TS, 33 y/o female w/ trauma from bicycle accident w/ open fracture of frontal bone, open fracture of r. orbit, open fracture of maxilla, head injury d/t trauma, traumatic pneumocephalus, periorbital swelling, fracture of sphenoid bone, fracture of l. ethmoid bone, laceration of scalp, periapical abscess, cerebral edema, subarachnoid hemorrhage, subdural hematoma.
Pathophysiology
TS had a bicycle accident on 2/24 following meth and cocaine usage. She was not wearing a helmet at the time and crashed into a 5' concrete canal. She broke several bones in her skull and had an open laceration on her skull that required sutures placed by a surgeon. She also had some bleeding into her skull and subarachnoid space and swelling in her brain from the trauma.
Secondary dx:
meth abuse
TS has a hx of methamphetamine and
cocaine abuse. She was high before
her bicycle accident which may have
caused her to crash. She has not
expressed interest in rehab or
trying to get clean.
Assessment
Asleep but opens eyes spontaneously. Oriented x3, (not to time). No numbness or tingling, normal heart rhythm and rate, lung sounds clear and equal bilat. Bowel tones normoactive. Skin is warm and intact except incision. Incision open to air.
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Pertinent labs,
diagnostic tests
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Complications
Infection from lack of proper
bacitracin application to
scalp laceration, or from lac
after suture removal.
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