CHIEF COMPLAINT: Motorcycle accident.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old man who was running his motorcycle when he had a low to moderate speed accident in which he fell to the ground and sustained some abrasions on his shoulder.
Apparently, the police had noticed that he was driving erratically and he then fled the scene and was pulled over again later when he was noted to be wheezing.
He is a fairly poor historian, but he denied loss of consciousness. He complained of left shoulder pain and left knee discomfort.
PAST MEDICAL HISTORY: He has a past medical history of hypertension.
SOCIAL HISTORY: He denied substance abuse or tobacco abuse.
REVIEW OF SYSTEMS: He denies headache, neck pain, dyspnea, chest pain, abdominal pain, nausea or vomiting. He was ambulatory at the scene. The rest of the systems are reviewed and are negative. The patient has an odor consistent of ethanol.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient was awake, alert and oriented.
VITAL SIGNS: Blood pressure 134/82, pulse 92, respiratory rate 20, temperature 97.4, pulse oximetry 96% on room air.
HEENT: Normocephalic and atraumatic.
NECK: He was in full spinal precautions. We kept the C-collar on. However, we did palpate his C-spine in the midline, and he had reported no pain to palpation there. Trachea was midline. There was no evidence of JVD.
CHEST: Clear to auscultation and percussion. He had obvious abrasion to the left shoulder, but there was good breath sounds throughout. No crepitus, equal excursion.
ABDOMEN: Soft, flat, nontender, nondistended. His bowel sounds were active.
PELVIS: Stable.
EXTREMITIES: Had a few minor contusions and abrasions, some tenderness in the soft tissue around the knee area, but no bony instability, no point tenderness, no deformity, and peripheral neurovascular status was intact throughout.
NEUROLOGIC: Nonfocal.
DIAGNOSTIC DATA: Scans: He had a CT of his head, C-spine, chest, abdomen and pelvis that showed no acute abnormalities, some degenerative joint diseases in the cervical and thoracic spine, but no acute injuries or traumatic injuries were reported.
LABORATORY DATA: He had a full complement of labs here in the ER that were reviewed. Normal white count, normal H and H, normal amylase and lipase. Chemistries showed an ALT of 114, an AST of 90, and a sodium of 147. The rest of the electrolytes were grossly within normal limits. Glucose was 126, calcium was 8.2, lipase was 150, normal coags. Urine had no evidence of infection or hematuria. Ethanol was 228.
ED COURSE: The patient remained hemodynamically stable. We provided wound care. We provided analgesia here. He had an IV of normal saline of 125 an hour. He was discharged.
CLINICAL IMPRESSION:
1. Motorcycle accident.
2. Abrasions and contusions of multiple sites.
PLAN:
1. He was advised to follow up with his PCP.
2. To return to the ER for any other problems, issues or concerns.
3. He was given p.o. analgesics to take as an outpatient.
4. We advised him to decrease or stop his alcohol intake. The rest of the systems were reviewed and negative.
5. He was discharged in stable condition.
DISPOSITION: Discharged.
