Case Study: John Doe – Emergency Department
Evaluate the information and formulate a conclusion based on your evaluation. Complete the critical thinking table and submit this completed template to the assignment dropbox.
evaluate and synthesize patient data to propose interventions for an individualized plan of care prioritizing health problems and health concerns.
PART I: Health History and Medical Information
Evaluate the health history and medical information for John Doe, presented below.
John Doe, a 35-year-old male, was riding his motorcycle under the influence and experienced a motor vehicle accident resulting in multiple fractures and a traumatic brain injury (TBI).
On scene, John Doe was alert but exhibiting restlessness and agitation with hands-on care. En route to the hospital, he displayed changes in level of consciousness (LOC), mood and behavior, nausea and vomiting (N/V), and dilated pupils. Upon arrival to the emergency department, John was unconscious with a Glasgow Coma Scale (GCS) score of 6, indicating a severe TBI. Prior to losing consciousness, he was exhibiting signs of extreme pain on the left side.
Objective Data – completed by ambulance personnel:
1. 84/60 BP, HR 136, RR 28 irregular, SpO2 92%
2. 5′ 11″ height, 180 lbs. weight
3. GCS Score: 6
a. No response in eyes: 1
b. No verbal response: 1
c. Flexion withdrawal from pain: 4
4. Change in LOC
5. Possible fractures to left leg and left ribs
6. Intubated in route to ED
Objective Data and Laboratory/Test Results – on arrival to the emergency department (initial results)
1. Complete blood count (CBC) –
a. White blood cells: 11.3
b. Hemoglobin: 15.6
c. Hematocrit: 41.5
d. Platelets: 316,000
2. Comprehensive Metabolic Panel (CMP) –
a. Alanine Aminotransferase (ALT): 32 U/L
b. Albumin: 4.8 g/dL
c. Alkaline Phosphatase (ALP): 122 U/L
d. Aspartate Aminotransferase (AST): 52 U/L
e. Blood Urea Nitrogen (BUN): 16mg/dL
f. Bilirubin: 1.4mg/dL
g. Calcium: 9.8mg/dL
h. Creatinine: 1.1mg/dL
i. Glucose: 112mg/dL
j. Potassium: 3.9 mEq/L
k. Sodium: 138 mEq/L
3. Prothrombin time (PT) – 12 seconds
4. Partial Thromboplastin time (PTT) – 37 seconds
5. Panscan CT (Polytrauma Whole Body Imaging): Results –
a. Closed left femur fracture
b. Hairline fracture of 3 left ribs
c. TBI consisting of frontal-temporal skull fracture
6. Urinalysis (UA) – positive for red blood cells in urine
7. Drug panel – positive for cannabinoids
8. Consent to treat options
