history of present illness: the patient is a 44-year-old gentleman status post motor vehicle crash, unrestrained driver ejected partially. the patient complaining of severe back pain and inability to move bilateral lower extremities on presentation. the patient was hemodynamically stable with coma scale of 15 on transfer by medical flight. past medical history: 1. left lower extremity fracture. 2. significant tobacco history. past surgical history: none. medications on admission: no medications at home. allergies: no known drug allergies. physical examination on presentation: on presentation, the patient's temperature was 98 degrees fahrenheit, his heart rate was 120, his blood pressure was 110/60, his respiratory rate was 24, and his oxygen saturation was 92% on face mask. on examination, the pupils were equal, round, and reactive to light. the extraocular movements were intact. there was ecchymosis inferior to the left eye. the trachea was midline. cardiovascular examination revealed a regular rate and rhythm. there were bilateral coarse breath sounds. tenderness to the thoracolumbosacral. the abdomen was soft, nontender, and nondistended. the pelvis was stable. there were no deformities or costovertebral angle tenderness to the bilateral flanks. the back and neck examination was positive for a gross deformity at t12-l1. the cervical spine had no deformities or stepoff tenderness. rectal examination revealed a decreased tone and was guaiac-negative. extremity examination was within normal limits with palpable pulses throughout, but inability to move bilateral lower extremities. pertinent laboratory values on presentation: complete blood count was within normal limits. chemistries and coagulations were within normal limits. his lactate was 1.6. urine was negative. toxicology screen was negative. urine toxicology screen was positive for cocaine. pertinent radiology/imaging: radiologic films with a chest x-ray which showed bilateral pulmonary contusions and rib fractures of six, seven, and nine on the right and nine on the left. this also revealed a left pneumothorax for which a chest tube was placed. a computed tomography of the abdomen also showed a large retroperitoneal hematoma and a l1 burst fracture with bone in the spinal canal. brief summary of hospital course: the patient was intubated with a orogastric tube inserted. a foley catheter was placed. the patient was put on a solu-medrol drip and was kept sedated while intubated in the intensive care unit. neurosurgery was consulted. lower extremity examination showed bilateral lower extremity placidity. no reflexes. no withdrawal to painful stimulation, and no clonus. also on admission to the intensive care unit, the patient had a swan-ganz catheter placed which showed depressed cardiac output and index. cardiology was consulted, and an echocardiogram was performed. this echocardiogram showed no effusion or evidence of tamponade with normal-appearing right ventricular function and possibly somewhat depressed left ventricular function. in addition, and ophthalmology consultation was called regarding fractures of the zygomatic arch and macular sinus. their conclusion was that the bilateral globes were intact, and subconjunctival hemorrhage of the left eye required no treatment and recommended conservative treatment. a magnetic resonance imaging of the lumbar spine was obtained on , when the patient was hemodynamically stable enough to have this study. the findings were abnormal signals in l1 anteriorly and posteriorly; consistent with fractures. it also showed abnormal cord signal with high-grade cord compression in t10, t11, l1, and l2. neurosurgery reviewed these films and decided to take the patient to the operating room. the patient is status post l1 laminectomy and t7 through l3 posterior fixation on . at this time, the patient had spiking temperatures with possible leukocytosis. cultures were obtained, and methicillin-resistant staphylococcus aureus from the sputum culture from , and escherichia coli from his sputum culture from , and klebsiella from a blood culture from . levaquin and vancomycin were started on and ; respectively. on , the patient was extubated and the chest tube was discontinued. the patient tolerated these events well. the rest of the patient's course was unremarkable. the patient was transfused packed red blood cells on an as needed basis. psychiatry was consulted for supportive care and two events of hallucinations at night. the speech and swallow service was also consulted. the patient passed the swallow study and was able to tolerate a regular diet upon discharge without problems. the patient had a persistent leukocytosis but remained afebrile with negative cultures throughout the hospital course. this was thought to be a leukemoid reaction secondary to the neurosurgical operation. the patient had no signs of infection. the patient was aggressively with physical therapy and occupational therapy and had a tlso brace in place throughout his hospital stay. upon discharge, the patient was afebrile with stable vital signs. the patient was tolerating a regular diet. the chest tube site was clean, dry, and intact. the patient had a regular rate and rhythm, and the lungs were clear to auscultation bilaterally. the patient's abdomen was soft, nontender, and nondistended. the patient was educated on self catheterization. the patient was on an aggressive bowel regimen and was having regular bowel movements upon discharge. the patient completed a course of vancomycin and was switched to by mouth levofloxacin for a 14-day course upon discharge. discharge diagnoses: 1. status post motor vehicle collision; partial ejection and bilateral lower extremity paralysis. 2. bilateral pulmonary contusions. 3. respiratory distress. 4. left pneumothorax; status post chest tube placement. 5. rib fractures of the left sixth, seventh, and ninth ribs and right ninth. 6. l1 burst fracture with retropulsion. 7. retroperitoneal hematoma. 8. bacteremia. 9. methicillin-resistant staphylococcus aureus pneumonia. 10. status post chest tube placement. 11. status post swan-ganz catheter placement. 12. status post l1 laminectomy. 13. posterior fixation of t7 through l3 secondary to l1 fracture/dislocation and chronic burst fracture. discharge disposition: the patient was to be discharged to a rehabilitation center with aggressive physical therapy and occupational therapy. discharge instructions/followup: 1. the patient should be followed by social work, psychiatric service for supportive care and possible outpatient followup and recommendations. 2. the patient's treatments are as per physical therapy and occupational therapy. 3. the patient should have vital signs per routine with self catheterization education. 4. the patient was to have tlso brace in place. 5. the patient was to follow up with neurosurgery in two weeks; the patient to call the office for an appointment. 6. the patient was also instructed to follow up with the trauma clinic in two to three weeks; the patient to call the office for an appointment. condition at discharge: condition on discharge was stable. medications on discharge: (discharge medications included) 1. albuterol inhaler 1 to 2 puffs q.4-6h. as needed. 2. polyvidone alcohol drops 1 to 2 drops both eyes as needed. 3. nicotine patch transdermally once per day. 4. heparin 5000 units subcutaneously q.12h. (until ambulating three times per day without problems). 5. 40 mg by mouth once per day. 6. bisacodyl 10 mg by mouth/per rectum once per day as needed. 7. lactulose 30 mg per rectum as needed. 8. levofloxacin 500 mg by mouth q.24h. (until ). 9. ativan 0.5 mg to 2 mg by mouth q.4-6h. as needed (for agitation). note: an addendum to this discharge summary will be made upon acceptance to rehabilitation center. , m.d. dictated by: medquist36 Procedure: Insertion of intercostal catheter for drainage Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Lumbar and lumbosacral fusion of the anterior column, posterior technique Pulmonary artery wedge monitoring Transfusion of packed cells Dorsal and dorsolumbar fusion of the posterior column, posterior technique Repair of vertebral fracture Fusion or refusion of 4-8 vertebrae Diagnoses: Bacteremia Methicillin susceptible pneumonia due to Staphylococcus aureus Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury Traumatic pneumothorax without mention of open wound into thorax Closed fracture of malar and maxillary bones Closed fracture of lumbar spine with spinal cord injury Closed fracture of base of skull without mention of intra cranial injury, unspecified state of consciousness Closed fracture of four ribs