tokens: 01909607 Admission Date : 2010-06-28 Discharge Date : 2010-07-01 Date of Birth : 1990-02-01 Sex : F Service : ORTHOPEDIC HISTORY OF THE PRESENT ILLNESS : This is a 20-year-old female with no significant past medical history , who was the unrestrained passenger in a high speed rollover motor vehicle accident on 2010-06-27 . By report , the patient was ejected from the vehicle on impact and found curled in the fetal position at the rear of the vehicle at the scene . The vehicle was noted to be extensively damaged . By report , the patient was noted to be awake , but confused at the scene of the accident with no memory of the incident . She was immobilized in the C-spine collar at the scene of the accident and subsequently transported by EMS to the New England Sinai Hospital & Rehab Center Emergency Department for further management . PHYSICAL EXAMINATION : Examination on presentation to the emergency room revealed the following : Temperature 35.4 Celsius , blood pressure 116/63 , pulse 105 , respiratory rate 18 , oxygen saturation 98% on room air . The patient was alert and oriented times three in no apparent distress . Boston Coma Scale of 15 . Tympanic membranes were noted to be clear . Pupils were equal , round , reactive to light at approximately 4 mm . The patient 's trachea was noted to be midline . The patient 's lung examination revealed the lungs to be clear to auscultation bilaterally , no crepitus , and a left clavicular deformity was grossly apparent on examination . CARDIAC : Cardiac examination demonstrated regular rate and rhythm , no murmurs , rubs , or gallops . ABDOMEN : Soft , nontender , nondistended . RECTAL : Examination was guaiac negative with good rectal tone . The patient 's pelvis was stable to AP and lateral compression . A 5 cm laceration was noted over the patient 's occiput on further inspection with no exposed underlying bone . Right upper extremity examination demonstrated intact motor , sensory , and vascular function . Left upper extremity examination demonstrated no gross deformities , tenderness to palpation in the mid forearm , intact motor function in the median , radial , and ulnar nerve distributions , intact sensation to light touch in the median and radial nerve distributions , decreased sensation in the ulnar-nerve distribution , warm and well perfused limb with 2+ radial pulses . Right lower extremity examination demonstrated mild swelling and ecchymosis of the right posterior thigh and approximately a 3 cm laceration in the lower leg , expressive of moderate amounts of standard sterile fashion . No gross deformities . Motor , sensory , and vascular examinations were intact in all distributions . Left lower extremity examination demonstrated no gross deformities and intact motor , sensory , and vascular examinations in all distributions . Radiographic studies demonstrated an inferior displaced left midclavicular fracture , no evidence of pneumothorax . Trauma series demonstrated no evidence of a pelvic fracture . Head CT demonstrated no evidence of intracranial bleeding . Trauma CT demonstrated mild pulmonary contusions , but no pelvic fracture . Cervical spine imaging demonstrated no evidence of cervical spine injury . Right tibial-fibular film series demonstrated no evidence of fracture displacement . Left humerus film series demonstrated no evidence of fracture or displacement . Right foot and femur series demonstrated no evidence of fracture displacement . Left forearm and wrist series demonstrated transverse mid shaft radial fracture with ulnar displacement . Diagnosis peritoneum lavage times two was negative for any signs of intra-abdominal bleeding . LABORATORY DATA : Studies on admission revealed the following : White blood cell 12.9 , hemoglobin 11.5 , hematocrit 32.8 , platelet count 197,000 , sodium 141 , potassium 3.6 , chloride 110 , bicarbonate 21 , BUN 20 , creatinine 0.7 , glucose 189 , PT 13.3 , INR 1.2 , PTT 30.0 , amylase 57 , arterial blood gas 7.32 , 35 , 159 , 19 , -7 . Urinalysis was within normal limits with 6 to 10 red blood cells . Toxicology screen was negative . HOSPITAL COURSE : The patient was evaluated by the Trauma Service in the emergency room , where she received four liters crystalloid and four units packed red blood cells with good response . In addition , the patient received the above-described diagnostic