2.1 Problem List

A 28-year old female belted driver was involved in a head-on collision with a transport truck during white-out conditions.  She was suffering from hypothermia as a result of the long extrication at the scene with a GCS 3.  Her injuries at the time included a severe diffuse axonal injury as well as a number of orthopedic injuries which were subsequently operated on and repaired.

The patient was admitted to rehabilitation 2 months post-injury.  When reviewed she was able to occasionally follow single step commands (thumbs up) on Rt. Side.   She had a flaccid left hemiplegia until recently and was now starting to demonstrate increased tone about the hand and elbow with decreased range of motion in all joints.  She had bilateral plantar flexor posturing which could be reduced to neutral position.  She was non-verbal, not even mouthing words as he had a tracheostomy.  She made occasional eye contact especially with her family who feel she is “in there”.  There was very little responsiveness to staff but had been seen to track during personal care.  She was a Rancho Los Amigos Level III.

Develop a Problem List for this Patient.        

  •  Hypothermia and GCS 3 at scene;
     
  • Severe diffuse axonal injury;
     
  • Orthopedic injuries;
     
  • Flaccid left hemiplegia

In rehab:

  • Occasionally follow single step commands (thumbs up) on Rt. Side;
     
  •  Increased tone about the hand and elbow with decreased range of motion;
     
  • Bilateral plantar flexion with decreased range of motion (ROM);
     
  • Non-verbal;
     
  • Tracheostomy;
     
  • Occasional eye contact with family;
     
  • Little responsiveness to staff