Injury to other specified blood vessels of head and neck Acute posthemorrhagic anemia Unspecified essential hypertension Insomnia unspecified Acquired absence of intestine (large) (small) Personal history of malignant melanoma of skin Acquired absence of both cervix and uterus Orthostatic hypotension Hypovolemia Fall resulting in striking against other object Abdominal pain unspecified site
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___
 
Chief Complaint:
lightheadedness 
 
Major Surgical or Invasive Procedure:
packed red blood cell transfussion

 
History of Present Illness:
___ F with history of HTN, p/w Left temporal artery aneurysm 
developing after traumautic fall 3 weeks ago, that started 
bleeding while washing her face yesterday morning.  
.  
The patient reports that she was washing her face yesterday 
morning when the left temple started bleeding. ___ was 
evaluating her at the time, she called lifeline and was ___ 
to the ER via EMS. Per report, she lost apporaixmately 200-300 
cc lost in field and additonal ~200cc in ED with uncontrolled 
bleeding during transport. Estimated blood loss is about 1 
liter.  
.  
In the ER, the artery was ligated with sutures at bedside by 
surgery. She was intially admitted to observation in the ER to 
moniter her Hct. On admission Hct was 37.2 and now has 
stabilized at around 29. She was not transfused, but SBPs 
dropped transiently to ___. She was given more fluids (500cc) 
and on re-evaluation vitals normalized but Pt continued to be 
symptomatic, stating she feels lightheaded with standing. She 
also developed abdominal pain and subsequntly had an 
Abdominal-CT which was negative. She was also orthostatic in the 
ER.  
She was given total approx 2000ml of NS in the ER.  
.  
On the floor the patient is lying comfortably in bed stating her 
only complaint is feeling lightheaded with standing. While in 
the room she was able to get up and go to the bathroom but felt 
very lightheaded. She also states that her abdominal pain/cramps 
is longstanding(years) and is unchanged from baseline. She 
denies any fever/chills, N/V, changes in bowel or bladder 
habits, recent weight loss or gain, SOB, chest discomfort, or 
headaches.  
.  
Review of sytems:  
(+) Per HPI  
(-) Denies fever, chills, night sweats, recent weight loss or 
gain. Denies headache, sinus tenderness, rhinorrhea or 
congestion. Denied cough, shortness of breath. Denied chest pain 
or tightness, palpitations. Denied nausea, vomiting, diarrhea, 
constipation or abdominal pain. No recent change in bowel or 
bladder habits. No dysuria. Denied arthralgias or myalgias.  

 
Past Medical History:
HTN
Colonic Volvulus with Colon resection
Hysterectomy
Incarcerated inguinal hernia with repair and small bowel 
resection
Insomnia
Melanoma

 
Social History:
___
Family History:
Noncontributory
 
Physical Exam:
 
Vitals: T: 98.7 BP 128/84 P: 106 R: 16 O2: 96%RA  
Orthostatics: Laying flat: 162/74 HR 80, sitting 160/80 HR 80, 
Standing 145/80 HR 88.  
General: Alert, oriented, no acute distress  
HEENT: Sclera anicteric, MMM, oropharynx clear. Left temple with 
with crusted blood, and sutures in place.  
Neck: supple, JVP not elevated, no LAD  
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, 
no rebound tenderness or guarding, no organomegaly  
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
Skin: no rashes, but multiple ecchaymoses. pt. states she 
___ for the past several years. denies abuse. left 
knee wound -- dressed.  
Neuro: Alert and oriented x 3.  
Motor: grossly intact  
Sensation: grossly intact  
DTR: intact  
___: unremarkable  
Gait: unsteady  

 
Pertinent Results:
CBC/HCT.
ON ADMISSION:
___ 12:50PM BLOOD WBC-11.8* RBC-3.80* Hgb-12.2 Hct-37.2 
MCV-98 MCH-32.2* MCHC-32.9 RDW-13.1 Plt ___
___ 08:45PM BLOOD WBC-11.0 RBC-3.32* Hgb-10.3* Hct-31.5* 
MCV-95 MCH-31.0 MCHC-32.6 RDW-13.0 Plt ___
___ 05:50AM BLOOD Hct-29.1*
___ 10:50AM BLOOD WBC-8.0 RBC-3.04* Hgb-9.5* Hct-29.2* 
MCV-96 MCH-31.2 MCHC-32.6 RDW-13.1 Plt ___
___ 07:25AM BLOOD WBC-7.2 RBC-3.05* Hgb-9.7* Hct-29.8* 
MCV-98 MCH-31.7 MCHC-32.4 RDW-13.4 Plt ___
ON DISCHARGE:
___ 06:35AM BLOOD WBC-9.6 RBC-3.47* Hgb-10.9* Hct-32.6* 
MCV-94 MCH-31.3 MCHC-33.4 RDW-15.1 Plt ___
.
ELECTROLYTES.
___ 10:50AM BLOOD Glucose-113* UreaN-19 Creat-0.8 Na-139 
K-4.3 Cl-103 HCO3-29 AnGap-11
___ 07:25AM BLOOD Glucose-85 UreaN-11 Creat-0.5 Na-138 
K-3.8 Cl-103 HCO3-27 AnGap-12
___ 06:35AM BLOOD Glucose-82 UreaN-11 Creat-0.5 Na-140 
K-3.9 Cl-103 HCO3-29 AnGap-12
.
LFTs
___ 10:50AM BLOOD ALT-13 AST-23 LD(LDH)-148 AlkPhos-53 
TotBili-0.2
.
URINE ANALYSIS.
___ 01:30PM URINE ___ Bacteri-NONE Yeast-NONE 
___ 01:30PM URINE Blood-TR Nitrite-NEG Protein-TR 
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:30PM URINE Color-Yellow Appear-Clear Sp ___
.
.
RADIOLOGY.
CHEST (PORTABLE AP) Study Date of ___ 10:02 AM : Mild loss 
of volume in the right lung reflected in rightward mediastinal 
shift is unchanged. There is no discrete atelectasis. Lungs are 
clear and there is no pleural effusion. Heart size normal. 
Pulmonary vasculature unremarkable. 
.
CT ABDOMEN/PELVIS W/CONTRAST Study Date of ___ 11:58 AM 
1. No evidence of diverticulitis or other acute abdominal 
process.  
2. New tiny pulmonary nodule at the right lung base. These could 
potentially be infectious/inflammatory in etiology. Correlation 
should be made with past medical history of malignancy. If none 
is known, a chest CT in one year may be warranted to document 
stability. 

