History of Present Illness: The patient is a 21-year-old male admitted through the emergency department after a skiing accident at a local ski area. He was traveling at a moderate rate of speed when he lost control and went off the trail, striking his right flank and back on a tree. A friend who was skiing with him says that he fell hard onto a rock, struck the back of his head, and "passed out" for 1-2 minutes. In the emergency department he was awake and oriented with full memory of the incident, complaining of a headache and severe mid to low back pain. When seen by this examiner the morning following admission, he stated that his head was better but his back was still very painful. He was able to ambulate, though with increased back pain. He denied chest pain, neck pain, nausea, vomiting, or abdominal pain.

Physical Exam: HEAD: Normocephalic. There was a small contusion felt on the back of the scalp without evidence of laceration. HEENT exam was unremarkable. Funduscopic exam normal. TMs clear without blood or CSF. Oropharynx benign with intact dentition. NECK: Trachea midline. No cervical tenderness, full range of motion. HEART: Regular rate and rhythm. CHEST: Lung fields clear, no chest wall tenderness. Sternum stable and nontender. BACK: Diffuse tenderness over the lumbar spine with extension to the right flank, no ecchymosis or loss of skin integrity. ABDOMEN: Soft, flat, nondistended and nontender with positive bowel sounds, no appreciable mass or organomegaly. GU unremarkable. PELVIS stable. EXTREMITIES atraumatic. NEURO: Awake, alert and oriented, cranial nerves II-XII intact. No sensory or motor deficit.

Lab and Imaging Data: Initial hemoglobin was 46.7 with a hematocrit of 16.2. Repeat on the morning following admission remained relatively unchanged at 42.8 and 14.5 respectively. Urinalysis demonstrated 10-12 red blood cells and 0-3 white cells.

Head CT was normal. Chest x-ray demonstrated a normal cardiomediastinal silhouette with a posterior fracture of rib T11 and mild blunting of the costophrenic angle. Lumbar spine film revealed multiple stable fractures of the transverse processes of L1, L2, L3 and L4. Abdominal and pelvic CT scan showed contusion and hematoma of the right kidney with a small amount of fluid tracking around the kidney. There is symmetric perfusion and excretion bilaterally. No free fluid was seen within the pelvis.

Hospital Course: The patient was kept an additional day primarily for pain control and to monitor his neurologic and renal status. He was given an initial dose of morphine sulfate IV to manage his back pain. On the afternoon prior to discharge he was switched to p.o.Toradol and was able to sleep relatively well on this with pain reported as 2 out of 10. He was seen by physical therapy for progressive ambulation.

At the time of discharge his pain is greatly improved, he is neurologically, hemodynamically and urologically stable. He has been instructed to follow up at home with his orthopedic surgeon for a detailed physical therapy program. He has been given written information regarding concussion, spinous process fractures, and kidney injuries. He has a prescription for Toradol to be taken every 4-6 hours as needed for his pain.

Discharge Diagnosis: Multiple trauma status post ski accident: 1. Vertebral fractures L1-L4. 2. Renal contusion. 3. Rib fracture. 4. Probable mild concussion with witnessed brief loss of consciousness.