allergies: sulfa (sulfonamide antibiotics) attending: chief complaint: bicycle struck by motor vehicle. major surgical or invasive procedure: -tracheostomy -open reduction internal fixation of thyroid cartilage fracture with mini plate -open reduction and internal fixation of -orbital ethmoid fracture. -open reduction and internal fixation of maxillary fracture via multiple approaches for frontozygomatic plating as well as orbital rim plating. -closed reduction with maxillomandibular fixation of the mandible fractures including the left condylar head fracture, the right parasymphysis fracture, and the right ramus mandible fractures. -manipulation and attempt to reseat the left condyle. -insertion of custom splint. -open reduction internal fixation of right mandibular fracture. -open reduction internal fixation of right mandibular parasymphysis fracture. -open reduction without fixation of left mandibular condyle followed by repositioning of the dislocated condyle in the fossa. -open reduction internal fixation of maxillary fractures. -placement of maxillary mandibular fixation. history of present illness: 37 f bicyclist struck by a motor vehicle. the patient was transported on a long spine board and collar and arrived at as a basic trauma activation. upon evaluation, the patient was seen to have multiple facial injuries. notably she was seen to have a displaced mandible fracture, multiple tooth fractures and bleeding from the oral cavity. she was able to maintain airway spontaneously and room air spo2 was 100%. past medical history: pmh- none psh- none social history: nc family history: nc physical exam: on admission, in trauma bay: hr:66 bp:144/94 resp:17 o(2)sat:100 and normal constitutional: alert and oriented x3, awake and conversant heent: pupils 3 mm to 2 mm bilaterally, equal and reactive, right periorbital ecchymosis, multiple broken/missing upper teeth, full-thickness laceration under the lower lip c-collar chest: clear to auscultation cardiovascular: regular rate and rhythm, normal first and second heart sounds abdominal: soft, nontender, negative fast pelvic: stable pelvis gu/flank: no costovertebral angle tenderness, no vertebral tenderness extr/back: skin is warm and well perfused, abrasions noted on the right fingers, tenderness to palpation of the left thumb skin: warm and dry neuro: speech fluent, follows commands, 5 over 5 strength, normal sensation bilaterally gait not tested psych: normal mentation pertinent results: ct cap - rul ground glass opacity, pneumomediastinum c/w tracheal laceration ct cspine - hyoid fracture, laryngeal laceration at level of hyoid fracture. ct sinus - 1. displaced mandibular arch, bilateral rami, left condylar fractures. 2. bilateral pterygoid plate fractures. 3. medial, lateral, posterior maxillary wall fractures. 4. maxillary arch fracture. 5. nasal bone fractures. ct head - no intracranial injury, facial fractures as above. brief hospital course: imaging revealed multiple complex facial fractures, bilateral mandibular condyle fracture, a fracture through the symphysis of the mandible with displacement. upon further evaluation, the patient was also seen to have a hyoid bone fracture as well as thyroid cartilage fracture. orthopedic surgery was consulted for l thumb fx anbd r scaphoid fracture and they recommended elevation and nwb b/l ue. the patient was admitted to the trauma icu for airway observation. the patient became progressively more hoarse, therefore, the decision was made to proceed to the operating room for examination, intubation and tracheostomy which was performed on . at the same setting, the plastic surgery service repaired complex facial lacerations and ent was consulted for repair of the thyroid cartilage. following this, the patient was extubated without difficulty and was transferred out of the icu to the floor for further management. pt was stable on floor and followed primarily by general surgery with the neurosurgery, plastics, and omfs services consulting. on , neurosurgery identified no emergent or urgent management issues and signed-off. on plastic surgery brought the patient to the or for reduction of the zygomatic, nasal, and right mandibular fractures including fixation when indicated. intermaximallary fixation was also achieved at this time. pt was returned to floor after uneventful stay in pacu with adequate pain control, excellent respiratory status and airway control via the existing tracheostomy. patient had an uneventful interval course on the floor leading up to when she was taken back to the or by omfs for plating of her r mandibular fractures and reduction of her l condylar fracture. she was returned to the floor after an uneventful recovery in the pacu at which time she complained of increased post-procedural pain. her iv pain regimen was titrated to control her pain with good result while maintaining excellent respiratory status. on patient returned to the or with omfs. she underwent open reduction internal fixation of right mandibular fracture, open reduction internal fixation of right mandibular parasymphysis fracture, open reduction without fixation of left mandibular condyle followed by repositioning of the dislocated condyle in the fossa, open reduction internal fixation of maxillary fractures, and placement of maxillary mandibular fixation. patient post operative course was uneventful. patient returned to a regular nursing floor. patient's diet was advanced to clears and fulls. at the time of discharge on , the patient was doing well, afebrile with stable vital signs. the patient was tolerating a full liquid diet, ambulating, voiding without assistance, and pain was well controlled. the patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. medications on admission: none discharge medications: 1. chlorhexidine gluconate 0.12 % mouthwash sig: fifteen (15) ml mucous membrane every twelve (12) hours. disp:*900 ml(s)* refills:*2* 2. