HWB Data Input
Orthopaedic Physician Input
S/P MVA, auto vs auto, speed > 60 mph, driver, belted, passenger space intrusion,
Major pelvic ring disruption, Lateral Compression 2, Tile B2, Lt comminuted pubic ramus fx, Letournel A2, Lt comminuted anterior wall acetabular fx, Lt impacted sacral alar fx, Denis 1, Letournel C, Seattle 2,
11/06/96 Rx Auto vs auto accident - 99252 Initial new/established patient consultation
11/07/96 Rx Lt anterior wall acetabular fx - 27226 Open rx with fixation of anterior wall, Open reduction, internal fixation, 4.0 mm cancellous screws, 10 hole 3.5 recon plate (enter)
Export to Med Records (MARS)
Report Type ...... HP - Orthopaedics Trauma Note
---- Progress notes:
12/8/94 - 12/12/94 - Hospitalization /MM
---- Orthopaedics ICD-9 Diagnoses:
---- Orthopaedic Procedures:
---- Trauma Surgery Injury Severity Scores:
PRINCIPAL PROCEDURE: CT scan of the head, CT scan of the abdomen, CT scan of the pelvis, CT scan of left shoulder, CT scan of the spine.
HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old painter who fell approximately 30 feet from a billboard on the day of admission with positive loss of consciousness. The patient was transferred from Centerville. CT scan of the head was done at the outside hospital which revealed an occipital fracture. The patient arrived complaining of left arm and left back pain. The patient was hemodynamically stable en route.
PAST MEDICAL HISTORY: Abdominal aortic aneurysm of unknown site according to son.
PAST SURGICAL HISTORY: Status post L5-S1 fusion.
MEDICATIONS ON ADMISSION: One aspirin per day.
SOCIAL HISTORY: Positive for tobacco, negative or alcohol or other drugs.
PHYSICAL EXAMINATION: Examination on arrival - blood pressure 147/70, pulse 70, respirations 26, pupils equal, round, reactive to light and accommodation, extraocular movements intact. Tympanic membranes were clear. Nose was stable. Mouth was negative for blood. Neck was in a C-collar. Trachea was midline, no battle signs noted. Mid face was stable. Chest examination showed a contusion of the left upper chest, no tenderness or subcutaneous air noted. Bilateral breath sounds present. Abdominal examination revealed right and left lower quadrant abdominal tenderness. Pelvis was stable. The patient had normal sphincter tone and smooth prostate and was heme positive from below. Back examination revealed tenderness in the thoracic spine area. Extremity examination revealed a left clavicle fracture and left shoulder ecchymosis. Neurologic examination - the patient was awake and oriented to person and place. The patient was moving all extremities with good equal strength.
Chest x-ray revealed a left pulmonary contusion and a 10th and 11th rib fracture on the left. Scapular view revealed a left scapular and clavicle fracture. CT scan of the head shows depressed occipital skull fracture into the parietal area approximately 8 mm. CT scan of the abdomen revealed a splenic laceration with some free fluid in the abdomen. There was also noted left adrenal hematoma.
INITIAL LABS: PCV of 40, SMA-7 was all within normal limits.
HOSPITAL COURSE: The patient was admitted to SICU for observation and further workup. While in the ICU the patient was agitated and became disoriented. The patient initially had some problems with oxygenization. The patient was supplemented with 5 liters per nasal cannula and saturated to 95 to 98 percent in the SICU. The patient was seen by neurologic spine consult and orthopedic surgery consult. The patient's back fracture was felt to be stable. The patient was fitted for a TLSO brace for comfort. By 12-12 the patient was considered to be stable enough for transfer to step-down observation bed. The patient remained hemodynamically stable and neurologically intact. The patient's mental status continued to gradually improve to the point of 12-15-94 in the A.M. when the patient was considered to be ready for discharge. The patient has been eating a regular diet, ambulating with minimal assistance, voiding without difficulty and requesting discharge this A.M.
