CHIEF COMPLAINT: Motor vehicle collision.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old man initially arrested after a DUI, car versus tree, who ultimately was brought to the emergency department for further evaluation. By report, the patient was a restrained driver who had a single car accident into a tree. The patient has no memory of the accident. He is unsure whether he lost consciousness. He does remember driving and states that he had approximately a 12-pack of beer this evening.
The patient describes chest pain, which is worse with taking a deep breath and worse on his right-hand side as well as across the front of his chest where he has some bruising present. He denies any abdominal pain. He denies nausea or vomiting. He denies any headache or visual changes. He denies any weakness or pain in his extremities. Tetanus is up-to-date.
PAST MEDICAL HISTORY: History of a hernia.
MEDICATIONS: None.
ALLERGIES: Penicillin.
SOCIAL HISTORY: The patient smokes cigarettes. He occasionally drinks alcohol and denies using drugs.
REVIEW OF SYSTEMS: See above. All other review of systems negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 130/72, pulse 114, respirations 18, pulse ox 99% on room air, and temperature 98.6.
GENERAL: The patient is sitting up in the exam room. He is alert and oriented x4. The patient does smell of alcohol. He answers questions appropriately and has a GCS of 15.
HEENT: Atraumatic, except a small abrasion to the forehead. No cephalohematoma, no depressed skull fractures, otherwise atraumatic. Pupils are equal and reactive to light. There is mild conjunctival injection bilaterally. The oral mucosa is moist with no lesions.
NECK: No midline tenderness. The patient arrives from EMS without a C-spine collar. However, a C-spine collar was placed on his arrival due to his apparent intoxication and inability to clear his C-spine at the time.
CHEST: Chest wall has tenderness along the right side as well as over the midsternum, and the patient has a positive seatbelt sign, and there is no crepitance, no subcutaneous air.
LUNGS: Clear to auscultation. No wheezes, rhonchi or rales.
ABDOMEN: Again, has a seatbelt sign. The patient has abdominal tenderness over his abdominal wall contusion in the lower abdomen. There is also an umbilical hernia, which reduces easily. The patient has mild diffuse abdominal tenderness, no rebound, no guarding.
BACK: No midline tenderness, no step-offs. No CVA tenderness.
PELVIS: Stable to rock.
EXTREMITIES: No cyanosis, clubbing or edema. No obvious deformity.
NEUROLOGIC: Alert and oriented x4. Cranial nerves II through XII grossly intact. Strength is 5/5 in all four extremities.
LABORATORY EVALUATION: White count 12.2, hemoglobin 14.8, hematocrit 44.2, platelets 154. Sodium 130, potassium 3.9, chloride 108, bicarbonate 21, BUN 8, creatinine 0.7, glucose 152. Coags within normal limits.
CT SCAN: CT of the head showed no acute disease. CT of the abdomen and pelvis revealed an abdominal wall contusion as well as rib fractures on the right-hand side bilaterally of ribs #6 through #8 and no free fluid, no evidence of visceral injury.
EMERGENCY DEPARTMENT COURSE: The patient was watched in the emergency department for over five hours until he was clinically sober. During this time, serial abdominal exams were done, and the patient continues to have mild tenderness over his abdominal wall contusion; however, he is otherwise nontender.
The patient was instructed on the use of an incentive spirometer. His family members were also advised to check on him today, and he was discharged home into their care. The patient was given pain medications. Should he develop any fevers, chills, increased shortness of breath, increased abdominal pain, vomiting or other worsening, he should return to the emergency department.
FINAL DIAGNOSIS: Abdominal wall contusion, multiple rib fractures after blunt trauma.
DISCHARGE CONDITION AND DISPOSITION: Stable, to home.
