Closed fracture of seven ribs Traumatic pneumothorax without mention of open wound into thorax Accidental fall on or from other stairs or steps Home accidents Alcohol abuse unspecified Unspecified essential hypertension
 
Name:  ___             Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: SURGERY
 
Allergies: 
Cephalosporins / Sulfa (Sulfonamide Antibiotics) / penicillin G 
/ ampicillin / codeine / erythromycin base / tetracycline
 
Attending: ___.
 
Chief Complaint:
s/p fall
 
Major Surgical or Invasive Procedure:
___: Left chest needle decompression and Left pigtail catheter 
placement 

 
History of Present Illness:
___ unwitnessed fall down ___ steps while intoxicated.
Was seen at ___ ED, had Ct chest that showed multiple
left sided rib fractures involving ___, 10th ribs and as
well as left PTX without evidenc eof tension. patient also had
normal Ct head and c spine as well. The patient was subsequently
transferred here for further management. on arrival to Ed,
patient became hypoxic to 75% while on 15L NRB, had left sided
needle decompression with, per Ed report, a rush of air. A
pigtail catheter was also placed at that time. Patient was
subsequently admitted to the Tsicu.
 
Past Medical History:
Past Medical History:  
- EtOH abuse
- HTN
- psych history

Past Surgical History:  
- TAH
- c-section
- laparoscopy
- tonsillectomy
- vein stripping 
 
Social History:
___
Family History:
noncontributory
 
Physical Exam:
FOCUSED PHYSICAL EXAMINATION:  
VITALS: T , HR 95, BP 127/58, RR 20, 96% O2sat 5L 
GENERAL: NAD
HEENT:  nonicteric, wnl
HEART:  RRR
LUNGS:  decreased breath sounds, left pigtail catheter
BACK:  no rashes, no scars
ABD:  soft, non-tender 
MSK/EXT:  no edema
 
Pertinent Results:
___ 04:30AM BLOOD WBC-7.9 RBC-3.47* Hgb-11.6* Hct-34.2* 
MCV-99* MCH-33.3* MCHC-33.8 RDW-14.1 Plt ___
___ 06:54AM BLOOD WBC-9.2 RBC-3.92* Hgb-12.6 Hct-38.1 
MCV-97 MCH-32.1* MCHC-33.0 RDW-14.4 Plt Ct-UNABLE TO 
___ 08:00PM BLOOD WBC-16.7* RBC-4.25 Hgb-13.9 Hct-41.2 
MCV-97 MCH-32.7* MCHC-33.6 RDW-14.3 Plt ___
___ 08:00PM BLOOD ___ PTT-28.2 ___
___ 04:30AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-134 
K-4.2 Cl-99 HCO3-30 AnGap-9
___ 03:33AM BLOOD Glucose-116* UreaN-13 Creat-0.6 Na-134 
K-4.6 Cl-101 HCO3-22 AnGap-16
___ 08:14PM BLOOD Glucose-135* Lactate-3.8* Na-140 K-4.6 
Cl-102
___ 05:11AM BLOOD Lactate-1.6

Imaging:  
CT chest: Small left pneumothorax, and nonhemorrhagic pleural
effusion with adjacent atelectasis. Multiple left-sided rib, 
nondisplaced fractures involving the second through sixth ribs 
laterally

CT head: negative 

___ CXR: 
1.  No pneumothorax. 
2.  Interval increase in left-sided pleural effusion, which is 
now small to moderate size. 

 
Brief Hospital Course:
___ multitrauma, transfer from OSH status post fall down 14 
stairs, +ETOH. Injuries include left sided pneumothorax, left 
anterior ___ rib fractures and left posterior ___ fractures, 
who became hypoxic in the ED and is status post left chest 
needle decompression and pigtail placement. The patient was 
admitted to the TSICU for continuous oxygen saturation 
monitoring, pain control, CIWA, serial chest xrays, and close 
respiratory monitoring/pulmonary toilet. Acute Pain Service was 
consulted and an epidural was placed for pain management. 

