Date of Admission: [DATE]. Date of Discharge:

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Griselda Doyle
6 years ago
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1 Date of Admission: [DATE]. Date of Discharge: History of Present Illness: Mr. [NAME] AKA [NAME] is a 31-year-old male who presents to the [PLACE] Trauma Surgery Service as a moderate trauma on [DATE] following an MVC rollover in which the patient was the driver of the car. The patient had sustained a right elbow laceration and large head laceration with complaints of neck pain and head pain. The patient reports traveling at approximate speeds of 40 to 45 miles per hour, was able to self extricate himself and states that he was restrained. On initial presentation, vital signs were as follows: 36.0 temperature, heart rate of 64, blood pressure 146/80, and O2 saturation 98% on room air. Positive physical exam findings included a 6 x 4 cm laceration avulsion to the occiput of the scalp, right elbow avulsion laceration. Initial laboratory diagnostics included a HemoCue of 16.9 and 16.1, ETOH of 121, UA negative, and lactate of 4.5. ABG as follows: 7.42, 31, 32, 20, -4, 99%. The patient following stabilized in trauma bay was taken for CT of his head, C-spine, chest, abdomen, and pelvis with initial consultations to include orthopedic surgical team for the right elbow, neurosurgery consultation, ophthalmic consultation as well as a plastics consultation. Radiological diagnostics include a CT of the head, which demonstrated no evidence of mass effect, mass, or midline shift. No evidence of acute intracranial abnormality; however, the large laceration to the left scalp was noted and a fracture of the right occipital condyle noted medially. There is also notation of fracture to the right nasal bone. CT of the C spine demonstrated multiple cervical spine fractures, a fracture through the C5 transverse process. There were fractures of the right occipital condyles, fracture of the lateral mass of C3 on the right, which extends to involve the C2-C3 right facet joints. There is a fracture of a right C5 transverse process extending to involve the transverse foramina and a fracture of the left C6 transverse process, but questionable fractures to involve the right superior facet of C4. CT of the chest was negative, CT of the abdomen was negative, and CT of the pelvis was negative for acute trauma. Extremity x-rays of the right elbow was noted with a soft tissue injury ( ) punctate densities. No evidence for acute fracture dislocation. X- ray of the left hand with no evidence of displaced or acute fracture dislocation. X-ray of the right knee was without evidence of soft tissue thickening anterior to the patella of the patellar tendon, continues to have contusion hematoma. No evidence of joint dislocation or gross displaced acute fracture. X-ray of the right shoulder negative for dislocation or fracture. Following subsequent studies to include MRA of the neck demonstrating injury to the right vertebral artery. CT angiogram of the neck demonstrating distal right vertebral narrowing segmental occlusion. Following stabilization in trauma bay, the patient was admitted under the [PLACE] Trauma Surgery Service for continued followup examination and care with consults by Orthopedics with final recommendations for wet-to-moist dressing changes to the right elbow and for antibiotic coverage. Initial assessments of the right elbow demonstrated no joint involvement and the patient was to follow up as needed. Neurosurgery was consulted for cervical spine injuries. Final recommendations were to include for C-collar for 6 weeks and activity as tolerated while C-collar is on. Final Plastics recommendations included p.o. Augmentin upon discharge for 7 to 10 days with Plastic Surgery and Vascular Surgery recommended anticoagulation with Lovenox to Coumadin transition with repeat imaging in 1 month and for anticoagulation for 3 months. Hospital Course: During his hospital course, the patient was taken to the OR on [DATE] for scalp washout and advancement of the flaps with Plastics taken back to the SICU for continued observation and care. Antibiotics of Ancef x48 hours were completed for the right elbow laceration. While in the ICU, the patient's diet was slowly advanced. Ophthalmology and face consults were ordered with suspense of no change to vision, no acute concerns and Ophthalmology had signed off. Plastics continued to following the patient following their scalp advancement rotation flap with recommendations for Zosyn and Augmentin for 7 days due to dirty wound with topical treatment of

