A 4-year-old boy is brought to a Perth emergency department with a swollen, bruised left forearm. At triage hi…

Question

A 4-year-old boy is brought to a Perth emergency department with a swollen, bruised left forearm. At triage his mother said he fell from a kitchen chair. When you take the history an hour later she says his older brother pulled him off a trampoline. Full skin examination shows no other marks. You are the resident who assessed him and you will not be involved in his ongoing care. Which one of the following is the most appropriate way to record the two explanations in his medical record?

Accepted Answer

Both accounts quoted verbatim, with times

Answer

Only the account given to you

Answer

The account you consider more plausible

Answer

Your clinical summary of both accounts

Answer

Your conclusion that the history is inconsistent

More from Paediatrics