Medical Text: Admission Date:  [**2177-8-29**]              Discharge Date:   [**2177-9-12**]

Date of Birth:  [**2156-2-27**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Helmeted motocyclist who hit tree

Major Surgical or Invasive Procedure:
[**2177-8-29**]
1. Irrigation and debridement down to and inclusive of
    bone, right open femur fracture.
2. Retrograde intramedullary nailing with Synthes 11 x 360
    nail.
3. Open reduction and internal fixation of patella fracture
    with K-wires and figure-of-8 tension band construct.

[**2177-9-4**]
Tracheostomy
IVC filter

[**2177-9-12**]
 PICC right bascilic vein


History of Present Illness:
21 y.o. male helmeted moped rider who struck a tree with
reported GCS of 6 on the scene. Patient was transported to OSH
and noted to have a right sided open femur fracture. He received
antibiotics and was intubated prior to transfer.
Patient was transported and had radiographic studies performed
that showed right femur fracture, SAH, grade II liver lac,
pulmonary contusions, and small PTX. Patient reportedly received
1 unit of pRBCs in the ED and was placed into a traction splint
on RLE.


Past Medical History:
None

Social History:
tobacco none
ETOH none

Family History:
Non-contributory.

Physical Exam:
96.9  130  150/97  20  100%
intubated and sedated
HEENT - L eye abrasions, pupils nonreactive bilaterally
CTA b/l
rapid HR, regular rhythm
SNDNT
pelvic fracture
+ palpable distal pulses

Pertinent Results:
[**2177-8-29**] 04:35AM BLOOD WBC-17.7* RBC-4.76 Hgb-15.2 Hct-45.5
MCV-96 MCH-32.0 MCHC-33.5 RDW-13.2 Plt Ct-314
[**2177-8-30**] 12:50AM BLOOD WBC-7.6 RBC-2.73* Hgb-9.0* Hct-25.0*
MCV-92 MCH-32.8* MCHC-35.9* RDW-13.5 Plt Ct-188
[**2177-8-31**] 01:49AM BLOOD WBC-9.4 RBC-2.42* Hgb-7.8* Hct-21.7*
MCV-89 MCH-32.1* MCHC-35.9* RDW-14.5 Plt Ct-148*
[**2177-9-1**] 03:13AM BLOOD WBC-9.2 RBC-2.87* Hgb-9.0* Hct-25.6*
MCV-90 MCH-31.6 MCHC-35.3* RDW-15.0 Plt Ct-128*
[**2177-9-2**] 01:40AM BLOOD WBC-7.7 RBC-2.78* Hgb-8.8* Hct-24.6*
MCV-88 MCH-31.5 MCHC-35.7* RDW-15.4 Plt Ct-164
[**2177-9-3**] 12:53AM BLOOD WBC-8.9 RBC-2.94* Hgb-9.3* Hct-26.2*
MCV-89 MCH-31.8 MCHC-35.6* RDW-15.7* Plt Ct-220
[**2177-9-4**] 01:08AM BLOOD WBC-7.7 RBC-2.99* Hgb-9.5* Hct-27.3*
MCV-91 MCH-31.7 MCHC-34.7 RDW-15.5 Plt Ct-313
[**2177-9-5**] 02:32AM BLOOD WBC-8.4 RBC-2.91* Hgb-9.0* Hct-26.9*
MCV-92 MCH-30.9 MCHC-33.5 RDW-15.6* Plt Ct-412
[**2177-9-6**] 01:58AM BLOOD WBC-12.1* RBC-2.86* Hgb-9.0* Hct-26.5*
MCV-93 MCH-31.6 MCHC-34.0 RDW-15.2 Plt Ct-418
[**2177-9-7**] 02:12AM BLOOD WBC-14.4* RBC-3.00* Hgb-9.3* Hct-27.6*
MCV-92 MCH-30.9 MCHC-33.7 RDW-14.7 Plt Ct-556*
[**2177-9-8**] 01:59AM BLOOD WBC-14.7* RBC-3.25* Hgb-10.0* Hct-29.7*
MCV-91 MCH-30.6 MCHC-33.6 RDW-14.5 Plt Ct-748*

[**8-29**]
CT head - Multiple foci of parenchymal hemorrhage as well as
small amount
of likely subarachnoid hemorrhage. The location of some of these
foci at the [**Doctor Last Name 352**]-white matter interface is concerning for
diffuse axonal injury
CT Cspine - No fracture or traumatic malalignment in the
cervical spine
CT torso - Extensive pulmonary contusions, worse on the right
than the left. Hepatic lacerations with a small amount of
abdominal and pelvic free fluid of intermittent density.
Bilateral rib fractures.
Right femur/knee xrays - There is a mid shaft femoral fracture
with mild varus angulation of the distal fragment relative to
the proximal. There is also medial subluxation by ~ 1 cortical
width.

[**9-2**]
MRI cspine - Edema in the interspinous ligaments from C3-C4
through C7-T1, without evidence of distraction. lobal central
canal narrowing due to congenital short pedicles. This is
slightly exacerbated by a disc bulge at C3-4. No cord signal
abnormality. Moderate right C4-5 neural foramen narrowing due to
uncovertebral osteophytes.

