Patient Name: Rylee Rue
DOB: 3/2/1991
DOS: 10/9/2022
ED Clinical Impression/Diagnosis:
Final Diagnosis: Pneumothorax, Forehead Laceration, LT Arm Fracture, Neck Sprain, Low back Strain
ED Disposition: Discharge
History of Present Illness (HPI):
Chief Complaint: MVA
37-year-old female who was in a motor vehicle accident about an hour ago. Arrived by ambulance and considered a trauma. Patient is in a C-collar. Patient has bruises and blood everywhere. A LT broken arm has been identified and splinted on scene. A forehead laceration that has been wrapped by EMS. Patient seems to have labored breathing. Airbags were deployed in patient’s vehicle. Patient was wearing her seat belt.
Presenting symptoms: multiple injuries- trauma MVA
Severity: trauma
Duration: less than an hour ago
Associated symptoms:
Risk Factors: collapsed lung.
ED Course:
Patient Medical History: unknown
Unable to obtain.
Past Surgical History:
Unable to obtain.
Social History:
Marital status: Single
Smoking status: never
Smokeless tobacco: never
Family History:
Mother: no known problems
Father: no known problems
Review of Systems (ROS):
Review of Systems:
Constitutional: Reviewed and all are negative.
HENT: All are negative.
Vision: Negative for eye pain and visual disturbance.
Respiratory: Positive for shortness of breath and wheezing.
Cardiovascular: Negative for chest pain and palpitations.
Gastrointestinal: Positive for abdominal pain.
Genitourinary: Negative for dysuria and hematuria.
Musculoskeletal: Positive for arm, back, neck, leg pain.
Skin: Negative.
Neurological: alert and awake.
All other symptoms reviewed and are negative.
Physical Exam (PE):
BP 150/105 Pulse 115 Temp 98.2 Resp 14 Wt 180 SpO2 98%
Physical Exam:
Constitutional:
General: Painful LT Arm. Sore all over.
Appearance: Well-developed and well-nourished.
Comments: Trauma MVA. Bruised and sore.
HENT:
Head: Atraumatic. No signs of injury. In C- collar until cleared.
Right Ear: Tympanic Membrane normal.
Left Ear: Tympanic membrane normal.
Nose: Nose normal. No nasal discharge.
Pharynx: Oropharynx is clear. Normal.
Tonsils: No tonsillar exudate.
Eyes:
Extraocular Movements: EOM normal.
Pupils: Pupils are equal, round, and reactive to light.
Cardiovascular:
Rate and rhythm: Normal rate and regular rhythm.
Pulmonary:
Effort: Pulmonary effort is not normal. Labored.
Breath sounds: fuzzy/wet.
Abdominal:
General: Bowel sounds are normal. There is no distention.
Musculoskeletal:
General: Neck is sore. Back is sore. LT Arm FX and splinted.
Neurological:
Mental Status: She is alert.
Skin:
General: Laceration on forehead.
Radiology:
XR Chest 2 Views (PA and LAT)
Final Results by Julie Raster, MD (10/09 0852)
IMPRESSION:
Pneumothorax
All radiology studies independently viewed by me and interpreted by the radiologist.
Procedure(s):
LT Arm, Shaft of Humerus Fracture was splinted on scene by EMS.
C-Collar was placed on scene by EMS.
Procedure Name: Laceration Repair
Location: Forehead
Procedure: Laceration repair, 2.5 cm repair
The area was prepped in the usual sterile fashion. Local anesthesia was achieved using 5cc of Lidocaine 1%. The wound was copiously irrigated. 2.5 cm repair, 3-0 Nylon interrupted sutures were placed. Estimated blood loss was less than 0.5 mL. A dressing was applied to the area. The patient tolerated the procedure well without complications.
Procedure Name: Chest Thoracostomy with Indwelling Tube
Indication: Pneumothorax
A time-out was called. The patient was positioned appropriately for chest tube placement. The patient’s right chest was prepped and draped in sterile fashion. 1% lidocaine was used to anesthetize the surrounding skin area. A 2cm skin incision was made in the mid-axillary line at the inframammary crease. Utilizing blunt dissection, a subcutaneous tunnel was created cephalad just adjacent to the superior rib. The pleural space was entered bluntly, and gush of air/blood was observed. A finger was inserted into the pleural space to check for anatomy and guide tube insertion. A 36F thoracostomy tube was inserted using a Kelly clamp and positioned appropriately. The chest tube was sutured securely to the skin and a sterile dressing applied.
Discharge Instructions:
Follow-up with Orthopedic Specialist in 2-3 days regarding LT Arm FX.
Follow-up in 2 weeks to remove stitches.
I have personally provided Total critical care time of 35 minutes. Time included discussion with consultants, review of radiology results, and monitoring for potential decompensation. Interventions were performed as documented above.
Electronically signed by Donnie Clark, DO 10/9/2022 10:24