CONDITION ON DISCHARGE: Stable.
INSTRUCTIONS TO THE PATIENT: Regular diet. Activity as tolerated. Cervical
fracture sling for comfort, Tylox one p.o. q. four p.r.n. pain, follow-up
with Orthopaedic Surgeon in the orthopedic clinic in two weeks. Follow-up with
General Surgery in one week. (enter)
10/26/96 TRACS Registry Data:
Injury Data: E Code 819.9, Injury Site - E849.5, Trauma Type - Blunt, Injury Date 10/26/96, Accident Position - Unspecified, EMS Transport - Helicopter
ER Data: Arrival 18:02 10/26/96, S/P MVC, Resp. to Pain, VS - R0 P141 BP140, GCS 7, Trauma Score 6, EtOH 0, Airway - Oral ETT, Base Deficit -5, Hct 29, Head CT - Positive, ISS 35
Discharge Data: DC Date 11/11/96, Hosp Days 16, ICU Days 12, Disposition
- Rehab, Hospital Charges $86751, Insurance - Commercial (enter)
OR data from 02/27/1998 - Case 187723, 1607 RESECTION OF BOWEL, anestimes 15:3316:5315:33, surgtimes 15:4516:45, GENERAL FRIPHENTANYL, no implant data
OR data from 02/28/1998 - Case 187767, 1607 RESECTION OF BOWEL, anestimes 07:5210:2407:52, surgtimes 08:0210:14, GENERAL MONFORANE, BARD 10021 T TUBE
OR data from 03/01/1998 - Case 188194, 93.44 APPLICATION OF EXTERNAL FIXATOR - ORTHOFIX, anestimes 07:5112:2007:58, surgtimes 08:3512:10, GENERAL SUNFORANE, RICHARDS 10-3452 RANCHO CUBES, RICHARDS 10-3453 RANCHO CUBES, RICHARDS 10-0550 8MM BOLT, RICHARDS 10-3405 CENTERING SLEEVE, RICHARDS 102102 BAYONET WIRE TIP, RICHARDS 102311 THREADED ROD, RICHARDS 101401 3 HOLE SUPPORT MALE END, RICHARDS 101600 MALE HINGE, RICHARDS 100700 WIRE FIXATION BOLTS SLOTTED, RICHARDS 103203 WIREFIX BOLT, RICHARDS 103300 WIRE FIX NUTS, RICHARDS 102701 WASHER, RICHARDS 102700 WASHER, RICHARDS 101305 HALF RING, RICHARDS 12-2709 HALF PIN, RICHARDS 121633 SCREW, RICHARDS 121633 SCREW, SYNTHES 218.080 SCREW, ZIMMER 1103-04 BONE GRAFT STRIP COLLAGRAFT, ZIMMER 187-02-59 SMOOTH STEINMIN PIN, ZIMMER 187-05-59 SMOOTH STEINMAN, SYNTHES 214.890 SCREW, SYNTHES 214.830 4.5 SCREW, SYNTHES 214.832 4.5 SCREW, RICHARDS 10-3451 RANCHO CUBE, SYNTHES 214.834 4.5 SCREW, SYNTHES 216.65 SCREW, SYNTHES 214.836 4.5 SCREW, SYNTHES 214.838 4.5 SCREW, SYNTHES 217.055 6.5 SCREW, SYNTHES 217.085 6.5 SCREW, SYNTHES 217.090 6.5 SCREW, RICHARDS 41-0236 6.5 GUIDE PIN, SYNTHES 310.31 (enter)
SMS Mainframe - Demographic Data
D 00004 0014466494 141145634038 DOE ,JOHN IA 1996-03-07 05.54.00- - 1981-03-21 F ORT MCE3 M08 GREEN, NEIL E. 0000000315 00014 0000000315 A B S 9 00000 417113298 GREEN, NEIL E. 00000 000.00 00000 Z 6N (enter)
PACS - Radiology Data