ON HD1, the patient self-discontinued her chest tube. A 
post-pull cxr did not reveal any new or increasing pneumothorax. 
 On HD2, the epidural was removed and the patient was converted 
to oral pain medication. The patient was hemodynamically stable 
and transferred out of the TSICU to the floor. On HD3  Physical 
therapy evaluated the patient and felt she was safe to return 
home without any services. 

During this hospitalization, the patient ambulated early and 
frequently, was adherent with respiratory toilet and incentive 
spirometry, and actively 
participated in the plan of care. The patient received  
subcutaneous heparin and venodyne boots were used during this 
stay.

At the time of discharge, the patient was doing well, afebrile 
with stable vital signs. The patient was tolerating a regular 
diet, ambulating, voiding without assistance, and pain was well 
controlled.  The patient was discharged home without services. 
The patient received discharge teaching and follow-up 
instructions with understanding verbalized and agreement with 
the discharge plan. She had follow-up scheduled in the ___ 
clinic.
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO QID 

 
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H pain  
2. Gabapentin 800 mg PO QID 
3. OxycoDONE (Immediate Release)  ___ mg PO Q3H:PRN Pain 
4. Docusate Sodium 100 mg PO BID 
5. Ibuprofen 800 mg PO Q8H pain  
RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight (8) hours 
Disp #*50 Tablet Refills:*0
6. Lidocaine 5% Patch 1 PTCH TD QAM left rib site 
RX *lidocaine-menthol [LidoPatch] 4 %-1 % 1 PTCH Qam Disp #*15 
Patch Refills:*0
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain  
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q3h 
Disp #*50 Tablet Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
1. Left anterior ___ rib fractures  
2. Left post ___ rib fractures 
3. Left pneumothorax

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

 
Discharge Instructions:
You were admitted to ___ after sustaining injuries from a 
fall. You you fractured your fractured multiple ribs on the left 
side and injured your lung, requiring a chest tube be placed. 
You were admitted for pain control, close respiratory 
monitoring, and chest tube management. The chest tube has been 
removed and your pain is under control with oral analgesia. Your 
vital signs are stable, and you are medically cleared for 
discharge home to continue your recovery. Please note the 
following discharge instructions: 

* Your injury caused rib fractures which can cause severe pain 
and subsequently cause you to take shallow breaths because of 
the pain.
 
* You should take your pain medication as directed to stay ahead 
of the pain otherwise you won't be able to take deep breaths. If 
the pain medication is too sedating take half the dose and 
notify your physician.
 
* Pneumonia is a complication of rib fractures.  In order to 
decrease your risk you must use your incentive spirometer 4 
times every hour while awake.  This will help expand the small 
airways in your lungs and assist in coughing up secretions that 
pool in the lungs.
 
* You will be more comfortable if you use a cough pillow to hold 
against your chest and guard your rib cage while coughing and 
deep breathing.
 
* Symptomatic relief with ice packs or heating pads for short 
periods may ease the pain.
 
* Narcotic pain medication can cause constipation therefore you 
should take a stool softener twice daily (e.g Colace and/or 
Senna) and increase your fluid and fiber intake if possible. If 
you do not have a bowel movement in the next couple of days, you 
can take a laxative such as Milk of Magnesia or Miralax as 
needed. 
 
* Do NOT smoke
 
* If your doctor allows, non-steroidal ___ drugs 
are very effective in controlling pain ( ie, Ibuprofen, Motrin, 
Advil, Aleve, Naprosyn) but they have their own set of side 
effects so make sure your doctor approves.
 
* Return to the Emergency Room right away for any acute 
shortness of breath, increased pain or crackling sensation 
around your ribs (crepitus).

It was a pleasure taking care of you
Your ___ team 

 
Followup Instructions:
___

{'Fall': ['Accidental fall on or from other stairs or steps'], 'Rib fractures': ['Closed fracture of seven ribs'], 'Pneumothorax': ['Traumatic pneumothorax without mention of open wound into thorax']}