Essential (primary) hypertension Unspecified fracture of sternum initial encounter for closed fracture Fall on same level from slipping tripping and stumbling with subsequent striking against other object initial encounter Sidewalk as the place of occurrence of the external cause Cardiomegaly Supraventricular tachycardia
 
Name:  ___              Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
Chief Complaint:
Hypertension 
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ with hx of HTN (prescribed unknown medication in ___ and 
recently ran out) who was sent in to the ED for hypertension 
found to have sternal fracture. Patient established care at ___ 
today and was noted to be significantly hypertensive to 190s 
systolic. While the patient did not have any overt symptoms, she 
was sent to the ED for evaluation of hypertensive 
urgency/emergency and initiation of antihypertensives. She 
reports that he was taking a medication for his hypertension but 
ran out 4 days ago.  

On arrival to the ED, initial vitals notable for afebrile, HR 
120, BP 175/106, RR 16, 98% RA. Labs notable for Chem 7 with 
mild hypernatremia to 148, normal CBC, bland UA without 
proteinuria, negative troponin. EKG sinus tach with LVF and no 
evidence of ischemia. CXR with concern for sternal fracture. CT 
chest then performed which confirmed minimally displaced lower 
sternal fracture and atelectasis. Trauma surgery consulted and 
patient reports fall/blunt trauma several days PTA (tripped 
walking over a curb and fell onto an elevated concrete structure 
with her chest. No head strike no LOC. First fall, denies prior 
history) however trauma service did not feel patient required 
admission for the fracture, but rec f/u in clinic in ___ weeks. 
Patient given 1gm tylenol 2.5mg oxycodone, amlodipine 5mg and 
IVF. Given the patient's labile BP and HR, she was admitted to 
medicine for pain control and further monitoring.  

Upon arrival to the floor, patient is resting in bed. She 
reports pain only with movement and deep inspiration. She also 
reports that her BP generally is in the 170s to 180s at 
baseline. No other acute complaints.  
 
Past Medical History:
Hypertension 
 
Social History:
___
Family History:
Sister has hypertension. No family history of heart attack, 
stroke, or cancer.
 
Physical Exam:
ADMISSION PHYSICAL EXAM

VITALS: 98.5; 190/110; 110; 20; 96RA; Pain ___  
 GENERAL: Pleasant, well-appearing, in no apparent distress.  
 HEENT - normocephalic, atraumatic, no conjunctival pallor or 
scleral icterus, PERRLA, EOMI, OP clear.  
 NECK: Supple  
 CARDIAC: tachycardic with occasional PVCs  
 PULMONARY: decreased breath sounds at bilateral bases ___ poor 
effort.  
 ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, 
no organomegaly.  
 EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or 
edema.  
 SKIN: Without rash.  
 NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, 
with strength ___ throughout.  

DISCHARGE PHYSICAL EXAM 

Vitals:  98.5 | 158/99 | 18 | 96% on RA
 General: lying in bed, pleasant, alert, oriented, no acute 
distress  
 HEENT: sclera anicteric, moist mucous membranes, oropharynx 
clear    
 Lungs: clear to auscultation bilaterally, no wheezes, rales, 
ronchi  
 CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, 
gallops  
 Abdomen: soft, non-tender, non-distended, bowel sounds present
 Ext: warm, well perfused, no evidence of edema  
 Neuro: CNs2-12 intact, motor function normal  
 
Pertinent Results:
COMPLETE BLOOD COUNT
=====================

___ 05:24AM BLOOD WBC-6.4 RBC-4.05 Hgb-11.5 Hct-36.2 MCV-89 
MCH-28.4 MCHC-31.8* RDW-13.7 RDWSD-45.1 Plt ___
___ 04:20PM BLOOD WBC-7.3 RBC-4.66 Hgb-13.1 Hct-41.3 MCV-89 
MCH-28.1 MCHC-31.7* RDW-13.8 RDWSD-44.4 Plt ___
___ 04:20PM BLOOD Neuts-53.9 ___ Monos-6.1 Eos-1.4 
Baso-0.4 Im ___ AbsNeut-3.96 AbsLymp-2.78 AbsMono-0.45 
AbsEos-0.10 AbsBaso-0.03

CHEMISTRIES
===========

___ 05:24AM BLOOD Glucose-113* UreaN-18 Creat-1.0 Na-142 
K-4.0 Cl-104 HCO3-28 AnGap-14
___ 04:20PM BLOOD Glucose-103* UreaN-18 Creat-1.0 Na-148* 
K-3.9 Cl-103 HCO3-30 AnGap-19
___ 05:24AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.8

URINE STUDIES
============

___ 04:00PM URINE Color-Straw Appear-Clear Sp ___
___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG 
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG

TROPONIN
========

___ 04:20PM BLOOD cTropnT-<0.01

IMAGING
=======

___ ImagingCHEST (PA & LAT)
1. Minimal cortical step-off involving the lower sternum is 
suspicious for a
minimally displaced sternal fracture.
2. Bibasilar atelectasis.

