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A 49-year-old man was struck by a van that was turning a street corner. He had a transient loss of consciousness.

In the trauma resuscitation area, the patient was awake and alert, but would repeatedly ask what had happened despite being told this information on several occasions. He complained of left hip and left-sided chest pain.

His vital signs were: blood pressure 110/70 mmHg, pulse 110 beats/min, respiratory rate 28 breaths/min, SO2 100% on 10 L/min O2. His physical examination was remarkable for contusions to the left side of his face and head, palpable tenderness and crepitus over the left lateral chest wall with diminished breath sounds on the left, and tenderness, swelling, and inability to move the left hip due to pain.

A chest tube was inserted on the left without return of blood or air. One liter of normal saline and 8 mg morphine sulfate were administered intravenously. Repeat vital signs were as follows: blood pressure 120/88 mm/Hg, pulse 88 beats/min, respirations 18 breaths/min.

Radiographs of the cervical spine, chest, and pelvis revealed a left chest tube, a left sixth rib fracture, and a left proximal femoral fracture. Bedside sonography was negative for intraperitoneal or pericardial blood.

The trauma service brought the patient to the radiology suite. A head CT revealed a small traumatic subarachnoid hemorrhage. An abdominal CT revealed a small splenic laceration and adjacent peritoneal blood without active arterial extravasation of contrast. Cervical spine CT was normal. An intertrochanteric femoral fracture was seen on left hip radiographs. Left hand and wrist radiographs revealed a fifth metacarpal shaft fracture.

The patient remained stable and was admitted to the surgical intensive care unit for monitoring and eventual repair of his orthopedic injuries.

His chest radiograph is shown in Figure 1.

  • Are any additional tests needed?

A 45-year-old man who was driving a small car struck a slow moving vehicle that had stopped short in front of him while he was going at approximately 30 miles per hour. He was wearing a seatbelt and his air bag deployed. The front end of his car was crushed inwards but there was no intrusion into the vehicle’s front passenger compartment.

There was no loss of consciousness. He complained of pain in the anterior chest, but had no shortness of breath.

His vital signs were as follows: blood pressure 120/70 mm/ Hg, pulse 84 beats/min, and respiratory rate 20 breaths/ min. On examination, his anterior chest wall was mildly tender, without crepitus. His breath sounds were normal. He had mild upper abdominal tenderness. There were superficial abrasions of his right eyebrow and nose.

The patient remained ...

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