Case Study: Ms. S is a 25 year-old female who was previously admitted to the trauma ICU for
multisystem trauma following a high-speed motor vehicle accident. She sustained a serious head
trauma and was in a coma for 3 weeks. Additional injuries are as follows: bilateral fernur
fractures, multiple rib fractures with a left hemomothorax, a lacerated liver (repaired), and a left
fractured clavicle. Also of note is that her best friend was driving and was killed in the accident.
The patient is being admitted to rehab so that she can work on ambulation and ADL's.
Assessment: Vital Signs: 98.2 PO , P = 75 , BP = 110/75 , C / O generalized pain 6/10 Alert and
oriented X 3 . Appears depressed with a flat affect. Clear breath sounds in all lung fields. O 2 sat.
is 99% on room air. S1 and $2 heart sounds auscultated. Abdomen soft and nontender with +
bowel sounds in all 4 quadrants. + pedal pulses. Healed incisions to right and left lateral thighs
and absomen. Functional assessment: Unable to ambulate. Able to perform limited ADL's (able
to brush her teeth with assist, unable to dress herself, unable to toilet herself-using bedpan or
clean herself. Labs: all within normal limits.
Case Study- Ms- S is a 25 year-old female who was previously admitted.pdf
1. Case Study: Ms. S is a 25 year-old female who was previously admitted to the trauma ICU for
multisystem trauma following a high-speed motor vehicle accident. She sustained a serious head
trauma and was in a coma for 3 weeks. Additional injuries are as follows: bilateral fernur
fractures, multiple rib fractures with a left hemomothorax, a lacerated liver (repaired), and a left
fractured clavicle. Also of note is that her best friend was driving and was killed in the accident.
The patient is being admitted to rehab so that she can work on ambulation and ADL's.
Assessment: Vital Signs: 98.2 PO , P = 75 , BP = 110/75 , C / O generalized pain 6/10 Alert and
oriented X 3 . Appears depressed with a flat affect. Clear breath sounds in all lung fields. O 2 sat.
is 99% on room air. S1 and $2 heart sounds auscultated. Abdomen soft and nontender with +
bowel sounds in all 4 quadrants. + pedal pulses. Healed incisions to right and left lateral thighs
and absomen. Functional assessment: Unable to ambulate. Able to perform limited ADL's (able
to brush her teeth with assist, unable to dress herself, unable to toilet herself-using bedpan or
clean herself. Labs: all within normal limits