[**9-3**]
Bilateral LE LENIs - No deep venous thrombosis involving the
right or left lower extremity.
LUE LENI -  No deep venous thrombosis in the left upper
extremity.

[**9-7**]
CT Abdomen/Pelvis - Right pleural effusion with associated
compressive atelectasis. Considerable improvement in the
appearance of the right lobe of the liver laceration. Small
amount of free fluid in the pelvis. Fractures of the left first
and right fourth and fifth ribs. Fracture of
the right transverse process of T1.


Brief Hospital Course:
The patient was admitted to the trauma ICU.

[**8-29**] - Patient was admittd to the ICU. He was taken to the
operation room with ortho for ORIF of his right femur (see
operative report for full details).  Neurosurgery was consulted
and an ICP was placed.  He was started on dilantin and q1 hour
neurochecks.

[**Date range (1) 58392**] - The patient was transfused 4u PRBC for a decreasing
Hct.  He had a right femur hematoma which was expanding but his
limb was soft and there was no fear of compartment symdrome.
His Hct stabilized. Head CT was stable.

[**9-1**] - His ICP was discontinued and neurosurgery signed off.
Head CT was stable.

[**9-2**] - MR of head and c-spine were performed.

[**9-3**] - Bilateral LE and LUE LENIs were performed which
demonstrated no DVT.

[**9-4**] - The patient went the OR with the acute care service for
tracheostomy and IVC filter placement.

[**9-6**] - Patient dc'ed his dophoff tube twice.

[**9-7**] - A CT A/P was done because of persistent fevers and rising
white count.  No source for his fevers was identified.  Patient
was put to trach collar.

[**9-8**]: Awake, off-versed, following commands. Passed S&S for
regular diet and Passy [**Last Name (un) 87596**] Valve. BAL cultures grew MRSA, kept
only on Vanc now. Patient ready to be transferred to floor,
waiting for a bed. `

Following transfer to the Surgical floor he continued to make
slow progress.  His trach tube was plugged with a PMV and he
tolerated it well.  After confirming no aspiration by video
swallow he was tolerating a regular diet with thin liquids.

The Physical Therapy and Occupational Therapy services followed
him on a daily basis to increase his mobility and increase
cognitive abilities.  His memory is decreased and he
occasionally has some confusion but is improving each day.

He has a PICC line placed on [**2177-9-12**] for IV antibiotics and will
require Vancomycin thru [**2177-9-16**] for MRSA pneumonia.  He has
minimal secretions but is undergoing nebulizer treatments.

Potentially his IVC filter can be removed but Dr. [**Last Name (STitle) **] will re
evaluate in a few weeks therefore he will need to return to the
[**Hospital 2536**] Clinic. He will also follow up in the Neuro cognitive clinic
with Dr. [**First Name (STitle) **] following his discharge from rehab.

After a lonfg hospitalization he was transferred to rehab on
[**2177-9-12**] for further therapy with the goal to return home soon.


Medications on Admission:
None

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for temp > 101.5.
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
4. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed for abrasions.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Vancomycin 1,000 mg Recon Soln Sig: 1500 (1500) mg
Intravenous every eight (8) hours: thru [**2177-9-16**].
10. Morphine Concentrate 20 mg/mL Solution Sig: Fifteen (15) mg
PO Q2H (every 2 hours) as needed for pain.
11. HYDROmorphone (Dilaudid) 1-2 mg IV Q2H:PRN pain
Please use for breakthrough only after PO/NG MSIR.
12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
S/P scooter v tree
1. Left eye abrasion
2. Rib fractures right [**5-5**], left 1
3. Bilat pulmonary contusions
4. Grade 2 liverlaceration
5. Open right femur fracture
6. Right thigh laceration
7. Right patellar fracture
8. Right metatarsal neck fracture [**3-7**]
9. Small SAH
10.Right TP fracture T1
11.[**Doctor First Name **]
12.Acute blood loss anemia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
* You were admitted to the hospital with multiple injuries
following your accident including head trauma, rib fractures,
knee fracture and liver laceration.
* You have made alot of progress but will need further
rehabilitation before you can return home.
* You are now breathing well on your own with your trach tube
plugged and hopefully it will be removed as you improve.
* Continue to work with physical therapy to increase your
mobility.

Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedics in 1
month, please call [**Telephone/Fax (1) 1228**] to schedule that appointment.

Call the [**Hospital 2536**] Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment
in [**3-5**] weeks

Call the Vascular Surgery Clinic at [**Telephone/Fax (1) 1237**] for an
appointment in 2 weeks with Dr. [**Last Name (STitle) **].

Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 1669**] for a follow up
appointment in 6 weeks with Dr. [**First Name (STitle) **].  You will need a Head CT
prior to your appointment.  The secretary can book that for you.

Call Dr. [**First Name (STitle) **] in the Neuro cognitive Clinic at [**Telephone/Fax (1) 1690**]
for an appointment after your discharge from rehab



Completed by:[**2177-9-12**]
ICD9 Codes: 2851