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: two (2) drop ophthalmic qid (4 times a day). 3. hydrocortisone 0.5 % cream sig: one (1) appl topical qid (4 times a day) as needed for rash. 4. docusate sodium 50 mg/5 ml liquid sig: five (5) ml po bid (2 times a day). disp:*300 ml* refills:*2* 5. magnesium hydroxide 400 mg/5 ml suspension sig: thirty (30) ml po q6h (every 6 hours) as needed for constipation. 6. bisacodyl 10 mg suppository sig: one (1) suppository rectal hs (at bedtime) as needed for constipation. disp:*20 suppository(s)* refills:*0* 7. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls po q6h (every 6 hours) as needed for pain. disp:*800 ml(s)* refills:*0* 8. augmentin 250-62.5 mg/5 ml suspension for reconstitution sig: ten (10) ml po twice a day for 7 days. disp:*140 ml* refills:*0* discharge disposition: home with service facility: hospice and vna discharge diagnosis: -pedestrian struck by vehicle -pan fascial midface fracture including lafort 3 levelfractures. -left condylar head fracture along with dislocation of the condyle lateral over the zygomatic arch. -compounded right parasymphysis fracture of the mandible. -comminuted right mandibular fracture. -malocclusion. -pain. -mastoid dysfunction. -multiple mandible fractures including displaced right parasymphysis mandible fracture, right comminuted ramus mandible fracture, left displaced condylar head mandible fracture. -other facial fractures include a nasal fracture,maxillary fracture, which is a left lefort ii, left zygomaticomaxillary complex fracture. -pain, malocclusion, and lateral displacement of the left condyle. -laryngeal and hyoid bone fracture discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: patient is to continue augmentin for one week total patient should rinse mouth with peridex twice a day patient should continue a full liquid diet please call your doctor or nurse practitioner or return to the emergency department for any of the following: *you experience new chest pain, pressure, squeezing or tightness. *new or worsening cough, shortness of breath, or wheeze. *if you are vomiting and cannot keep down fluids or your medications. *you are getting dehydrated due to continued vomiting, diarrhea, or other reasons. signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *you see blood or dark/black material when you vomit or have a bowel movement. *you experience burning when you urinate, have blood in your urine, or experience a discharge. *your pain in not improving within 8-12 hours or is not gone within 24 hours. call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *you have shaking chills, or fever greater than 101.5 degrees fahrenheit or 38 degrees celsius. *any change in your symptoms, or any new symptoms that concern you. please resume all regular home medications , unless specifically advised not to take a particular medication. also, please take any new medications as prescribed. please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. avoid lifting weights greater than lbs until you follow-up with your surgeon. avoid driving or operating heavy machinery while taking pain medications. incision care: *please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *avoid swimming and baths until your follow-up appointment. *you may shower, and wash surgical incisions with a mild soap and warm water. gently pat the area dry. *if you have staples, they will be removed at your follow-up appointment. *if you have steri-strips, they will fall off on their own. please remove any remaining strips 7-10 days after surgery. followup instructions: follow up in one week with omfs - dr. - call () to make appt follow up in weeks with ent- dr. call ( please follow up in hand clinic: ( please call to make an appointment please follow up in plastic surgery clinic for non-emergent surgery plastic surgery clinic: ( acute care surgery clinic, call ( to schedule appt. Procedure: Temporary tracheostomy Closure of skin and subcutaneous tissue of other sites Open reduction of maxillary fracture Insertion of synthetic implant in facial bone Insertion of synthetic implant in facial bone Closed reduction of mandibular fracture Other open reduction of facial fracture Open reduction of nasal fracture Repair of laryngeal fracture Other closed reduction of facial fracture Closed reduction of maxillary fracture Diagnoses: Traumatic subcutaneous emphysema Closed fracture of malar and maxillary bones Closed fracture of orbital floor (blow-out) Street and highway accidents Motor vehicle traffic accident involving collision with other vehicle injuring pedal cyclist Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness Closed fracture of nasal bones Open wound of tooth (broken) (fractured) (due to trauma), without mention of complication Open fracture of malar and maxillary bones Closed fracture of base of thumb [first] metacarpal Open fracture of mandible, multiple sites Open fracture of larynx and trachea Open fracture of navicular [scaphoid] bone of wrist