Alcohol withdrawal Other convulsions Acute alcoholic intoxication in alcoholism continuous Closed fracture of nasal bones Unarmed fight or brawl Accidents occurring in unspecified place Esophageal reflux Tobacco use disorder
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Assault/EtOH withdrawal
 
Major Surgical or Invasive Procedure:
none
 
History of Present Illness:
 ___ with past medical history of ETOH withdrawal and seizure 
who presents after an assault early on AM of admission. In the 
ED, he reported that someone attempted to get money from him for 
marijuana at which point he was assualted. 

In the ED, initial VS were 98.0 105 153/77 20 98% RA.  Labs 
notable for clean UA (no bloodwork sent).  CT head showed small 
posterior subgaleal hematoma but no intracranial bleed. CT 
sinus/mandible showed communited fracture of nasal bone through 
nasal septum.  CT C-spine showed possible avulsion injury of 
superior endplate of C5, no compression Fx or retropulsion.  
C-spine flex-ex was normal; CT abdomen-pelvis showed no acute 
abdominal process.  Neurosurgery evaluated the patient and felt 
no evaluation was necessary.  The patient was initially 
comfortable but became tremulous, tachycardic, and c/o HA, 
suspicious for EtOH withdrawal.  Patient received 5 mg Diazepam 
CIWA Q2H; this was insufficient, so he was escalated to 20 mg 
Q1H for a brief period in the ED.  This controlled his 
withdrawal symptoms and he was noted to be drowsy but arousable 
thereafter.  He was switched to Q2H Diazepam and admitted.  He 
also received thiamine, folate, Ibuprofen, and Zofran.  VS on 
transfer were 85 113/76 19 97%.

On arrival to the floor, patient reports that he has a bad 
headache and feels shaky. His last drink was early this AM 
(before 6 AM). He drank particularly heavily overnight, 
reporting ___ beers and "lots" of whisky shots. He normally 
drinks one 6-pack of beers and several shots every day or every 
other day. 

 
Past Medical History:
ETOH ABUSE
ETOH WITHDRAWAL COMPLICATED BY SURGERY
GERD

 
Social History:
___
Family History:
Reports that all his family is deceased, denies significant 
medical history.
 
Physical Exam:
ADMISSION PHYSICAL EXAM:  
VS -  97.5 88 18 143/84 96 RA
General:  Mildly uncomfortable, but non-toxic appearing, 
well-nourished
HEENT:  Contusions over glabella, ecchymosis over left eyelid. 
PERRLA, EOMI. Oropharynx clear. Poor dentition
Neck:  Soft supple, full ROM. No TTP of cervical vertebrae
CV:  RRR. S1 and S2. No m/r/g
Lungs:  No increased WOB. CTAB
Abdomen:  + BS. Soft, non-distended. Mild TTP of RUQ. Negative 
___ sign. No peritoneal signs.
GU:  Deferred
Ext:  Warm, well-perfused without cyanosis, clubbing or edema
Neuro:  Cn2-12 grossly intact, AAOx3, moves all extremities to 
commands
Skin: Contusions as per HEENT

DISCHARGE PHYSICAL EXAM:
 
Pertinent Results:
ADMISSION LABS:

___ 01:55AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 
LEUK-NEG
___ 01:55AM URINE  COLOR-Straw APPEAR-Clear SP ___

PERTINENT LABS:

DISCHARGE LABS:

IMAGING:
___ NON-CON HEAD CT:IMPRESSION:  
Small posterior subgaleal hematoma. No fracture. Otherwise 
normal head CT. No intracranial hemorrhage. 

___ CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST IMPRESSION: 
Deformity of the nasal bone and anterior septum due to fracture 
of undetermined age.  No additional fracture. No soft tissue 
hematoma. 

___ CT C-SPINE W/O CONTRAST
IMPRESSION:   
Bony oaaicle near superior endplate of C5 indicating avulsion 
injury of 
undetermined age. No compression fracture. No retropulsion. 

___ C-SPINE FLEX AND EXT ONLY 2 VIEWS IMPRESSION:  
Preliminary Report1. 3 mm ossific fragment inferior to C4 
vertebral body, better assessed on CT 
Preliminary Report2 hr prior. 
Preliminary Report2. No abnormal vertebral movement on flexion 
and extension views. 
Preliminary Report3. For details on C7 and the dens please refer 
to CT cervical spine. 

