1.1 Problem List

A 47-year old male unbelted driver was involved in single vehicle rollover while intoxicated.  He was thrown from his vehicle and found in ditch.  Glasgow Coma Scale (GCS) was initially 3. There was a question as to whether he suffered a seizure.   He progressed to a GCS 12-13 and combative but deteriorated again to a GCS 7 in ER and required intubation and ventilation.

The patient’s injuries included a Rt. frontal smear subdural hematoma, traumatic subarachnoid /intraventricular hemorrhage and bifrontal and bitemporal contusions. He was not considered a surgical candidate. He also suffered a brachial plexus injury and road rash. He was admitted to rehab day 14 post-injury.

Subdural Hematoma

(SDH)

Bifrontal Hemorrhagic Contusions

At the time of admission to rehabilitation he was oriented to name only and was unable to complete the mini-mental exam. He was able to only inconsistently understand what was being said to him and although he had fluent speech, it was often tangential or nonsensical. He was not able to properly use common objects (toothbrush, comb, cup) and was observed to attempt to eat soap and paper. He required for 2 persons moderate-maximum assist to stand and ambulate for short distances. His Berg Balance score is a 2. He falls twice in the first 24 hours before restraints were applied (to abdomen and limbs); he also continually wants to pull out G-J tube. He had failed an early VMBS swallowing study, had aspirated without coughing and was NPO but perseverates on the need to drink (He had SIADH and was on fluid restriction).

Pictures reproduced with permission 3.Image reprinted with permission from eMedicine.com, 2009. Available at: http://emedicine.medscape.com/article/337782-media4.

Provide a problem list for this case study.

  • Rt. frontal subdural hematoma
     
  • Traumatic subarachnoid /intraventricular hemorrhage
     
  • Bifrontal and bitemporal contusions
     
  • Brachial plexus injury
     
  • Road rash
     
  • Oriented x1, cognitive problems
     
  • Aphasic
     
  • Apraxic
     
  • Impaired balance, 2 person assist to ambulate
     
  • Impulsive
     
  • Perseverative
     
  • Aspiration (silent)
     
  • G-J tube
     
  • SIADH