2 bacitracin ointments q.i.d. Further recommendations to follow up in outpatient clinic with further instructions for head elevated due to increased edema. The patient was placed out of bed, continued to work with physical therapy and occupational therapy, deemed independent. Plastics recommended okay for shower. Vascular Surgery consulted for vertebral artery dissection, continued to follow the patient with no further recommendations. The patient was to follow up with Dr. [NAME] on [DATE] at 9:20 a.m. On the day of discharge, the patient was without complaints of constitutional symptoms of nausea, vomiting, fever, or chills. He will tolerate diet, pain controlled on oral pain medications with flatus. Denying focal neurological symptoms such as double vision, loss of conscious, seizures, and activities of tremors. Physical Examination Vital Signs: Vital signs were as follows: Temperature of 37.2, respiratory rate of 18, heart rate of 57 to 59, and blood pressure 151 to 164 over 94 to 95 with p.o. intake of 660 and adequate urine output of 500. Neurological: Neurologically, the patient remained awake, alert, and oriented. Glasgow scale of 15 with cranial nerves 2 through 12 are grossly intact. HEENT: PERRLA, right eye. Right sclera was noted with erythema. Scalp laceration was with bacitracins, clean, dry, and intact with staples. Cardiovascular: Rhythm and rate was regular. Pulmonary: Lung sounds were clear to auscultation bilaterally. The patient was able to move all extremities with multiple abrasions to bilateral upper extremity and right knee with approximate total body surface less than 3% of superficial abrasions. Diagnostic Data: Laboratory diagnostics include white blood cell count of 5.3, H and H of 14.8 and 42.0, and platelets of 230. PT of 10.4, INR of 0.99, and PTT of On day of discharge, the patient's antibiotics of ertapenem was changed over to Augmentin p.o. with discharge pending anticoagulation transition from Lovenox to Coumadin. Impression: A 31-year-old male, status post rollover motor vehicle accident, multiple cervical spine fractures with vertebral artery dissection and scalp and elbow laceration, status post scalp washout and plastics closure. The patient is to be discharged in stable condition with followup appointments with Orthopedics, Neurosurgery, Plastics, and Vascular. The patient is to be discharged and furnished with pain medication as well as anticoagulation medications, stool softeners, and further followup instructions with [PLACE] Trauma Surgery Service. Further discharge instructions will be given by nursing staff when to seek additional emergency room care and management of injuries.

3 Date of Admission: [DATE]. Date of Discharge: [DATE]. Addendum: [NAME] who was scheduled to be discharged on [DATE], was accompanied by his family with concerns regarding safety of home discharge due to nausea and vomiting x1, living situation, Lovenox training, and mobility. After discussion with the case manager, a discussion was made with insurance company for approval for overnight stay. The patient and the family understand that the overnight stay was not necessary, but still requests to stay for better discharge arrangements. The patient is to be discharged in the morning on [DATE], if continues to be in stable condition. Discharge instructions regarding followup care and Coumadin dosing as well as coagulation checks were discussed at great length with the patient and the patient's father accompanied by case manager [NAME], for which both the patient and the patient's father verbalized understanding.

4 Date of Consultation: [DATE]. Service Provided: Inpatient Consultation. Requesting Service: SICU Service. Service Provided By: Vascular Surgery. Chief Complaint: Possible vertebral artery dissection. History of Present Illness: This is a 31-year-old male status post motor vehicle collision, admitted as a trauma on [DATE]. He had scalp laceration, went to the OR for complex closure and flap of the scalp. Also, he has had multiple C-spine fractures. Neurosurgery recommended a C-collar for 6 weeks. Vertebral artery injury was suspected on the basis of his C-spine fractures. The patient does not complain of any neurologic problems. He states he does have some neck pain, however. Allergies: IODINE DYE. Medications: He is currently on ertapenem. Past Medical History: No chronic medical problems. Past Surgical History: Reconstructive facial surgery after a previous motor vehicle collision and tonsillectomy. Social History: Positive for alcohol. Family History: Noncontributory. Physical Examination Vital Signs: Temperature 36.7, heart rate 55, blood pressure 145/75, satting 97% on room air, and breathing rate is 23. General: In no apparent distress. The patient is in C-collar. HEENT: Extraocular muscles are intact. Sclerae are anicteric. Status post scalp surgery. Neck: He has a C-collar in place. Upon removing C-collar, there is no obvious external injury to the anterolateral neck. There is no hematoma or wounds. Heart: Regular rate and rhythm. No murmurs. Lungs: Clear to auscultation bilaterally. Abdomen: Soft and nontender. No palpable pulsatile mass. Extremities: No clubbing, cyanosis, or edema. DP, PT, and femoral pulses are 2+ bilaterally. Neurologic: Cranial nerves 2 through 12 are intact. Strength 5/5 in all extremities. Imaging: The C-spine showed multiple fractures to include a lateral mass at C3 on the right which extends to involve C2-C3 right facet joint, fracture of right C5 transverse process with extensive involvement of the transverse foramina, fracture of left C6 transverse process, and possible fracture involving the right superior facet at C4. The MRA of the neck was done tonight and reports signal loss in distal portion of right V2 and proximal right V3 suggesting possible dissection from trauma. Laboratories: Hemoglobin 15.2, platelets 162, and white count 12.7.

5 Assessment and Plan: This is a 31-year-old male with a possible vertebral artery dissection and multiple C-spine fractures. Recommendations: We recommend a CT angio of the neck as this is more sensitive for picking up an injury and it would be better to have this to make the definitive diagnosis prior subjecting this patient to several months of anticoagulation. This case was discussed with Dr. [NAME]. He will follow up the results of the CT angio of the neck and further recommendations to follow.

History Data Panel. Case 030 Preg Trauma. Presenting Complaint Altered mental status s/p MVC. Person Giving Information EMS

History Data Panel. Case 030 Preg Trauma. Presenting Complaint Altered mental status s/p MVC. Person Giving Information EMS History Data Panel Presenting Complaint Altered mental status s/p MVC Person Giving Information EMS History of Present Illness 28 year old woman, 35 weeks pregnant per report of her husband the passenger.