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59-year-old woman presenting to the Emergency Department after a motor vehicle collision. She was a restrained driver in a Fiat which collided into a tree at a high rate of speed. Air bags were deployed. She was pinned in the vehicle and there was a prolonged extrication of an hour and 45 minutes due to entrapment of her right foot. She was noted to have an open left femur fracture and a fair amount of bleeding in the field. She arrived to the Emergency Department on a backboard in cervical spine collar. She states that she has pain in bilateral legs. She denies any abdominal pain or chest pain. She denies any back pain or neck pain. She reports that she does not remember the events of the accident. She denies any alcohol use. Patient does have a history of seizure disorder; however, she reports she has not had any recent seizures and she has been compliant with her Dilantin. REVIEW OF SYSTEMS: Unable to obtain due to clinical condition. PAST MEDICAL HISTORY: Seizure disorder and atrial fibrillation. PAST SURGICAL HISTORY: 1. Breast augmentation. 2. Thyroid surgery. 3. Temporal Lobectomy ALLERGIES: None. HOME MEDICATIONS: Dilantin 300 milligrams per day. Pradaxa 150 milligrams twice a day. FAMILY HISTORY: Negative for bleeding disorders. SOCIAL HISTORY: Patient is married. She reports 1-pack-a-day tobacco use, rare alcohol use, no recreational or street drug use. PHYSICAL EXAM: Dictation cut off. ABDOMEN/PELVIS CT IMPRESSION: 1. Horseshoe kidney. Demonstration of parenchymal laceration involving the medial cortex of the left renal moiety associated with large left perinephric hematoma along the medial aspect. There is high attenuation material noted within the perinephric hematoma suggesting active extravasation with vascular injury. Delayed excretory phase imaging through the kidneys demonstrates high attenuation material outside of the collecting system adjacent to the site of laceration along the medial aspect of the left renal moiety suggesting calyceal injury. Findings suggestive of grade 4 renal injury of the left renal moiety of the horseshoe kidney. 2. Delayed imaging through bladder with optimal opacification shows no extravasation of the contrast to suggest urinary bladder injury
3. No evidence of intraperitoneal free fluid or hematoma or
extraluminal gas.
4. No evidence of acute displaced fracture of the lumbar spine or the
pelvis.
5. Please see separately dictated CT chest report for thoracic findings
including thoracic spine.
Question 1
Based on the information listed above what comorbidities are present?
35yo male s/p MVC ejected from car on 7/21 w/TBI, small punctate intracranial hemorrhages , right ICA dissection , right C7 transverse process fracture, 8,12 R rib fractures, comminuted fracture of the left calcaneus and multiple facial fractures (crista galli, cribriform plate, anterior cranial fossa floor, right orbital floor fracture, nasal septum). Patient stabilized on ventilator and weaning appropriately. Now s/p ORIF of facial fx by OMS. Review of Systems: Unable to obtain Home Medications: Unknown. Allergies and Intolerances: Unknown Past Medical History: Unknown. Past Surgical History: Unknown. Family/Social: Unknown Vitals for 08/06/2012 Temp: 37.3 Heart Rate: 103 Resp Rate: 21 BP: 114/64 O2 Sat: 97% SIMV 30% Nutrition: TF's @ 75cc/hr Physical Exam General: Intubated, sedated HENT: Grossly normocephalic, trach collar in place. ETT, OG, dobhoff. CV: RRR w/out MRG Resp: Mechanical breath sounds limited exam, no wheezes or crackles GI/ABD: Firm, mildly distended, no indication of tenderness or guarding. GU: Foley draining clear yellow urine. MS: LUE soft cast, RUE mit restraignt, LLE soft cast Skin: No ulcers, rashes or lesions Neuro: Sedated, unable to assess. All other physical exams during the next 10 days in the ICU indicate the same/similar examination. Cultures: QUANT RESPIRATORY CULT/SMR Source:BRONCHO-ALVE BAL 07/27/12 1713 FEW POLYMORPHONUCLEAR LEUKOCYTES NO ORGANISMS SEEN ---------- FINAL REPORT ---------- 07/30/12 0822 CULTURE YIELDS >10,000 CFU/ML ENTEROBACTER CLOACAE Avoid 2nd and 3rd generation cephalosporins and penicillin-based