S:

53 y/o F, with no significant PMHx, who presented to the ED via EMS s/p a mechanical fall that occurred five hours ago. Patient states she was going downstairs in her apartment complex when she tried to step over a puddle of water and fell down 10 stairs, landing on her left side. She states she was able to get herself back into her apartment and call for help. Surgery consult called as CXR revealed left 9-11 rib fractures. Patient reports left sided chest wall pain, difficulty breathing with deep inspiration and left arm pain but denies fever, chills, nausea, vomiting, dizziness, lightheadedness or loss of consciousness.

PMHx: Gestational DM

Surgical Hx: none

Allergies: NKDA

Medications: none

Family history: non-contributory

Social history: current smoker .5 ppd x30 years, denies alcohol or illicit drug use

O:

VS: Temp 98.7 F, RR 17 breaths per minute, HR 62 bpm, O2 saturation 99% on room air, BP 127/80

PE:

General: Alert and oriented x3, laying in stretcher, in no acute distress

            Skin: ecchymosis to left elbow

HEENT: normocephalic, atraumatic

Neck: FROM, nontender

CV: Regular rate and rhythm

Respiratory: CTA bilaterally, left sided lateral chest wall tenderness. Mild ecchymosis to left chest wall. No crepitus

Abd: soft, nontender, nondistended

MSK: Tenderness to left elbow. LLE 4/5 strength baseline per patient, RLE 5/5 strength with FROM. FROM of UE with 5/5 strength

Labs:

10.82 | 13.1 | 201

             40.6

141 | 104 | 16     114

4.2  | 27   | 0.68

PT: 10.8

INR: 0.92

PTT: 27.1

CT abdomen/pelvis with IV contrast: Fracture of left 9^th, 10^th and 11^th ribs. No pneumothorax or hemothorax. No evidence of splenic laceration or other abdominal visceral injury identified. No evidence of hemoperitoneum or retroperitoneal hematoma.

Thoracic XR: no compression deformity of thoracic spine.

Lumbar XR: No compression deformity of lumbar spine

Left Humerus XR: No acute displaced fracture of left humerus.

Left forearm XR: No acute displaced fracture or dislocation of the left forearm

Left elbow XR: no acute displaced fracture or dislocation of the left elbow

Left wrist XR: no acute displaced fracture or dislocation of the left hand and left wrist.

Left hip XR: No acute displaced fracture or dislocation of the left hip.

CXR: No evidence of acute pulmonary disease. Multiple left lower rib fractures.

CT head without contrast: no evidence of intracranial hemorrhage identified.

CT chest without contrast: Fracture of left 9^th, 10^th and 11^th ribs. No pneumothorax or hemothorax. No evidence of splenic laceration or other abdominal visceral injury identified. No evidence of hemoperitoneum or retroperitoneal hematoma.

A:

53 y/o F who presented to the ED via EMS s/p a mechanical fall with fractures to left 9^th, 10^th and 11^th ribs.

P:

No surgical intervention at this time, patient can be discharged from ED

Control pain with medication as per ED

Spirometry at 10x per hour

Follow up in the surgery clinic on Tuesday afternoon