473-week 4 inclass.docx - Anika Amin Maryam Ansari Abigail...

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Anika Amin Maryam Ansari Abigail Andrew Patient Profile M.P., a 19-year-old African American male, has a spinal cord injury following a gunshot wound 2 weeks ago. The gunshot injury occurred during a hunting accident when his best friend’s gun accidentally discharged. His injury is at the T5 level. The goal is to prepare him for transfer to a rehabilitation unit in the next few days. Subjective Data Has just completed his first year of college as an engineering student States he is depressed and “he cannot get used to the idea of not walking again” Objective Data Physical Examination Supine blood pressure 120/68, sitting blood pressure 114/62, pulse 68, temperature 99.8° F, respirations 16 Slight edema bilateral lower extremities – ace wraps wrapped around lower extremities Abdominal binder in place Urinary catheter intact and draining dark yellow urine Last bowel movement 2 days ago; it was hard, small and brown Full head, neck, shoulder and upper extremity movement with normal muscle strength and sensation Complete paralysis of lower body and legs with no sensation present Full passive range of motion without crepitation in the bilateral lower extremities Diagnostic Studies Spinal series x-rays: Complete transsection at T5 MRI: Confirmed transection and revealed no clots or masses present Laboratory results:
White blood cells: 9500/µL Hemoglobin: 16 g/dL Hematocrit: 45%

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