SPLOŠNA BOLNIŠNICA [REDACTED]

Oddelek za urgentno medicino — Sprejemna enota

General Hospital [REDACTED] — Emergency Department — Admissions Unit

KLINIČNA DOKUMENTACIJA / FOR INTERNAL USE ONLY — CLINICAL RECORD

POROČILO O SPREJEMU / ADMISSION REPORT

Date: 22 August 2007 | Time of admission: 06:14 | File No.: SB-2007-0822-019

Triage classification: Rdeča — takojšnja obravnava / Red — immediate attention

PODATKI O PACIENTU / PATIENT DATA

• Name: Unknown
• Gender: Male
• Estimated age: 35–45
• ID document: None carried
• Next of kin: None at admission
• Origin: Lake [REDACTED], local road [REDACTED], Cerkljansko area. Transported by ambulance following call to 112 at 05:51.

REASON FOR ADMISSION

Male patient admitted in unconscious state. Transported from lake shore after being found partially submerged by civilians. Witnesses report having observed the subject moments earlier walking into the lake without stopping. No response to verbal or pain stimuli at time of admission.

MEDICAL HISTORY

Not available. No documentation. No next of kin.

Note from paramedic, Cerkno rescue unit: "Witnesses at the scene — an adult couple with a small child — report that the subject entered the water fully clothed, without running, without shouting. Walking slowly. The child began to cry before the subject reached the water. The witnesses said they did not know why the child was crying. When we asked for their contact details for the report, the man said he would bring them later. They did not return."

INITIAL ASSESSMENT — 06:19

Attending: Dr. T. Kovač, on-call physician

Vital signs:

• Heart rate: 41 bpm
• Blood pressure: 86/52 mmHg
• Respiratory rate: 7 rpm
• Temperature: 36.1°C

Note on temperature: Normal. No clinical hypothermia despite prolonged immersion in water estimated at 9–12°C by the transporting paramedic. The patient's skin presented no coldness to the touch at any point since rescue. This is noted explicitly due to inconsistency with the immersion presentation. No explanation available.

PHYSICAL EXAMINATION

General appearance: Patient unconscious. Clothing completely soaked. No visible external injuries. No signs of trauma. No marks of violence.

Skin: Normal coloration. Complete absence of pallor or peripheral cyanosis. Notable given estimated exposure time.

Neurological: Glasgow 3/15. No motor, verbal, or ocular response.

Pupils: Symmetrical. Light response: absent. The iris of both eyes presents a diffuse opacity of whitish coloration, homogeneously distributed. The corneal surface shows irregular texture upon examination with flashlight — this physician describes it as a vitreous appearance, as though the surface had hardened. Does not correspond to any known cataract presentation. Does not correspond to postmortem findings: patient has a pulse. Ophthalmology consultation requested.

Chest and abdomen: No relevant findings.

Extremities: No edema. No signs of trauma.

Dorsal region: During examination, an area of altered skin texture was identified in the right paravertebral region, approximately at the T10 level, roughly 3–4 cm in diameter. No erythema, no wound, no edema. Skin is intact. The alteration is exclusively tactile: a surface irregularity that has no precise name in this examination. Noted for the record.

CLINICAL IMPRESSION — 06:34

Deep unconsciousness of undetermined cause. Presentation is not consistent with drowning: no significant water in airway, no hypothermia, no signs of struggle. According to witnesses, entry into the lake was voluntary and unhurried.

The bilateral ocular alteration is the primary finding and has no available explanation. Direct trauma ruled out. Pharmacological cause cannot be ruled out pending toxicology.

Hemodynamic state precarious but stable.

PLAN

• Preventive orotracheal intubation
• Full blood count, biochemical profile, arterial blood gases, blood and urine toxicology
• Emergency EEG
• Neurology and ophthalmology consultation
• Request Policija access to road records for lake access route for patient identification
• Attempt to relocate witnesses

NURSING NOTE — 07:08

Attending: Irena Možič, shift A nurse

No hemodynamic changes since admission.

During patient preparation for transfer I noticed that the dorsal area Dr. Kovač noted is easier to feel than to see. I ran my fingers over it twice because I wasn't sure I had felt it the first time. The second time I was sure.

I cannot describe it better than he did. I will only add: it was neither cold nor warm. It felt the same as the rest of the skin. It was something else.

I don't know what.

END OF SHIFT STATUS — 08:00

Patient transferred to ICU. No recovery of consciousness. Identity unconfirmed. Laboratory results pending. Ophthalmology did not respond to consultation request within the shift.

Witnesses not located. Policija reports no vehicle records on the lake access road between 04:00 and 06:00 that morning.

[Handwritten note in right margin, Dr. Kovač's handwriting. No date assigned.]

I went to the ICU at 11 to check on him.

His eyes weren't like that anymore.

I asked the ICU nurse if ophthalmology had come by. She said no, they still hadn't responded to the consultation.

I don't know what to write. If I write that the eyes changed without intervention, the file looks wrong. If I don't write it, the file is incomplete.

I decided not to write it.

I'm writing it here.