allergies: no known allergies / adverse drug reactions attending: chief complaint: mvc major surgical or invasive procedure: retrograde nail right femur, eua left femoral head, incision & drainage right knee history of present illness: 18 year old male s/p unrestrained driver transferred from osh for liver laceration and open right femur fracture. the vehicles windshield was "exploded", and patient had extensive repetitive questioning at the scene. pt arrives a+o and able to engage in conversation. pt has known 5th and 6th rib fractures, open femur fracture, sternum fracture, liver laceration and a right pneumothorax. past medical history: none social history: (-) tobacco, (-) etoh, (-)illicit drug use family history: non-contributory physical exam: physical exam on admission: constitutional: awake heent: laceration over left eyebrow, occipital hematoma, pupils equal, round and reactive to light trachea midline, c-collar applied on arrival chest: breath sounds left>r, no crepitus, tenderness chest wall abdominal: soft, nontender, nondistended rectal: normal tone extr/back: positive dp and pt pulses bilaterally skin: large laceration over right knee neuro: gcs 14 intact distal motor upper and lower extremity physical exam upon discharge: vs: t 98.5, 86, 112/60, 18, 100/ra neuro: aaox4, nad. cv: rrr, normal s1, s2. no mrg. pulm: lungs cta bilaterally. abd: soft/nondistended, minimally tender to palpation. wound: ace bandage applied over abrasions right knee. c/d/i. ext: + pedal pulses +csm. no edema, cyanosis, clubbing. pertinent results: : blood hct-25.2* : blood plt ct-103* blood calcium-7.9* phos-2.2* mg-1.8 08:29pm blood fibrino-141* glucose-130* lactate-2.8* na-139 k-3.8 cl-107 calhco3-22 hgb-12.5* calchct-38 freeca-0.97* radiology chest (portable ap) impression: there is a tiny right apical pneumothorax after chest tube removal. ct a/p: liver laceration, right displaced femoral shaft fx, nondisplaced fracture left femoral head ct chest: right 5th/6th rib fracture, sternal fracture. femur a/p: mid femoral comminuted fracture and avulsion fracture from the lateral femoral condyle. brief hospital course: mr. was initially admitted to the icu for care s/p unrestrained driver of vehicle involved in mvc with prolonged extrication transferred to ed, with the following injuries: nondisplaced sternal fx, right rib fx 5,6 nondisplaced, grade 3 liver lac (7cm), right femur shaft fx, left femoral head fx, right pneumatocele, pulmonary contusion, and left ear laceration. he had a relatively uneventful icu course. his hematocrit was checked every 4-6 hours; he did have an episode of decreasing hct on postoperatively after orthopaedic intervention for debridement via arthrotomy of right open knee and retrograde nailing segmental femur fracture and underwent cta demonstrating no acitve arterial extravasation. his chest tube was placed to waterseal which he tolerated well. patient was stable and transferred to the floor on . on , his chest tube was pulled and cxr showed a tiny stable right apical pneumothorax after chest tube removal. patient was anticoagulated with subcutaneous heparin, but was transitioned to lovenox on the day of discharge that he will continue for next several weeks. physical therapy evaluated patient and deemed him safe to be discharged home with pt services. patient was voiding large amounts of urine. pain was well controlled with oral pain medications. he was tolerating a regular diet. vital remained stable and patient was afebrile upon discharge. he will followup outpatient in weeks. medications on admission: none discharge medications: 1. oxycodone (immediate release) 5-15 mg po q3h:prn pain hold for increase sedation and rr<10. rx *oxycodone 5 mg 1 tablet(s) by mouth every 4-6 hours disp #*40 tablet refills:*0 2. enoxaparin sodium 40 mg sc daily rx *enoxaparin 40 mg/0.4 ml 40 mg daily disp #*30 syringe refills:*0 3. docusate sodium 100 mg po bid discharge disposition: home with service facility: all care vna of greater discharge diagnosis: nondisplaced sternal fratures right rib fx 5,6 nondisplaced grade 3 liver lac (7cm) right femur shaft fracture left femoral head fracture right pneumatocele, pulmonary contusion left ear laceration 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: * your injury caused several rib fractures 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 * if your doctor allows, non steroidal antiinflammatory drugs are very effective in controlling pain ( ie, ibuprofen, motrin, advil, aleve, naprosyn) but they have their own set of side effects so make sure your doctor approves. * return to the emergency room right away for any acute shortness of breath, increased pain or crackling sensation around your ribs ( crepitus ). do not take past in any physical contact sports for the next weeks. if you feel lightheaded or dizzy, go to nearest emergency room. followup instructions: department: orthopedics when: thursday at 3:20 pm with: ortho xray (scc 2) building: sc clinical ctr campus: east best parking: garage department: orthopedics when: thursday at 3:40 pm with: , np building: campus: east best parking: garage department: general surgery/ when: tuesday at 1:30 pm with: , md with: acute care clinic building: lm bldg () campus: west best parking: garage *you will need a chest x-ray prior to this appointment. please go to , clinical center, radiology 30 minutes prior to your appointment. Procedure: Insertion of intercostal catheter for drainage Other local excision or destruction of lesion of joint, knee Open reduction of fracture with internal fixation, femur Closed reduction of fracture with internal fixation, femur Suture of laceration of external ear Diagnoses: Open wound of scalp, without mention of complication Open wound of forehead, without mention of complication Hypotension, unspecified Closed fracture of sternum Traumatic pneumothorax without mention of open wound into thorax Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle Closed fracture of two ribs Contusion of lung without mention of open wound into thorax Open fracture of shaft of femur Other closed transcervical fracture of neck of femur Injury to liver with open wound into cavity, laceration, moderate Open wound of other and multiple sites of ear, without mention of complication