antibiotics for the treatment of moderate-severe Enterobacter and Citrobacter infections. These organisms could produce an inducible beta-lactamase that confers resistance to cefuroxime, ceftriaxone, and ceftazidime. --------------- SUSCEPTIBILITIES --------------- E CLOAC CEFEPIME MIC VALUE <=1 INTERP S PIPER/TAZOB MIC VALUE 2 INTERP S CEFAZOLIN MIC VALUE >=64 INTERP R CEFTRIAXONE MIC VALUE <=1 INTERP S AZTREONAM MIC VALUE <=1 INTERP S MEROPENEM MIC VALUE <=0.25 INTERP S GENTAMICIN MIC VALUE <=1 INTERP S TOBRAMYCIN MIC VALUE <=1 INTERP S AMIKACIN MIC VALUE <=2 INTERP S TRIMETH/SULFA MIC VALUE <=1 INTERP S CIPROFLOXACIN MIC VALUE <=0.25 INTERP S LEVOFLOXACIN MIC VALUE <=0.12 INTERP S Chest X-Rays: 07/22/2012 through 07/24/2012 Low lung volumes. Positioning limiting evaluation. Unchanged position ET tube. No acute process. 07/25/2012 02:20:57 Low lung volumes. Linear opacity at the right lung base, may represent atelectasis, however contusion is possible given history of trauma. Left lung is clear. No pneumothorax. 07/25/2012 06:49:08 1. Increased right basilar opacity may be a combination of small pleural effusion and worsening right lower lobe collapse, likely distal to a mucous plug. 2. No other interval change. Tiny right pleural effusion. Persistent but improved atelectasis in the right lower lobe.
07/28/2012 07:23:04
1. Endotracheal tube, nasogastric tube, and right PICC line all remain
in place.
2. There is new increased opacity in the right upper lung, particularly
in the suprahilar region. There is also evidence of volume loss on the
right with elevation of the right hemidiaphragm. These findings would
suggest atelectatic changes involving the right upper lobe.
3. Additional streaky and hazy opacities are seen in the remaining
right lung which also likely represent areas of atelectasis.
4. There now appears to be a tiny right pleural effusion.
5. The exam is otherwise unremarkable. The left lung remains clear.
There is no evidence of a pneumothorax.
07/29/2012 07:47:48
1. Endotracheal tube remains in place with its tip approximately 9.5 cm
above the carina. Nasogastric tube extends into the stomach. Right PICC
line is in place with its tip in the mid to lower superior vena cava.
2. Increased basilar opacities are seen with obscuration of the
costophrenic angles. These findings would be compatible with small
bilateral pleural effusions and associated basilar airspace changes,
likely atelectasis. These findings have increased when compared with
the previous exam.
3. The exam is otherwise unremarkable. No other acute abnormalities are
seen. There is no evidence of a pneumothorax.
Question 2
Does this patient meet the criteria for pneumonia? (Circle one)

Why or why not?

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83-year-old male with a history of A-fib, who is not on Coumadin, presenting
to the Emergency Department after having a mechanical fall and injuring his
left shin and right chest wall while salsa dancing.
During his hospitalization, DVT scan demonstrates acute brachial and axillary
vein DVT’s on 3/10/12. There is no mention of the DVT’s in the daily
progress notes. He has no procedures performed during his stay. Patient’s
only medications during his stay are Tylenol and Colace. He is discharged
on these medications only on 3/11/12.
Question 3
Does this patient meet criteria for DVT? (Circle one)
Why or why not?

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DC 3242890380432

84-year-old female with a history of A-fib, who is not on Coumadin,
presenting to the Emergency Department after having a mechanical fall and
injuring his right shin, left chest wall, and right occiput after her husband
and her were salsa dancing.
During her hospitalization, DVT scan demonstrates acute subclavian vein DVT
on 3/6/12. There is no mention of the DVT in the daily progress notes.
Neurology feels she has exam consistent with clinical brain death. Family
agrees with care withdrawal. Her only inpatient medication of metoprolol is
discontinued, she is extubated, and expires.
Question 4
Does this patient meet criteria for DVT? (Circle one)
Why or why not?

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