Maxillary fracture left side initial encounter for closed fracture Fracture of orbital floor left side initial encounter for closed fracture Unspecified viral hepatitis C without hepatic coma Conjunctival hemorrhage left eye Fracture of nasal bones initial encounter for closed fracture Zygomatic fracture left side initial encounter for closed fracture Chronic kidney disease unspecified Nicotine dependence cigarettes uncomplicated Unspecified place or not applicable Fall (on) (from) unspecified stairs and steps initial encounter Atherosclerotic heart disease of native coronary artery without angina pectoris Old myocardial infarction Gastro-esophageal reflux disease without esophagitis
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
Sulfa (Sulfonamide Antibiotics)
 
Attending: ___.
 
Chief Complaint:
Facial pain
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ y/o M transferred For trauma evaluation after a fall. Patient 
poorly fell down a flight of stairs. Had imaging which showed a 
facial fractures as well as a small cerebral contusion.
 
Here patient complains of pain to his head and neck. Denies 
other injuries.

 
Past Medical History:
PMHx: CAD, angina, MI, GERD, HCV, HL, migraines, OSA, atrophic L 
kidney  
PSHx: appendectomy, carpal tunnel release, spine surgery 
(cervical)  

 
Social History:
___
Family History:
Non-contributory
 
Physical Exam:
ADMISSION PHYSICAL EXAM:
Temp: 97.2 HR: 86 BP: 134/75 Resp: 18 O(2)Sat: 96 Normal
Constitutional:   Constitutional: Lying in bed, protecting
airway
Head / Eyes: NC, PERRL, EOMI, Left periorbital ecchymosis
ENT: OP WNL
Resp: CTAB
Cards: RRR.
Abd: S/NT/ND
Pelvis stable
Skin: no rash, warm and dry
Ext: No c/c/e
Neuro: speech fluent
Psych: normal mood

DISCHARGE PHYSICAL EXAM:
Gen: awake, alert, pleasant and interactive.
CV: rrr
PULM: Clear to auscultation bilaterally.
ABD: Soft, non-tender, non-distended. active bowel sounds
EXT: Warm and dry. 2+ ___ pulses.
 
Pertinent Results:
___ 03:22AM BLOOD WBC-5.6 RBC-4.32* Hgb-11.7* Hct-35.7* 
MCV-83 MCH-27.1 MCHC-32.8 RDW-14.3 RDWSD-42.6 Plt Ct-96*
___ 03:22AM BLOOD Glucose-103* UreaN-11 Creat-0.9 Na-139 
K-4.5 Cl-98 HCO3-30 AnGap-11
___ 01:30AM BLOOD ALT-26 AST-45* AlkPhos-102 TotBili-0.6
___ 03:22AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.8
___ 01:43AM BLOOD Lactate-1.3

 
Brief Hospital Course:
Mr. ___ is a ___ yo M who presented to emergency department 
after reportedly a fall down a flight of stairs sustaining left 
sided facial trauma. He was hemodynamically stable. CT head 
negative for acute intracranial process. Imaging reveals a small 
left zygomatic arch fracture, left orbital floor fracture, and 
lateral orbital wall fracture. The patient was seen and 
evaluated by plastic surgery who recommended non-operative 
management of his fractures. the patient was evaluated for 
ophthalmology for eye injury/muscle entrapment which there was 
none. He was admitted to the surgical floor for observation and 
pain control.

Pain medication were titrated with good effect. On HD4 he was 
discharged to home on sinus precautions, doing well, afebrile 
and hemodynamically stable. The patient was tolerating a diet, 
ambulating, voiding without assistance, and pain was well 
controlled. The patient received discharge teaching and 
follow-up instructions with understanding verbalized and 
agreement with the discharge plan.
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NIFEdipine (Extended Release) 30 mg PO DAILY 
2. Simvastatin 80 mg PO QPM 
3. Terazosin 2 mg PO QHS 
4. FLUoxetine 60 mg PO DAILY 
5. Sumatriptan Succinate 6 mg SC ONCE:PRN headache 
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 
7. Omeprazole 20 mg PO DAILY 
8. HYDROmorphone (Dilaudid) 4 mg PO TID pain 
9. Diazepam 10 mg PO QHS anxiety 
10. Gabapentin 300 mg PO TID 
11. Morphine SR (MS ___ 120 mg PO Q12H 