___HEST W/O CONTRAST
1.  Minimally displaced lower sternal fracture with adjacent 
small hematoma. 
No other fractures identified.
2.  Bibasilar atelectasis.
 
 
Brief Hospital Course:
___ ___ female with history of chronic hypertension who 
presents to the hospital after being found to be hypertensive to 
the 190s and found to have sternal fracture.

#Hypertension
At presentation patient had BP 175/106 and asymptomatic. She 
reports taking an unknown medication for hypertension 
(prescribed by provider in ___ and having been off the 
medication for the past 4 days because she ran out of it. 
Patient denied any vision changes, headaches, shortness of 
breath, or palpitations while interviewed in ___. 
Initial workup showed no evidence of proteinuria on UA or 
cardiac ischemia on ECG. Radiograph was notable for sternal 
fracture which was confirmed on CT (see below). Patient is 
thought to have elevation of baseline chronic hypertension which 
was triggered by pain from sternal fracture and being off 
medication.

#Sternal Fracture
Patient experienced mechanical fall without evidence of loss of 
consciousness or head strike on ___. Patient found to have 
some sternal tenderness on exam. Fracture is depressed but 
stable on palpation. CXR revealed minimal cortical step-off 
involving the lower sternum is suspicious for a minimally 
displaced sternal fracture and atelectasis. CT confirmed these 
results. Acute Care Surgery evaluated patient in the ED and 
recommended ambulatory follow up in ___ weeks. Patient was 
started on tramadol and acetaminophen for pain management. 

TRANSITIONAL ISSUES
#Hypertension: Given 1-month supply of amlodipine, please 
titrate as appropriate
#Concern for Osteopenia/Osteoporosis:
Recommend getting outpatient DEXA scan as an outpatient. 
Patient started on Vitamin 1000U daily and Calcium Carbonate 
1000mg daily given concern for osteoporosis/osteopenia. 
#ACS follow-up: Voice mail to arrange appointment with ACS for 
follow-up left at ___, please ensure that appointment 
is made. 
#Pain management: Discharged with prescription for 10-day course 
of tramadol 50mg q6h:prn
 
Medications on Admission:
Unknown antihypertensive prescribed in ___ 
 
Discharge Medications:
1. amLODIPine 10 mg PO DAILY 
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30 
Tablet Refills:*0
2. Calcium Carbonate 1000 mg PO DAILY osteoporosis  
RX *calcium carbonate 500 mg calcium (1,250 mg) 2 tablet(s) by 
mouth once a day Disp #*60 Tablet Refills:*0
3. traMADol-acetaminophen 37.5-325 mg oral Q6H:PRN Duration: 10 
Days 
RX *tramadol-acetaminophen 37.5 mg-325 mg 1 tablet(s) by mouth 
every six (6) hours Disp #*40 Tablet Refills:*0
4. Vitamin D ___ UNIT PO DAILY osteoporosis 
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth 
once a day Disp #*30 Tablet Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Chronic Hypertension
- Sternal Fracture

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

 
Discharge Instructions:
Dear Ms. ___,

You came to the hospital after being seen at ___ 
___ on ___ with an elevated blood pressure. In the 
Emergency Department you where evaluated and also were found to 
have experienced a fall on ___ causing you to experience 
increased pain. Imaging showed that you have a sternal fracture. 
It is likely that your blood pressure was elevated in the 
setting of not taking your medication and stress caused by pain. 
We started you on amlodipine for your blood pressure and 
tramadol and Tylenol for your pain. It is likely that you have 
some bone mineral deficiency so we are also recommending that 
you take Vitamin D and Calcium at home. Acute Care Surgery (ACS) 
evaluated you while you were in the Emergency Department and 
recommend that you follow up in ___ clinic in ___ weeks. Please 
also follow up with your primary care physician.
It was a pleasure taking care of you. We wish you well.

Sincerely,
Your ___ Care Team 
 
Followup Instructions:
___

{'Hypertension': ['Essential (primary) hypertension'], 'Sternal Fracture': ['Unspecified fracture of sternum', 'initial encounter for closed fracture'], 'Fall': ['Fall on same level from slipping', 'tripping and stumbling with subsequent striking against other object', 'initial encounter', 'Sidewalk as the place of occurrence of the external cause'], 'Cardiomegaly': ['Cardiomegaly'], 'Supraventricular tachycardia': ['Supraventricular tachycardia']}