Open fracture of shaft of femur Injury to thoracic aorta Acute edema of lung unspecified Closed fracture of four ribs Urinary tract infection site not specified Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Streptococcus infection in conditions classified elsewhere and of unspecified site streptococcus group D [Enterococcus] Street and highway accidents Tobacco use disorder Obesity unspecified Long-term (current) use of anticoagulants
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: SURGERY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
S/P MVC
Right leg and chest pain
 
Major Surgical or Invasive Procedure:
___
1. Irrigation debridement skin to bone right femur.
2. Open reduction internal fixation with intramedullary
    nail right open femur fracture.

 
History of Present Illness:
___ year old female who unrestrained
driver in a high-speed MVC with intrusion to the dashboard
noted to have open R femur fx and R rib fx's

 
Past Medical History:
PMH
none

PSH
none
 
Social History:
___
Family History:
non contributory
 
Physical Exam:
Constitutional: uncomfortable
HEENT: Normocephalic, atraumatic
Trachea midline
Chest: Clear to auscultation equal breath sound tender
along right chest
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
Extr/Back: Open wound with swelling to right thigh
Skin: No rash pulses intact distally
Neuro: Speech fluent
Psych: Normal mood, Normal mentation Cranial nerves II
through XII grossly intact, Motor ___ in all extremities,
sensory without focal deficits

 
Pertinent Results:
___ 05:00AM   WBC-21.2* RBC-4.83 HGB-14.2 HCT-40.9 MCV-85 
MCH-29.5 MCHC-34.8 RDW-13.7
___ 05:00AM   PLT COUNT-337
___ 05:00AM   ___ PTT-21.3* ___
___ 05:00AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG 
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:07AM   GLUCOSE-247* LACTATE-3.3* NA+-140 K+-3.6 
CL--102 TCO2-24
___ 05:00AM   UREA N-15 CREAT-0.9

___ CXR :
Minimally displaced rib fractures, left first through third 
ribs. 

___ CTA Chest :
1. Traumatic focal dissection in the proximal descending aorta 
with expanding contained thrombus since ___.  
2. No central pulmonary embolism. 
3. Mild pulmonary edema. 
4. Small bilateral pleural effusions and adjacent atelectasis. 
5. Stable anterior proximal left rib fractures. 
6. Fatty liver. 

___ MRI Left knee :
1. No evidence of injury to the menisci, ligaments, or tendons. 
2. Medial femoral condyle osseous contusion. 
3. Full thickness chondral fissure in the lateral tibial 
plateau. 
4. Diffuse subcutaneous soft tissue and vastus muscle edema. 

___ CTA Chest :
1. Focal contained, post-traumatic aortic dissection in the 
proximal 
descending aorta is unchanged since previous CT dated ___.  
2. Stable fractures involving the anterior ends of first and 
second ribs on left side.  

  

 
Brief Hospital Course:
On ___, the patient went to the OR for femur fx repair, she had 
low O2 sats postoperatively, requiring a non rebreather. On ___, 
the patient's C-spine was cleared and her diet was slowly 
advanced. Logroll precautions were d/c'd and patient was started 
on dilaudid PCA. ON ___, the patient had an acute drop in her 
HCT down to 23.7, she received a unit of blood and responded 
appropriately. She continued to have some desaturation with 
turning/sleeping, but she was able to be transitioned from NRB 
to NC. On ___, the patient underwent CTA to rule out PE, which 
showed dissection of the descending aorta. Cardiac surgery was 
consulted and recommended no surgery, but instead strict blood 
pressure control. On ___, patient was started on labetalol gtt 
for better HR and BP control, and this was transitioned to po 
Lopressor and labetalol gtt was discontinued. Otherwise, patient 
was doing well, tolerating regular diet. Ortho recommended 50% 
weight bearing on right leg and full wt bearing on the left leg. 
The patient was transferred to the floor on ___. 

Following transfer to the Trauma floor she continued to make 
good progress.  Vascular surgery was consulted regarding her 
descending thoracic aortic dissection and they recommended 
Coumadin, aspirin and keeping SBP < 140 mmHg.  Her Coumadin was 
started on ___ at 5mg followed by 7.5 mg on ___ and ___.  
Her INR on ___ is 1.7 and she will take 5mg daily with an INR 
check on ___. Dr. ___ PCP ___ dose her Coumadin 
starting on ___. Her last CTA chest was on ___ 
which showed no progression of her dissection.

Blood pressure control was successful with Lopressor and 
hydralazine with SBP 95-120/70 and heart rates in the 70's.  She 
will be discharged on Labetolol alone at 100 mg BID and the ___ 
will follow up with blood pressure checks for the first few 
days.