procedures , which demonstrated injuries limited to a posterior scalp laceration , left fractured clavicle , left fractured radius , right thigh hematoma , and right leg laceration . The patient was subsequently admitted to the Trauma Service on 2010-06-28 under the direction of Dr. Lowery . Given the patient 's right thigh hematoma , a duplex evaluation of the right lower extremity was performed on 2010-06-28 and demonstrated no evidence of major arterial or venous injury in the level of the right inguinal region . On 06-28 , the patient was also cleared for removal of her C-spine collar and deemed stable for transfer to the Orthopedic Service under the direction of Dr. Ronda Lopez . The patient remained stable through 2010-06-29 at which point she was sent to the operating room to undergo a left radial fracture open reduction and internal fixation procedure . The patient tolerated the procedure well and demonstrated a postoperative hematocrit of 40.9 . Of note , the scalp and right lower leg lacerations were closed primarily by the trauma team on admission and on hospital day #1 were noted to be clean , dry , and intact . Nonoperative treatment was elected for the patient 's left clavicular fracture . On postoperative day #1 , 2010-06-30 , the patient was noted to be clinically stable , tolerating oral intake , and expressive of adequate amounts of urine independent of a Foley catheter . The patient 's head wound laceration was noted to be clean and dry with intact staples . There was no erythema or purulence . The left clavicle was noted to have continued ecchymosis decreased from prior examination with a minor stepoff and mild tenderness to palpation decreased from prior examinations . The left forearm dressing was noted to be in place , clean , dry , and intact with no saturation . The patient was noted to be able to wiggle her fingers with intact flexor , extensor , abductor , and adductor function . Mild swelling was noted in the left hand . Sensation was intact in the median , radius , and ulnar-nerve distributions . Fingers were warm and well perfused with capillary refill less than 3 seconds . The patient 's right anterior tibial wound was noted to be clean , dry , and intact with sutures intact and no erythema or purulence noted . On 06-30 , the patient was evaluated by Occupational Therapy and fitted for a left upper extremity splint . The patient was also administered adaptive training for activities of daily life and advised regarding wound care . In addition , the patient was also fitted with a figure-of-eight clavicular splint and instructed in its proper use . On 2010-07-01 , the patient was discharged from the hospital with instructions for follow up care on return to the United Kingdom . CONDITION ON DISCHARGE : The patient is to be discharged to home . DISCHARGE STATUS : Stable . DIAGNOSIS : 1. Left transverse mid shaft radial fracture with ulnar displacement status post left radial open reduction and internal fixation . 2. Left midclavicular fracture managed nonoperatively . 3. Occipital scalp laceration . 4. Right anterior tibial laceration . DISCHARGE MEDICATIONS : Percocet one to two tablets PO q.4h. to 6h.p.r.n. pain . FOLLOW-UP CARE : The patient is medically cleared for a flight to return to her home in the United Kingdom . The patient is to maintain her figure-of-eight clavicular splint and left posterior forearm splint in place for fourteen days following discharge . The left forearm and right lower leg wound should be kept clean and dry with regular dressing changes with dry gauze once per day . Scalp laceration should be kept clean and dry for five days following discharge after which point the patient may once wash her hair . Percocet for pain as needed . The patient is to followup with an orthopedist in the United Kingdom fourteen days following discharge at which point repeat x-rays of her left forearm should be obtained and her left forearm scalp and right lower leg sutures and staples may be removed . Questions regarding follow up may be referred to Dr. Ronda Lopez at the Ayer Orthopedic Group . Telephone #: ( 658 ) 842-8661 . Ortiz V Baugher , M.D. 75-285 Dictated By : Catherine K Thomas , M.D. MEDQUIST36 D : 2010-06-30 17:18 T : 2010-06-30 17:39 JOB #: 03326 Signed electronically by : DR. Kisha Jones on : Jose 2010-07-01 8:27 AM ( End of Report )