Case Study Assignment #1

Case study John Hoppe is a 21-year-old senior at the University of Delaware, majoring in economics. While on spring break in Florida, John was involved in a one-vehicle motorcycle accident. In the accident, John was thrown from his bike to the pavement, landing on his back. A police officer witnessed the accident and immediately called for medical assistance. Emergency personnel arrived within minutes, and upon recognizing the seriousness of John’s back injury, immobilized his neck and secured him to a rigid board prior to transporting him to the emergency room of the nearest hospital. When he arrived at the hospital, John was conscious and complained of pain in his lower back. Upon examination by the emergency room personnel, John was found to have numerous abrasions and contusions, and loss of both sensation and motor control of his legs. After he was stabilized, a complete physical and neurological exam was performed to assess and localize John’s injury. History and Physical Examination Patient Name: Hoppe, John Date: 6/15/2009 Referral Source: ER Data Source: Patient Chief Complaint & ID JH is a 21 y/o male with possible spinal cord injury. History of Present Illness JH is conscious and complaining of lower back pain. Past Medical History Medical History: o No medical problems. Immunizations: o Flu vaccine – 11/08 Current Health Status Medications: o Prescription drugs: none o No illegal drug use. o NKA Diet, Sleep, Exercise o Diet – no special diet. o Sleep – Average of 7h/night. o Exercise – weight lifting 3/wk Habits: o Alcohol use: None. o Tobacco use: None. PSIO 201 Assignment #1 Department of Physiology SSI 2009 Family History Mother, 51, colon cancer, currently undergoing chemotherapy. Father, 55, hypertension and osteoarthritis. Review of Systems HEENT: No major head injury. Abrasions. Cadiovascular: Normal. Gastrointestinal: Fecal incontinence. Genitourinary: Urinary incontinence. Musculoskeletal: See neuromuscular exam below. Lower back pain after the injury. Loss of sensation and motor control of his lower limbs. Neurological: See neuromuscular exam below. Physical Examination Vital Signs: Blood Pressure 100/68, Pulse 78 bpm, Respirations 12/min, Temperature 37 C. General: o JH is conscious and cooperative. Skin: o Abrasions and contusions. Otherwise normal. HEENT: o Scalp normal. o Pupils normal, reactive to light and accommodation. Fundoscopic exam shows normal vessels without hemorrhage. o Tympanic membranes and external auditory canals normal. o Nasal mucosa normal. o Oral pharynx normal. Tongue and gums are normal. Neck: o Freely moveable w/out resistance. Thyroid gland is normal – no masses. o No bruit noted over carotid artery Chest: o Lungs are clear to auscultation and percussion bilaterally. No crackles. Heart sounds are normal. Abdomen: o The abdomen is symmetrical without distention; bowel sounds are normal in quality and intensity in all areas. No splenomegaly. Extremities: o No cyanosis. Nodes: o No palpable nodes in the cervical, supraclavicular, axillary or inguinal areas. Genital/Rectal: o Decreased rectal sphincter tone; no rectal masses or tenderness. Stool is brown and guaiac negative. Musculoskeletal: o Normal or near normal strength for upper limbs. PSIO 201 Assignment #1 Department of Physiology SSI 2009 o Loss of motor control in lower limbs (no strength for lower limbs) Neurological: o JH demonstrated normal or near normal strength in flexing and extending his elbows, extending his wrists, and when flexing his middle finger and abducting his little finger on both hands. o He exhibited no movement when medical personnel tested his ability to flex his hips, extend his knees, and dorsiflex his ankles. o Stretch reflexes involving the biceps, brachioradialis, and triceps muscles were found to be normal, while those involving the patella and ankle were absent. o Normal sensitivity to pin prick and light touch in areas of his body above the level of his inguinal region, but not below that region of the body.

Analysis Answer the following questions: 1) What is the major body system involved in this case study. What are the possible consequences of such an injury?

2) Describe the prevalence and management of the injury highlighted in this cases study. In addition, discuss the factors that determine the prognosis for this condition.

3) What other body systems are involved in this injury?

4) What health professionals/specialist will be utilized through the course of treatment and rehabilitation?

5) Discuss the multisystem injuries and treatment presented in the case.

Requirements: 1) All assignments must be typed, double spaced and concise. Students should answer the questions fully but avoid repetition. 2) Late assignments will NOT be accepted for credit. 3) Assignments should include credible references for your information. Resources such as Medline Plus, the CDC, and Mayo Clinic are examples of acceptable references.