Her blood sugars have been elevated since admission in the high 
100-240 range.  She was encouraged to follow up with Dr. ___ 
___ further management.

From an Orthopedic standpoint she has done well post op.  Her 
incision is healing well and after many Physical Therapy visits  
she is able to crutch walk safely.  Her weight bearing status is 
partial (50%) on the right leg and full weight bearing on the 
left.  Her staples will be removed by the ___ on ___.

After a long recovery she was discharged home on ___ with 
___ services for BP checks and Coumadin teaching and monitoring.

 
Medications on Admission:
none
 
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 
4 hours) as needed for fever/pain.  
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day).
Disp:*60 Tablet(s)* Refills:*2*
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day) as needed for constipation.  
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  
6. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3 
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
7. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day).
Disp:*60 Tablet(s)* Refills:*2*
8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H 
(every 12 hours): thru ___.
Disp:*4 Tablet(s)* Refills:*0*
9. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR 
___ to determine future.
Disp:*30 Tablet(s)* Refills:*2*

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
___ Diagnosis:
S/P MVC
1. Open right femur fracture
2. Proximal descending thoracic aortic dissection with contained 
thrombus
3. Left rib fractures ___. Right first rib fracture

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 
Discharge Instructions:
* You were admitted to the hospital after your car accident with 
multiple injuries including a broken right leg, rib fractures 
and a small tear in your aorta which sealed over.

* Your orthopedic surgery went well and your weight bearing 
status on the right leg is partial weight bearing with crutches. 
 The ___ will take your staples out.

* Your injury caused left rib fractures ___ and the right first 
rib which can cause severe pain and subsequently cause you to 
take shallow breaths because of the pain.
 
*  You should take your pain medication as directed to stay 
ahead of the pain otherwise you won't be able to take deep 
breaths. If the pain medication is too sedating take half the 
dose and notify your physician.
 
*  Pneumonia is a complication of rib fractures.  In order to 
decrease your risk you must use your incentive spirometer 4 
times every hour while awake.  This will help expand the small 
airways in your lungs and assist in coughing up secretions that 
pool in the lungs.
 
*  You will be more comfortable if you use a cough pillow to 
hold against your chest and guard your rib cage while coughing 
and deep breathing.
 
*  Symptomatic relief with ice packs or heating pads for short 
periods may ease the pain.
 
*  Narcotic pain medication can cause constipation therefore you 
should take a stool softener twice daily and increase your fluid 
and fiber intake if possible.
 
*  Do NOT smoke

* The aortic dissection was noted on your initial CT scan.  You 
need to have good blood pressure control and also must stay on a 
blood thinner called Coumadin.  You will need to have your blood 
tested frequently in the beginning of therapy but after you are 
regulated it should be once a month.  Maintain safety 
precautions while on Coumadin so that you don't bleed.  Be 
careful with sharp objects. Shave your legs with an electric 
razor to prevent cuts that will bleed excessively. Do not use 
ibuprofen or any product with Ibuprofen in it as it can increase 
your bleeding tendency.

 * Dr. ___ will regulate your Coumadin dose.
 
* Your blood sugars have been on the high side since your 
admission and you should talk to your PCP about further testing 
for diabetes.

*  Return to the Emergency Room right away for any acute 
shortness of breath, increased pain or crackling sensation 
around your ribs ( crepitus ), chest pain, or increased leg 
pain.
 
Followup Instructions:
___

{'Right leg and chest pain': ['Open fracture of shaft of femur', 'Injury to thoracic aorta'], 'Minimally displaced rib fractures': ['Closed fracture of four ribs'], 'Traumatic focal dissection in the proximal descending aorta': ['Injury to thoracic aorta'], 'Mild pulmonary edema': ['Acute edema of lung'], 'Small bilateral pleural effusions and adjacent atelectasis': ['Acute edema of lung'], 'Fatty liver': ['unspecified'], 'No evidence of injury to the menisci, ligaments, or tendons': ['unspecified'], 'Medial femoral condyle osseous contusion': ['unspecified'], 'Full thickness chondral fissure in the lateral tibial plateau': ['unspecified'], 'Diffuse subcutaneous soft tissue and vastus muscle edema': ['unspecified'], 'Focal contained, post-traumatic aortic dissection in the proximal descending aorta': ['Injury to thoracic aorta'], 'Stable fractures involving the anterior ends of first and second ribs on left side': ['Closed fracture of four ribs'], 'Low O2 sats postoperatively': ['unspecified'], 'Acute drop in her HCT': ['unspecified'], 'Desaturation with turning/sleeping': ['unspecified'], 'Elevated blood sugars': ['unspecified']}