thumb, and still actively bleeding.Timing: 14:00Exacerbating symptoms: Throbbing. No boney tenderness on palpation and pain or discomfort on thumb movement.Score: 4/10 pain. 1g of paracetamol administered.O/E RS RR at 18. SP02 98% (Air).Equal air entry.Equal rise and fall.Trachea central.Equal resonance throughout.Chest sounds: Clear.(Health References, 2012). CVSHR 64. BP 128/78. Cap Refill <2. CNSTemp 36.5 ABDONAD LMSGood radial pulse. Hands, fingers and thumb warm to touch. No loss of sensation. Left thumb swollen. Two half cm sized puncture wounds to left thenar eminence. Approximate 15ml of blood loss. Patient described the pain as throbbing. No boney tenderness on