SOLVED114

The patient is a 63 yrs. old male who was involved in a high speed motor vehicle collision. He was a restrained driver and stated that he lost control on the road and hit a tree. The patient reported that he lost consciousness, and the next thing he knew was that he woke up in an ambulance. The patient has a right calcaneus fracture along with a right distal fibula fracture. He also had a subdural hematoma, rib fracture, and facial fractures. He complains of 8 out of 10 pains in his right calcaneus worse with palpation and movement of his heel. Pain is better with rest immobilization. Patient currently not ready to fix ankle due to swelling and blistering, Patient is non weight bearing at this time. Rehab is recommended . Patient is self pay. Patient meet charity so may be able to go to rehab. Patient has an history of osteoarthiritis of knee and hypertension.Test Results& Date 02/21/2024 02/22/24 Normal Values WBC 10.5 7.3 3.3- 10.5 M/CUMM RBC 2.91↓ 2.93↓ 4.15 – 5.75M/CUMM Hematocrit 29.7↓ 28.7↓ 38.8 – 50.2 % Hemoglobin 9.9↓ 9.9↓ 12.8 – 16.9 g/dL RDW 12.1 11.4↓ 11.5 – 15 % Chloride Normal 108↑ 98 – 107 mmol/L Glucose 115↑ 102↑ 65 – 99 mg/dL Troponin Normal 0.05↑ < 0.03ng/mL Creatine serum 0.54↓ 0.50↓ 0.66 - 1.25 mg/dL Calcium 8.3↓ 8.2↓ 8.4 - 10.2 mg/dL Anion gap 4↓ 6↓ 7 - 17 mmol/L Test Results X-ray Right Foot. Right distal fibula fracture. Right calcaneus fracture X-ray Right Hand Unilateral No acute findings on right-hand CTA Neck w/o Contrast No major vascular occlusion, flow limiting stenosis or vascular dissection CT Head w/o Contrast Head - Mixed attenuation right holohemispheric subdural hematoma up to 9mm in thickness with right to left shift of 2mm. - Perimandibular soft tissue contusion with multiple locules of gas could be from an open wound. Multiple mandibular fractures. Fractures of the left mandibular body. Fractures of the left mandibular ramus is partly included. Comminuted fracture of the right mandibular ramus. Vitals 02/22/24 (AM) 02/22/24 (PM) Blood Pressure 148/82 (Left upper Arm) 169/80 (Left upper Arm) Temperature 97.9 97.7 Heart Rate 61 60 Respiration 16 16 Oxygen Saturation 98 (oxymask) 93 (room air) Review collected data and provide analysis: Significant changes since admission, any noted trends, concerns. SCIENCE HEALTH SCIENCE NURSING

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