tokens: Admission Date : 2015-10-26 Discharge Date : 2015-10-30 Date of Birth : 1998-01-05 Sex : M Service : SURGERY Allergies : Sulfa ( Sulfonamides ) / Penicillins Attending : Mary T Davis , M.D. Chief Complaint : s/p Pedestrian struck by auto Major Surgical or Invasive Procedure : 2015-10-27 Open reduction and internal fixation of right tib/fib fractures History of Present Illness : 17 yo male pedestrian who was struck by auto at unknown speed ; +LOC . He was medflighted to The Hospital for Orthopedics for ongoing trauma care . Upon arrival GCS 15 , alert and oriented x3 . Past Medical History : Attention deficit disorder ( diagnosed @ 14 yrs of age ) Social History : High school student Resides with parents and siblings Family History : Noncontributory Pertinent Results : 2015-10-26 08:48 PM GLUCOSE - 101 LACTATE - 2.9 * NA+ - 142 K+ - 3.6 CL- - 102 TCO2 - 26 2015-10-26 08:34 PM UREA N - 12 CREAT - 1.0 2015-10-26 08:34 PM AMYLASE - 44 2015-10-26 08:34 PM ASA - NEG ETHANOL - NEG ACETMNPHN - NEG bnzodzpn - NEG barbitrt - NEG tricyclic - NEG 2015-10-26 08:34 PM WBC - 16.0 * RBC - 4.89 HGB - 14.5 HCT - 40.4 MCV - 83 MCH - 29.7 MCHC - 35.9 * RDW - 13.4 2015-10-26 08:34 PM PLT COUNT - 247 2015-10-26 08:34 PM PT - 12.7 PTT - 23.8 INR(PT) - 1.1 CT HEAD W/O CONTRAST Reason : STUCK BY AUTO UNDERLYING MEDICAL CONDITION : 56 year old man s/p struck by auto REASON FOR THIS EXAMINATION : eval for bleed CONTRAINDICATIONS for IV CONTRAST : None . INDICATION : Struck by car . COMPARISONS : None . TECHNIQUE : Axial MDCT images of the brain without IV contrast . FINDINGS : There is a linear nondepressed right temporal calvarial fracture extending into the mastoid process . There is a small subdural hematoma with components of pneumocephalus tracking from the mastoid air cells . There is no shift of normally midline structures . There is also a left occipital scalp contusion but no associated skull fracture . Prominent sutures in this young patient , the right calvarial suture extending into the right temporal bones appears more prominent than its counterpart on the left , however , does not appear to represent an acute fracture . No other acute fractures are appreciated . There is small amount of mucosal thickening in the sphenoid sinuses . No air-fluid levels to suggest occult facial fractures . Orbits are unremarkable . IMPRESSION : Linear right temporal calvarial fracture extending into the mastoid process with small associated right posterior convexity subdural hematoma and pneumocephalus . Discussed with trauma team during the study . CT C-SPINE W/O CONTRAST Reason : STUCK BY AUTO UNDERLYING MEDICAL CONDITION : 56 year old man s/p struck by auto REASON FOR THIS EXAMINATION : eval for fx CONTRAINDICATIONS for IV CONTRAST : None . INDICATION : 18-year-old hit by car . Head injury to the occiput . COMPARISONS : None . TECHNIQUE : Axial MDCT images of the cervical spine with coronal and sagittal reformats without IV contrast . FINDINGS : C1 through T1 are well visualized . There is normal alignment of the cervical vertebral bodies without acute fracture or traumatic malalignment . The posterior elements are intact . There is no significant prevertebral soft tissue swelling . The C1-C2 relationship is within normal limits . The dens is intact . The lung apices are clear without pneumothorax . The upper ribs are intact . There is a linear right temporal calvarial fracture extending into the right temporal bones . This appears to stop short of the carotid canal . Multiple posterior right - sided mastoid air cells are opacified with blood . IMPRESSION : 1) No acute cervical spine fracture . 2) Linear right temporal calvarial fracture extending into the mastoid with a small right posterior convexity subdural hematoma and pneumocephalus ; see head CT report . CHEST ( PA & LAT ) Reason : Please r/o acute process . UNDERLYING MEDICAL CONDITION : 17 year old man with post-op fever . REASON FOR THIS EXAMINATION : Please r/o acute process . INDICATION : Postoperative fever . COMPARISONS : Comparison is made to 2015-10-27 . TECHNIQUE : PA and lateral views of the chest . FINDINGS : The heart is of normal size . Mediastinal and hilar contours are within normal limits . The lung fields are clear . There are no pleural effusions or focal consolidations . There is no evidence of CHF . IMPRESSION : No evidence of significant abnormality . TIB / FIB ( AP & LAT ) SOFT TISSUE Reason : eval for alignment , post op changes UNDERLYING MEDICAL CONDITION : 56 year old man with open RLE fx now s/p fixation REASON FOR THIS EXAMINATION : eval for alignment , post op changes INDICATION : Fracture . Assess for alignment . RIGHT TIBIA / FIBULA , AP AND LATERAL VIEWS : An intramedullary rod is seen fixating a proximal diaphyseal comminuted tibial fracture with six proximal and two distal screws . Additionally , a side plate is seen medially fixating the fracture . There is a non-displaced comminuted fracture of the proximal fibular diaphysis . There is surrounding soft tissue swelling . Os trigonum is visualized . IMPRESSION : Comminuted proximal tibiofibular fractures status post ORIF of the tibia with an intramedullary rod and side plate . No evidence of immediate hardware complication . CT HEAD W/O CONTRAST Reason : follow up ct UNDERLYING MEDICAL CONDITION : 17 year old man with pneumocephalus s/p CMED CCU v. mvc REASON FOR THIS EXAMINATION : follow up ct CONTRAINDICATIONS for IV CONTRAST : None . CLINICAL HISTORY : History of pneumocephalus status post pedestrian versus motor vehicle collision . Follow up CT scan . COMPARISON : Non-contrast head CT from 2015-10-27 . TECHNIQUE : Non-contrast head CT . FINDINGS : The previously noted subdural hemorrhage in the right posterior fossa appears less conspicuous . The pneumocephalus adjacent to the linear skull fracture appears to have decreased in size . There are persistent bifrontal and right parietal hemorrhagic contusions with surrounding edema and possible small left frontal subarachnoid hemorrhage ( adjacent to falx ) which are largely unchanged . There is no shift of normally midline structures or hydrocephalus . The ventricles , cisterns and sulci are normal . The air- fluid level in the right sphenoid sinus and bilateral opacification of the mastoid air cells are unchanged . IMPRESSION : 1. Decreased size of right posterior subdural hemorrhage . 2. Multifocal hemorrhagic contusions and surrounding edema are largely unchanged . Brief Hospital Course : He was admitted to the trauma service . Orthopedics and Neurosurgery were consulted because of his injuries . His Neurosurgical issues were nonoperative ; he was loaded with Dilantin ; serial head CT scans were performed and were stable . He will need to follow up with Dr. Mckinney in 4 weeks for repeat head imaging and continue with Dilantin for one month . His right tib / fib fracture was repaired by Orthopedics on 10-27 ; postoperatively there were no complications . Weight bearing status was increased to weight bearing as tolerated . He was fitted with a hinged Mcdonald brace for his LLE . He will need to continue on Lovenox injections for at least 4-6 weeks . He was transfused with 3 u packed cells for a hematocrit of 21 , post transfusion HCT was 26.1 ; there was a questionable transfusion reaction at the end of his first unit of packed cells ; he did subsequently receive the remaining 2 units without any further reaction . Physical and Occupational therapy were consulted and have recommended home with services . Medications on Admission : None Allergic to PCN and Sulfa Discharge Medications : 1. Phenytoin 50 mg Tablet , Chewable Sig : Two ( 2 ) Tablet , Chewable PO three times a day for 1 months . Disp :* 180 Tablet , Chewable (s)* Refills :* 0 * 2. Oxycodone 5 mg Tablet Sig : Two ( 2 ) Tablet PO Q4H ( every 4 hours ) as needed for pain . Disp :* 75 Tablet (s)* Refills :* 0 * 3. Docusate Sodium 100 mg Capsule Sig : One ( 1 ) Capsule PO BID ( 2 times a day ). 4. Magnesium Hydroxide 400 mg / 5 mL Suspension Sig : Thirty ( 30 ) ML PO Q6H ( every 6 hours ) as needed for constipation . 5. Lovenox 40 mg / 0.4 mL Syringe Sig : 0.4 ML 's Subcutaneous once a day for 30 days . Disp :* 30 * Refills :* 0 * Discharge Disposition : Home with Service Discharge Diagnosis : s/p Pedestrian Struck by Auto Subdural hematoma Skull fracture Right comminuted tibia / fibula fracture Discharge Condition : Good Discharge Instructions : Return to the emergency room if you develop fevers , chills , severe headaches , visual disturbances , nause , vomiting and / or any other symptoms that are concerning to you . You will need to conrtinue with your Lovenox injections for at least 4-6 weeks as instructed by Orthopedics Followup Instructions : Follow up with Dr. Garza , Orthopaedics in 10-14 days , call 953 6923 for an appointment . Follow up with Dr. Melendez , Neurosurgery in 4 weeks ; call 745 8256 ext - 6468 for an appointment . Inform the office that you will need a repeat head CT scan for this appointment . Lori Dorothy MD 79-290 Completed by : Christopher Sandy NP 80-BYL 2015-11-03 @ 1526 Signed electronically by : DR. Muriel Zech on : WED 2015-11-04 11:30 AM ( End of Report )