tokens: Admission Date : 2017-08-12 Discharge Date : 2017-08-16 Date of Birth : 1995-02-03 Sex : F Service : SURGERY Allergies : Shellfish Attending : Maria X White , M.D. Chief Complaint : Motor vehicle accident Major Surgical or Invasive Procedure : None History of Present Illness : 22 year old female transfer from outside hospital after a motor vehicle accident with diagnosed liver laceration by CT scan . Past Medical History : None Social History : Social alcohol Family History : Non pertinent to admission Physical Exam : Patient was alert , oriented x3 . Neck with cervical collar . Left forarm and right knee abrasions . Chest clear to auscultation bilateral , S1 S2 normal and with no murmors . Abdominal pain predominally on the right upper quadrant , no signs of peritoneal irritation . Pertinent Results : 2017-08-12 11:41 PM GLUCOSE - 74 UREA N - 9 CREAT - 0.7 SODIUM - 139 POTASSIUM - 3.5 CHLORIDE - 106 TOTAL CO2 - 23 ANION GAP - 14 2017-08-12 11:41PM ALT(SGPT) - 241 * AST(SGOT) - 207 * ALK PHOS - 51 TOT BILI - 0.8 2017-08-12 11:41 PM CALCIUM - 8.2 * PHOSPHATE - 3.1 MAGNESIUM - 2.2 2017-08-12 03:15 PM GLUCOSE - 75 UREA N - 10 CREAT - 0.6 SODIUM - 137 POTASSIUM - 3.7 CHLORIDE - 103 TOTAL CO2 - 23 ANION GAP - 15 2017-08-12 03:15 PM ALT(SGPT) - 318 * AST(SGOT) - 307 * ALK PHOS - 61 TOT BILI - 0.9 2017-08-12 03:15 PM WBC - 8.3 RBC - 3.64 * HGB - 12.6 HCT - 36.1 MCV - 99 * MCH - 34.7 * MCHC - 35.0 RDW - 12.4 2017-08-12 03:15 PM PT - 11.6 PTT - 26.0 INR(PT) - 0.9 Brief Hospital Course : Patient was admited , pain was managed with a PCA and later with PO medication . The liver laceration was stable , no sign of rupture or further complication , did not required surgical managment . The liver enzimes come down , no signs of biliary stasis . She was able to tolerate diet , ambulate , having a bowel movement and dischargo home in good conditions . Medications on Admission : None Discharge Medications : 1. Docusate Sodium 100 mg Capsule Sig : One ( 1 ) Capsule PO BID ( 2 times a day ) for 4 days . Disp :* 8 Capsule (s)* Refills :* 0 * 2. Hydromorphone 2 mg Tablet Sig : One ( 1 ) Tablet PO Q2H ( every 2 hours ) as needed for Pain for 4 days . Disp :* 30 Tablet (s)* Refills :* 0 * Discharge Disposition : Home Discharge Diagnosis : Motor vehicle accident Discharge Condition : Good Discharge Instructions : - Follow up with Trauma Surgery Clinic with the Result from the CT scan abdomen - Call for appointment to ( 289 ) 411-5387 for the Trauma Clinic and Abdominal CT scan of the Abdomen in 4 weeks - If any abdominal pain , fever or dizziness , go to the Emergency Room - Avoid contact sport until seen in the Clinic - Analgesic ( Percocet ) as needed Followup Instructions : - Trauma Surgery Clinic in four weeks with CT abdomen results . Call Trauma Clinic to coordinate the study , result and appointment dates (( 289 ) 411-5387 ). Ida Doris MD 79-274 Completed by : Jane Ashmore MD 50-063 2017-08-16 @ 0950 Signed electronically by : DR. Jennifer Green on : FRI 2017-09-01 1:04 PM ( End of Report )