 
Brief Hospital Course:
This is a ___ with history of HTN who p/w Left temporal artery 
aneurysm c/b rupture with approximately 1L of blood loss s/p 
ligation with here with orthostatic hypotension.  

# Temporal Artery Bleed: Left temporal aneurysmal 
bleed(approximately 500 ml-1 liter) at home after washing her 
face presenting to the ED with stable vitals initially and HCT 
of 37.2 and complaints of lightheaded. Trauma Surgery was 
consulted in the ER and ligated her left temporal artery. The 
temporal artery was stable while admitted to the floor. She will 
follow up with Dr. ___ surgery) as an outpatient. Her 
sutures were placed ___ and should be removed in about ___ 
days. She has an appt scheduled with her primary care doctor, 
___ on ___. 

# Lightheadedness/Orthostasis: The first day on the floor she 
continued to have symptoms of lightheadedness and was positive 
for orthostatics (BP 160/74 laying down, 145/74 standing). She 
was given IVF. The following day she also had feelings of 
lightheadedness, borderline orthostatics and was transfused 1 
unit of packed red blood cells given no improvement in her 
symptoms and her advanced age. After the transfusion her Hct 
went from 29.8 to 32.6. with improvement in symptoms of 
lightheadness but still feelings of unsteadiness while walking. 
Physical therapy was consulted and felt she would benefit from 
Rehab. On day of discharge she no longer had symptoms of 
lightheadedness when standing from sitting and orthostatics were 
negative. 

# Abdominal Pain/Cramps: In the ED patient complained of cramps 
and subsequently had an Abdominal-CT which was negative, however 
she stated that this pain was due to her long standing cramps 
for years that are normally controlled with OTC pain 
medications. She did not have any abdominal pain and an 
unremarkable abdominal exam as well as normal LFTs throughout 
the hospitalization . 

 
Medications on Admission:
 
Escitalopram 10mg daily  
Atenolol 25mg daily  
Amlodipine 2.5mg daily  
Aspirin 81mg daily  
Calcium Carbonate 500mg twice a day  
Cholecalciferol 400unit twice a day  
lunesta PRN  
MVI  

 
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 
PO DAILY (Daily).  
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) 
Tablet, Chewable PO QID (4 times a day) as needed for advanced 
age.  
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) 
Tablet PO DAILY (Daily).  
5. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day.  
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.  

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
___ Diagnosis:
Acute blood loss from Temporal Artery bleed

secondary:
HTN

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

 
Discharge Instructions:
You were seen and treated at ___ for bleeding from your 
temporal artery which was stopped in the ED. After the bleeding 
was stopped you continued to have lightheadedness in the ED so 
you were transferred to the medicine floor for further 
evaluation. 
While on the medicne floor your red blood cell count was low but 
stable. This was also most likely due to your blood loss. Since 
you continued to have symptoms of lightheadness/dizziness and 
after 3 days and a low red blood cell count you were given one 
unit of red blood cells. On the day of discharge you were seen 
by physical therapy, who felt you were stable enough to go to 
rehab for further physical therapy before going home. 
You have been scheduled to see your primary care physciain for 
follow up on  .....

 
                             ___ MD ___
 
Completed by: ___

{'lightheadedness': ['Injury to other specified blood vessels of head and neck', 'Acute posthemorrhagic anemia', 'Unspecified essential hypertension'], 'orthostatic hypotension': ['Injury to other specified blood vessels of head and neck', 'Acute posthemorrhagic anemia', 'Unspecified essential hypertension'], 'abdominal pain': ['Injury to other specified blood vessels of head and neck', 'Acute posthemorrhagic anemia', 'Unspecified essential hypertension']}