 
Discharge Medications:
1.  Acetaminophen 650 mg PO Q8H:PRN Pain - Mild 
do not exceed 4000 mg Tylenol/ 24 hours.   
2.  Docusate Sodium 100 mg PO BID  
3.  Ibuprofen 400 mg PO Q8H:PRN Pain - Mild 
  Reason for PRN duplicate override: Alternating agents for 
similar severity
Alternate with Tylenol.  
4.  Omeprazole 20 mg PO DAILY  
5.  Polyethylene Glycol 17 g PO DAILY:PRN constipation  
6.  Senna 8.6 mg PO BID:PRN constipation  
7.  HYDROmorphone (Dilaudid) 4 mg PO Q8H:PRN Pain - Severe  
8.  HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN BREAKTHROUGH PAIN 
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every 
four (4) hours Disp #*20 Tablet Refills:*0 
9.  Diazepam 10 mg PO QHS anxiety  
10.  FLUoxetine 60 mg PO DAILY  
11.  Gabapentin 300 mg PO TID  
12.  Morphine SR (MS ___ 120 mg PO Q12H  
13.  Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain  
14.  Simvastatin 80 mg PO QPM  
15.  Sumatriptan Succinate 6 mg SC ONCE:PRN headache  
16.  Terazosin 2 mg PO QHS  
17. HELD- NIFEdipine (Extended Release) 30 mg PO DAILY  This 
medication was held. Do not restart NIFEdipine (Extended 
Release) until instructed by primary care provider. 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Left comminuted Maxillary sinus fracture- both walls  
Small Left zygomatic arch fracture
Small Left orbital floor fracture  
Small lateral orbital wall fracture  

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

 
Discharge Instructions:
Dear Mr. ___, 

You were admitted to the Acute Care Trauma Surgery service on 
___ after a fall sustaining multiple facial injuries. You 
were seen by the plastic surgery team who evaluated your facial 
fractures and recommended non-operative management at this time 
and follow up in outpatient clinic to determine if further 
surgery is needed. Please continue to follow sinus precautions 
(no nose blowing, sneeze with your mouth open, no drinking 
through straws). You were evaluated by the ophthalmology team 
who determined there are no injuries to your eyes that require 
intervention at this time. Please follow up in clinic to 
re-evaluate your vision and assess for worsening symptoms. 

You are now doing better, tolerating a regular diet, and ready 
to be discharge to home to continue your recovery.

Please note the following discharge instructions:

Please call your doctor or nurse practitioner or return to the 
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or 
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your 
medications.
*You are getting dehydrated due to continued vomiting, diarrhea, 
or other reasons. Signs of dehydration include dry mouth, rapid 
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a 
bowel movement.
*You experience burning when you urinate, have blood in your 
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone 
within 24 hours. Call or return immediately if your pain is 
getting worse or changes location or moving to your chest or 
back.
*You have shaking chills, or fever greater than 101.5 degrees 
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern 
you.

Please resume all regular home medications, unless specifically 
advised not to take a particular medication. Also, please take 
any new medications as prescribed.

Please get plenty of rest, continue to ambulate several times 
per day, and drink adequate amounts of fluids. Avoid lifting 
weights greater than ___ lbs until you follow-up with your 
surgeon.

Avoid driving or operating heavy machinery while taking pain 
medications.

 
Followup Instructions:
___

{'Facial pain': ['Maxillary fracture', 'Fracture of orbital floor', 'Zygomatic fracture'], 'Fall down stairs': ['Fall (on) (from) unspecified stairs and steps'], 'Head and neck pain': ['Maxillary fracture', 'Fracture of orbital floor', 'Zygomatic fracture'], 'Cerebral contusion': ['Cerebral contusion']}