Ophthalmology Case Study

HISTORY
Patient is a 68-year-old female who was involved in a motor vehicle accident in Marianna, Florida on Sunday, December 30.  She evidently hit a guardrail, flipped the car twice, and an 18-wheeler hit them.  The car was destroyed.  She was evidently cut out of the roof of the car, she and her husband, and transported to a local hospital, Jackson Hospital, where they sewed them up, cleaned their cuts up.  They put multiple staples in her head.  Did a CT scan of her neck, back, and thoracic spine.  There were obvious thoracic fractures they identified.  Cervical, they were not sure, so she was transferred to Flowers Hospital the same afternoon to get ophthalmological consult along with pulmonary and neurology.  They winded up getting on neurosurgeon's service and was taken care of.  They really wanted to come back home.  Family was over there visiting but they just were concerned because she just was not getting much better, and she was having a breathing problems.  They called pulmonology in, according to my phone call to neurosurgery over there today prior to discharge, did an x-ray and some tests and said she has hypoxia secondary to atelectasis and a small right pleural effusion.  She was on Lortab.  They had been getting IV antibiotics while there for the last 3 days.  All these records have not been totally reviewed at this time.  Last record I get was saturation was 88% on room air, 93% on 3 L, and laboratory data was done over there, which showed everything had been stable.  She supposedly got a CT scan of her C-spine, which shows some degenerative changes.  There is a questionable nondisplaced hairline fracture in the right lamina of C2, which is why she is transferred to Flowers.  This was all done in Jackson Hospital.  She had a portable chest x-ray, which showed cardiomegaly, otherwise unremarkable.  No rib fractures identified.  She had a CT scan of the head, which showed no midline shift.  Scalp lacerations were identified.  The bony cranium was intact.  There were no fractures in the hand or arm.  I cannot find the CT scan report of the rest of her thoracic spine and that is what I keep looking for, but they did CT of her head, sinuses, facial bones, even a CT scan of her abdomen and nothing was ruptured.  Patient desired to come back home, but with still being on O2, they recommended transfer to another acute hospital.  Neurosurgeon called me.  We elected to take the patient in transfer.  She is a patient here in my clinic, and we will get a spine surgeon involved, because they wanted her thoracic spine evaluated and probably repeat her C-spine films, according to neurosurgeon, although he took the brace off.

PAST MEDICAL HISTORY

She has no known allergies.  She had her gallbladder out 40-plus years ago as well as appendix at same time.  She had a shoulder surgery 10 years ago for frozen shoulder.  She has had high blood pressure for about 10 years ago.  She has a diagnosis of sarcoid years ago, but has not had a flare-up since.  She also was recently diagnosed with Cameron ulcers and underwent Nissen fundoplication, which was very successful and she has not had any reflux and currently has been maintained on just Norvasc 5 milligrams a day for blood pressure and Lexapro 10 milligrams a day for anxiety, and this was situational depression with family issues.

FAMILY HISTORY

Mother died at 97.  Dad passed away with heart disease at 78.  She has been married for 46-plus years.  She does not smoke.  She has 2 children.

PHYSICAL EXAMINATION

GENERAL:  When I see patient lying in the bed, she is bruised and battered.  She has multiple staples in her scalp.  On the left, there are multiple ones.  On the right, there are 5 to 6.  She has small abrasions throughout and marked ecchymosed.  She is complaining of like chest wall pain, mainly when she moves over or takes a deep breath, like somebody just putting a knife through her.  Her back is sore at all times and the brace seems to be making her chest pain worse.

ENT EXAM:  Her pupils are equal, round, and reactive to light.  She is talking but they said she has been a little groggy, but we gave her some Demerol and Phenergan when she got here from the ambulance ride because she was in intense pain.

CHEST:  She has bilateral breath sounds, slightly diminished in the bases, but I do not hear any wheezes.

CARDIAC:  Her cardiac examination is regular.

ABDOMEN:  Soft.  She has positive bowel sounds.

EXTREMITIES:  She has multiple contusions, raised, but really there is no edema.  She has TED hose in place.

RECTAL:  Did not do at this time.

GYNECOLOGIC:  Did not do at this time.

LABORATORY DATA

She had a CMP, which showed slightly low potassium of 3.5, albumin a little bit low at 3.  Her H and H was 10.8 and 33.1.  I am sure this is secondary to blood loss from her scalp lesion because evidently she had a lot of bleeding and she still has some dried blood.

ADMISSION DIAGNOSES

1.            Motor vehicle accident with multiple trauma patients.  She evidently has known thoracic fractures, possible cervical fractures.  This is going to be reexamined today because the neurosurgeon stated it was ruled out in Dothan, but we will need C-spine films.

2.            Hypoxia.  Hopefully, all related to atelectasis.  We will repeat a chest x-ray.

3.            Hypertension has been stable.

4.            History of reflux and gastro esophageal reflux disease, but have been well controlled since the Nissen.  She has actually been off everything.  We are going to put her back on her Protonix while she is in this situation, resume her LexiROM.  Also we are going to put her on Lovenox 30 milligrams b.i.d.  We will replace her potassium.  We have consulted _______ for spine surgery.

NOTE

Preop is for cataract surgery, going to be performed by ___________.  His surgery is scheduled for January 17, 2008.