CHIEF COMPLAINT: Car accident.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female with a history of hypercholesterolemia who presented to the ER with complaints of being involved in a car accident around 9:30 this evening. The patient was a restrained driver traveling in a car that was not airbag equipped. The patient T-boned another car with significant damage done to the front end of her vehicle. She was unable to drive the car from the accident. She states her chest hit the steering wheel, and now, she is complaining of left greater than right lateral rib pain that is worsened with coughing, laughing and hiccups. The patient does report associated shortness of breath. Denies abdominal pain. The patient rates her pain as a 6/10 in severity. It does not radiate. She also complains of bruises to the left upper arm and left knee as well as a laceration to her right knee. She denies paresthesias, numbness, coldness, loss of range of motion or weakness in the extremities. She has been ambulatory. Denies neck or back pain or head trauma. She, otherwise, has no complaints.
PAST MEDICAL HISTORY: Hypercholesterolemia, carpal tunnel syndrome, status post tubal ligation. Last normal menstrual period was 1 week ago.
MEDICATIONS: Xanax, Celexa, nortriptyline.
ALLERGIES: None.
FAMILY HISTORY: None elicited.
SOCIAL HISTORY: The patient smokes half pack of cigarettes a day. Denies alcohol or illicit drug abuse.
REVIEW OF SYSTEMS: As stated above in the HPI, significant for bilateral rib pain with shortness of breath, multiple bruises and a right knee laceration. She has, otherwise, been well without fevers, chills, nausea, vomiting, abdominal pain, changes in urinary or bowel habits, polyuria, polydipsia, heat or cold intolerance, fatigue, recent weight changes, rashes or lesions. Further review is otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 140/52, pulse 64, respirations 18, temperature 98.6 and pulse ox on room air is 98%.
GENERAL: This is a moderately obese female in no acute distress. She is alert and oriented x3.
HEENT: Normocephalic and atraumatic. Pupils are equal, round and reactive to light. Extraocular muscles intact. Mucous membranes are pink and moist.
NECK: Supple. There is no cervical midline tenderness. She has full range of motion of the neck without pain.
CHEST: Respirations are easy and unlabored. She does have tenderness with palpation to the bilateral lateral ribs. No ecchymosis or abrasions noted here or palpable deformity.
LUNGS: Clear to auscultation bilaterally without wheezes, rales or rhonchi.
HEART: Regular rate and rhythm without murmur, rub or gallop.
ABDOMEN: Soft, obese, nondistended and moderately tender in the left upper quadrant. There is no referred tenderness, rebound tenderness or guarding. Bowel sounds normoactive in all 4 quadrants.
EXTREMITIES: No cyanosis, edema or clubbing. Examination of the left upper extremity exhibits a large area of ecchymosis to the anterior aspect of the upper arm; this is minimally tender to palpation. There is no bony tenderness. She has full range of motion at the elbow and shoulder and full strength with resisted movement. She also has an area of ecchymosis noted to the anteromedial left knee, which is tender to palpation. She also has patellar tenderness here. No other focal bony tenderness. No tenderness with palpation to the medial and lateral joint lines. No laxity with varus or valgus stress. Anterior and posterior drawer tests are negative. She is weightbearing and has full range of motion of the knee. The extremities are otherwise unremarkable for any bony trauma or deformity.
MUSCULOSKELETAL: There is no CTLS midline tenderness. No paraspinous muscle tenderness or palpable spasm.
SKIN: The patient has a 5 cm superficial laceration noted to the infrapatellar space of the knee on the right. There is no active bleeding. There is no subcutaneous tissue exposed here. Skin otherwise is warm, dry and intact.
EMERGENCY DEPARTMENT COURSE: The patient had IV access established. She was given 1 liter of normal saline as well as morphine 4 mg IV and Phenergan 12.5 mg IV. Her tetanus was updated. She was then started on an incentive spirometer. Her right knee laceration was cleansed with Hibiclens and saline and dermabonded without difficulty. Laboratory studies included CBC with a white blood cell count of 11.6, hemoglobin 13.6, hematocrit 39.6 and platelets 318 with a normal differential. Renal panel showed sodium 138, potassium 2.9, chloride 104, bicarbonate 26, BUN 7, creatinine 0.8 and glucose 114. The patient had a chest x-ray, which was negative as reviewed by the radiologist. No evidence of fracture. The left knee x-ray was also negative for fracture. The patient had a CT of the abdomen and pelvis with IV contrast only to evaluate her left upper quadrant tenderness for splenic injury. This was negative for any intra-abdominal injury as reviewed by the radiologist. There is mild sigmoid diverticulosis and bilateral ovarian cysts, 2.5 cm on the right and 3 cm on the left, and a right paracervical cyst. Pelvic ultrasound was recommended for followup as reviewed by the radiologist. The patient was given 40 mEq of potassium p.o., which she tolerated without difficulty.
DIAGNOSES:
1. Left rib contusion.
2. Right knee laceration.
3. Left knee contusion.
4. Left arm contusion.
PLAN:
1. The patient is given a prescription for Vicodin to take as directed for severe pain. She is told not to drive with this.
2. The patient is to otherwise take Advil or Motrin as needed for mild to moderate pain.
3. The patient is to use the incentive spirometer every hour as instructed while awake.
4. Follow with her primary care physician if there is no improvement in the next 3 to 4 days.
5. Return to the ER for any worsening symptoms.
6. Apply ice as needed for pain.
DISPOSITION: The patient was discharged home in good condition.
