Age: 48.0
Sex: F
Vaccine: COVID19
Symptoms: Subarachnoid haemorrhage, Subdural haematoma, Tibia fracture, Vitamin D deficiency, Wound closure
Clinical narrative: Discharge Examination & Summary  Admission Date and Time: 12/19/2023  6:46 PM Discharge Date: 12/31/2023 Admission Diagnosis: Mild traumatic brain injury Discharge Diagnosis: Mild traumatic brain injury  Diagnosis ? Mass of uterine cervix ? Anemia ? Depression ? Invasive squamous cell cancer of the cervix ? Malignant neoplasm of endocervix ? Gallstones ? Mild traumatic brain injury ? SAH (subarachnoid hemorrhage) ? SDH (subdural hematoma) ? Orbit fracture, right ? Closed fracture of distal phalanx of right little finger ? Anxiety ? Constipation ? Vitamin D deficiency ? Scalp laceration ? Fracture of distal end of right humerus ? Tibia/fibula fracture, right, closed, initial encounter ? Major traumatic injury                                                    PREMORBID FUNCTIONAL STATUS Premorbid Functional Status:  Level of Independence: Independent with transfers; Independent with ambulation    REHABILITATION COURSE  Pt. is a pleasant 50 YO right handed female with anxiety who presented 12/19/2023  6:46 PM to hospital after primary admission to  Hospital for major multiple trauma after MVC.  On 12/12/23, patient remembers that she was driving and then hitting a car passing perpendicularly in front of her on the side of their car. Then her car was hit from behind and then she blacked out. She remembers the EMTs but doesn't remember if in or out of ambulance. Then she remembers waking up again when they were explaining that she was being taken to hospital and then woke up again at hospital.  List of injuries as follows:  Right arm (distal humerus) fracture Right leg, foot (tibia, fibula) fractures Scalp lacerations Subarachnoid hemorrhage  Subdural hemorrhage  Right periorbital contusion and blowout fracture  Right fifth distal phalanx fracture  She underwent the following procedures: 12/12: Repair of scalp lacerations  12/12: Reduction of right lower extremity fracture by Orthopedic surgery 12/12: Wrist splinting of right upper extremity by Orthopedic surgery 12/12 Left great toe washout and closure  12/13: ORIF R Ankle fracture, pinning 1st and 2nd toes 12/14 - ORIF R distal humerus fracture 12/15 - ORIF R bimall ankle fx, R syndesmotic repair, gissane spike for ankle dislocation, ORIF 1st and 2nd proximal phalanx, open reduction without fixation of 4th proximal phalanx, I&D R open 1st, 2nd, 4th proximal phalanx, I&D R knee traumatic arthrotomy, closed tx w/o manipulation of R calcaneus anterior process fx, R short leg splint application   Hospital course was complicated by incidental cholelithiasis which patient may follow up with PCP outpatient. She was also seen by SLP and neuropsych who found her demonstrating good cognitive recovery  When medically stable, the patient was discharged for acute inpatient rehabilitation of functional and cognitive deficits.  Symptoms related to these abovementioned conditions and events were well-controlled, and the patient was discharged medically stable and improved. There were no significant acute episodes that affected length of stay or tolerance to therapies.   The patient was also provided orthotics / durable medical equipment to ensure improved function and safety in the rehabilitation and home setting.  Occupational, Physical and Speech Language Pathology therapists and a Neuropsychologist were consulted for evaluation and treatment so as to best determine the amount and extent of services required for cognitive and functional optimization. The patient received a minimum of 180 minutes of therapy per day for 5 out of 7 days, or more than 15 hours of intensive therapy over the course of a week.   While in the unit, the acute rehabilitation service also held interdisciplinary team conferences on a weekly basis to establish specific short- and long-term goals during rehabilitation, and for discharge. Barriers to discharge were also noted and updated as they were addressed. Plans to assure continuity and coordination of care after discharge from the acute rehabilitation unit were also established and explained to the patient and care provider(s). Discharged to home.