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Demographic Information:
The patient is a 43-year-old Caucasian, English-speaking man with a postgraduate education.
Social History:
The patient is married with two teenage children. He recently moved to the state of Washington with the military and participates in social athletics, including baseball, basketball, and ice hockey.
Employment:
Patient is a member of the executive staff in a military medical group as a nurse practitioner and chief of nursing.
Living Environment:
Patient lives in a one-story private home with one 6-inch (15 cm) step to enter.
General Health Status:
Patient is an active, healthy individual.
Medical History:
Hypertension (controlled with lisinopril), bradycardia, basal cell carcinoma (removed without complication), kidney stone several years ago, hyperlipidemia (controlled with Zocor), allergic rhinitis (controlled with Singulair); no known drug allergies.
Current Condition/Chief Complaints:
On November 21, patient was driving a borrowed all-terrain vehicle (ATV) when he lost control. He was thrown from the vehicle and hit his head/helmet on a pipe in a gully. He felt immediate pain in his back. He reports that he had difficulty breathing owing to rib pain and immediately had no feeling in his legs (“I couldn’t feel or move my legs”). He was transported by helicopter to a hospital in Reno, Nevada. The patient also reported he was able to contract his quadriceps slightly until just before reaching the hospital. He was found to have:
L1 burst fracture
Left 1st through 10th rib fractures with left pulmonary contusion
Left hemopneumothorax requiring chest tube placement
Left T1 transverse process fracture
T2 to T7 spinous process fractures
T10 to T12 right posterior medial rib fractures
Left scapular body fracture
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On November 24, the patient underwent surgery for a T11–L3 laminectomy and posterior lateral fixation. He was immobilized in a custom thoracolumbosacral orthosis (TLSO), weight-bearing as tolerated (WBAT) on left upper extremity (UE).
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