Course Project Case Study: Mr. Clooney is a 76-year-old Caucasian male who was admitted to the
rehabilitation hospital following a 6 week stay in a local acute care hospital. He suffered a T3 burst
fracture after a MVA and the site was surgically stabilized. He is paralyzed in his lower extremities and
has no sensation below the clavicles. He is incontinent of bowel and bladder and has a stage 3 pressure
ulcer to his coccyx. Medical history includes asthma, substance abuse (alcohol), obesity, constipation,
prediabetes (has not progressed to type II diabetes) and tested positive for Covid-19 in November 2020
after experiencing shortness of breath and fever.
Mr. Clooney is single and lives alone in a second story apartment. His son lives three states away and he
has no relatives in the area. He is a retired construction worker, denies any religious affiliation, and
PT, OT TID, 5 days per week
Dressing changes to sacral pressure ulcer: cleanse with wound wash, alginate dressing daily
Cervical collar when OOB
Transfer with sliding board per PT
Ensure high protein shake BID
Foley catheter to dependent drainage
Cleanse catheter site with soap and water BID
Dulcolax suppository every 3 days rectally
Baclofen 5mg PO QID
Midodrine 10 mg PO at 0800, 1300 and 1800
Albuterol inhaler: 180 mcg (2 puffs) every 6 hours PRN
Metformin 500 mg PO BID
1.) Patient suffers from a traumatic spinal injury located at the third thoracic vertebra or T3 is fractured with shards of vertebra penetrating surrounding tissues and possible spinal canal. This fracture type called burst is considered more severe than a compression fracture because long-term neurologic damage can follow. The patient had surgery to stabilize the fracture. This injury was sustained from a motor vehicle accident or MVA. The diagnosis was confirmed using an X-ray and CT-Scan OR computerized tomography. The patient also suffers from paraplegia or paralysis of the lower limbs. This is a common condition those who have traumatic spinal cord injuries suffer from. The patient has no sensation below his collar bone or clavicle. The upper extremities are not paralyzed but the patient is unable to detect or feel any sensation, touch, or movement in them. The patient suffers from involuntary loss of urine and feces or bowel and bladder. Another complication of traumatic spinal injuries. This was confirmed using an electromyography -a test that checks how well the muscles and nerves of the anus and pelvic floor are working.
2.) Patient has a history of a pulmonary condition characterized by chronic inflammation of the lower respiratory tract, tightening of respiratory smooth muscles, and episodes of bronchoconstriction or more commonly known as asthma (Gordon, 1996). There are two different categories for asthma, either allergic or non-allergic. Its exact cause is unknown, it is suspected to be due to genetic and or environmental factors. Medication and treatment depend on the varying of symptoms and rather it is allergic or non-allergic.
3.) Patient has a history of substance abuse in the form of alcohol. In individuals who suffer from alcohol abuse, the overconsumption of alcohol is associated with the neurotransmitters involved in the reward system are affected. Alcohol stimulates the release of dopamine from cells originating in a region of the brain called the ventral tegmental area (VTA). Causing the individual to feel a sense of reward in relation to the consumption of alcohol. Long-term use and exposure to alcohol generally will increase the risk of damage to the gastrointestinal, cardiovascular, immune, nervous, and other bodily systems (Minnick, 2014).
4.) Patient has an open sore that is located on the coccyx that has localized areas of tissue necrosis that progress and extend into the tissue beneath the skin forming a crater. Fat is visible but no muscle, bone, or tendon is exposed, this is also called a stage 3 pressure injury or pressure ulcer. This is a possible complication associated with paralysis of his lower extremities. This injury typically happens when soft tissue is compressed between a bony prominence and an external surface for a long period of time. This stage, which is now stage 3, it involves full-thickness skin loss extending to the subcutaneous tissue layer with possible undermining and tunneling (Montoya, 2012).
5.) Patient has a history of an infectious disease caused by the SARS-CoV-2 virus that causes severe acute respiratory syndrome coronavirus. The coronaviruses are a group of related RNA viruses that cause diseases in mammals and birds. In humans and birds, the virus causes a respiratory tract infection that can range from mild to lethal. This is more commonly known as the Covid-19 virus (Yuki, 2021). In addition to this virus, the patient will have his condition of asthma become exacerbated.
THIS IS THE ASSIGNMENT:
Write a detailed physical assessment and interview on your case study client. You will have to know what to expect in your client by using the information from #1 above and your case study. You will have to be creative.