___ CT ABD & PELVIS W/O CON 
IMPRESSION:  
1.  Hepatic steatosis. 
2.  No acute lower thoracic or lumbar vertebral fracture. 
3.  Largely distended, normal-appearing bladder. 
4. No acute intra-abdominal pathology. No free fluid. 

 
Brief Hospital Course:
___ with history of EtOH abuse, ETOH withdrawal with seizures 
who presents after an assault for management of EtOH withdrawal.

___- transferred to the ICU for persistent symptoms 
despite q2H diazepam on CIWA. He is almost 48hrs after last 
drink which is usual window to experience withdrawal, and given 
chronic use and hx he is at high risk for withdrawal seizure. 
Slurring words likely from benzo intoxication on floor. RR 12 as 
of ___.
-d/c CIWA, IV phenobarb protocol started
-Check phenobarb level

#EtOH Abuse: Patient with history of ETOH withdrawal and 
seizures. Patient spaced to Q2H diazepam in ED. Reports he 
started drinking after his mother died in ___, and expresses 
interest in quitting.
- Start 100 mg thiamine, 1 mg folic acid daily, multivitamin
- Social work consult

#trauma S/p assault: Imaging in ED revealed a subgaleal hematoma 
but no intracranial bleed, communited fracture of nasal bone 
through nasal septum, and possible avulsion injury of superior 
endplate of C5. was evaluated by neurosurgery who recommend no 
further intervention. ENT recommends outpatient follow up for 
nasal fracture Neurosurgery consulted, do not recommend further 
intervention. 
- Pain control with acetaminophen/ibuprofen
- Per ENT, can follow up as outpatient in clinic for nasal 
fracture ___
- Per neurosurgery, no need for followup or repeat imaging

#Isolated elevated PTT (59.1). INR 1.0. Unclear etiology - needs 
confirmation.
- Recheck labs
- If sustained consider putting on Pneumoboots prophylaxis

#RUQ tenderness: Most likely ___ trauma from altercation. CT 
abd/pelvis without acute pathology.  LFTs mildly elevated 
consistent with acute alcohol use.
-CTM, pain control per below

#GERD: continue home omeprazole

TRANSITIONAL ISSUE:
======================
- F/u ENT as outpatient
 
Medications on Admission:
OMEPRAZOLE 20 MG DAILY
 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Alcohol withdrawal
Broken nose (nasal spetum fracture)
Alcohol abuse

 
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Dear Mr ___,

You were admitted to the ICU for alcohol withdrawal. You were 
treated with medications to prevent like-threatening 
complications of alcohol withdrawal. We recommended you stay in 
the hospital longer for close monitoring and evaluation by 
social work for help with your alcohol abuse. You understood the 
risks of leaving the hospital at this time were severe, and 
included seizure, injury, and DEATH. You expressed an 
understanding in this, and decided to leave AGAINST MEDICAL 
ADVICE. Please return to the hospital if you experience seizures 
or other medical complications (SEE BELOW).
 
Followup Instructions:
___

{'Assault': ['Unarmed fight or brawl'], 'EtOH withdrawal': ['Alcohol withdrawal'], 'Seizures': ['Other convulsions'], 'Heavy drinking': ['Acute alcoholic intoxication in alcoholism', 'continuous'], 'Nasal fracture': ['Closed fracture of nasal bones'], 'Headache': [], 'Tremulous': [], 'Tachycardic': [], 'HA': [], 'Thiamine': [], 'Folate': [], 'Ibuprofen': [], 'Zofran': [], 'Diazepam': [], 'CT head': ['Small posterior subgaleal hematoma', 'No intracranial bleed'], 'CT sinus/mandible': ['Deformity of the nasal bone and anterior septum due to fracture of undetermined age'], 'CT C-spine': ['Bony oaaicle near superior endplate of C5 indicating avulsion injury of undetermined age'], 'CT abdomen-pelvis': ['Hepatic steatosis', 'No acute lower thoracic or lumbar vertebral fracture', 'Largely distended, normal-appearing bladder', 'No acute intra-abdominal pathology', 'No free fluid'], 'Neurosurgery': [], 'ENT': [], 'RUQ tenderness': [], 'Elevated PTT': [], 'INR': [], 'GERD': ['Esophageal reflux'], 'Tobacco use disorder': []}