Closed fracture of nasal bones Subendocardial infarction initial episode of care Acute kidney failure unspecified Thrombocytopenia unspecified Syncope and collapse Epistaxis Coronary atherosclerosis of native coronary artery Leukocytosis unspecified Hypoxemia Other and unspecified hyperlipidemia Pure hypercholesterolemia Old myocardial infarction Unspecified essential hypertension Aortic valve disorders Fall from other slipping tripping or stumbling Accidents occurring in unspecified place Peripheral vascular disease unspecified Long-term (current) use of antiplatelet/antithrombotic Personal history of tobacco use
 
Name:  ___               Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
Chief Complaint:
Epistaxis
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
Mr. ___ is an ___ with history of AAA s/p repair 
complicated by MI, hypertension, and hyperlipidemia who presents 
upon transfer from outside hospital with nasal fractures and 
epistaxis secondary to fall. The patient reports that he was at 
the ___ earlier this afternoon. While coughing, he tripped 
on the curb and suffered trauma to his face. He had no loss of 
consciousness. However, he had a persistent nosebleed and 
appeared to have some trauma to his face, thus was transferred 
to ___ for further care. There, a CT scan of 
the head, neck, and face were remarkable for a nasal bone and 
septal fracture. Given persistent epistaxis, bilateral 
RhinoRockets were placed. He had a small abrasion to the bridge 
of his nose which was not closed. Bleeding was well controlled. 
While in the OSH ED, he had an episode of nausea and coughed up 
some blood. At that time, he began to feel lightheaded and was 
noted to be hypotensive and bradycardic. Per report, he had a 
brief loss of consciousness, though quickly returned to his 
baseline. His family noted that his eyes rolled back into his 
head. The patient recalls the event and denies post-event 
confusion. He had no further episodes of syncope or hemodynamic 
changes.  Given the syncopal event and epistaxis, the patient 
was transferred for further care.

In the ED, initial vital signs 98.9 92 140/77 18 100%/RA. Labs 
were notable for WBC 11.3 (91%N), H/H 14.1/40.2, plt 147, BUN/Cr 
36/1.5. HCTs were repeated which were stable. A urinalysis was 
negative. A CXR demonstrated a focal consolidation at the left 
lung base, possibly representing aspiration or developing 
pneumonia. The patient was given Tdap, amoxicillin-clavulanate 
for antibiotic prophylaxis, ondansetron, 500cc NS, and 
metoprolol tartrate 50mg. Clopidogrel was held.
 
Past Medical History:
MI after AAA repair when he was ___ y/o
HTN
Hypercholesterolemia
 
Social History:
___
Family History:
Patient is unaware of a family history of bleeding diathesis.

 
Physical Exam:
ADMISSION:
VS: 98.5 142/65 95 18 98RA
GENERAL: Alert, oriented, no acute distress  
HEENT: Sclerae anicteric, MMM, oropharynx clear, bruising under 
both eyes, swollen nose with mild tenderness, RhinoRockets in 
place  
NECK: Supple, without LAD  
RESP: Generally CTA bilaterally  
CV: RRR, (+)S1/S2 no m/r/g  
ABD: Soft, non-tender, non-distended
GU: Deferred 
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
NEURO: CN II-XII grossly intact, motor function grossly normal
SKIN: No excoriations or rash.

DISCHARGE:
VS: 98.4 125/55 73 18 94RA
GENERAL: Alert, oriented, no acute distress  
HEENT: Sclerae anicteric, MMM, oropharynx clear, bruising under 
both eyes, swollen nose with mild tenderness, RhinoRockets in 
place  
NECK: Supple, without LAD  
RESP: Generally CTA bilaterally  
CV: RRR, (+)S1/S2 no m/r/g  
ABD: Soft, non-tender, non-distended
GU: Deferred 
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
NEURO: CN II-XII grossly intact, motor function grossly normal
SKIN: No excoriations or rash.
 
Pertinent Results:
ADMISSION:
___ 08:15PM BLOOD WBC-11.3* RBC-4.30* Hgb-14.1 Hct-40.2 
MCV-93 MCH-32.8* MCHC-35.1* RDW-12.8 Plt ___
___ 08:15PM BLOOD Neuts-91.1* Lymphs-4.7* Monos-3.8 Eos-0.3 
Baso-0.1
___ 08:15PM BLOOD ___ PTT-26.8 ___
___ 08:15PM BLOOD Glucose-159* UreaN-36* Creat-1.5* Na-141 
K-4.1 Cl-106 HCO3-21* AnGap-18
___ 06:03AM BLOOD CK(CPK)-594*

CARDIAC MARKER TREND:
___ 07:45AM BLOOD cTropnT-0.04*
___ 06:03AM BLOOD CK-MB-36* MB Indx-6.1* cTropnT-0.57*
___ 03:03PM BLOOD CK-MB-23* MB Indx-4.2 cTropnT-0.89*
___ 05:59AM BLOOD CK-MB-8 cTropnT-1.28*
___ 01:16PM BLOOD CK-MB-5 cTropnT-1.29*
___ 06:10AM BLOOD CK-MB-4 cTropnT-1.48*
___ 07:28AM BLOOD CK-MB-2 cTropnT-1.50*

DISCHARGE LABS:
___ 07:28AM BLOOD WBC-4.2 RBC-3.85* Hgb-12.5* Hct-36.0* 
MCV-94 MCH-32.5* MCHC-34.7 RDW-12.9 Plt ___
___ 07:28AM BLOOD Glucose-104* UreaN-30* Creat-1.6* Na-142 
K-4.3 Cl-106 HCO3-26 AnGap-14

IMAGING:
___ CXR
PA and lateral views of the chest provided. The lungs are 
adequately 
aerated. There is a focal consolidation at the left lung base 
adjacent to the lateral hemidiaphragm. There is mild vascular 
engorgement. There is bilateral apical pleural thickening. The 
cardiomediastinal silhouette is remarkable for aortic arch 
calcifications. The heart is top normal in size. 

___ ECHO
The left atrium is mildly dilated. Left ventricular wall 
thicknesses and cavity size are normal. There is mild regional 
left ventricular systolic dysfunction with focal apical 
hypokinesis. The remaining segments contract normally (LVEF = 55 
%). No masses or thrombi are seen in the left ventricle. Right 
ventricular chamber size and free wall motion are normal. There 
are three aortic valve leaflets. There is mild aortic valve 
stenosis (valve area 1.7cm2). Mild (1+) aortic regurgitation is 
seen. The mitral valve leaflets are mildly thickened. Trivial 
mitral regurgitation is seen. The pulmonary artery systolic 
pressure could not be determined. There is a trivial/physiologic 
pericardial effusion. 

IMPRESSION: Normal left ventricular cavity size with mild 
regional systolic dysfunction most c/w CAD (distal LAD 
distribution). Mild aortic valve stenosis. Mild aortic 
regurgitation. 
 
Brief Hospital Course:
Mr. ___ is an ___ with history of AAA s/p repair 
complicated by MI, hypertension, and hyperlipidemia who 
presented with nasal fractures and epistaxis after mechanical 
fall with hospital course complicated by NSTEMI.

#Epistaxis, nasal fractures
Patient presenting after mechanical fall with Rhinorockets 
placed at outside hospital for ongoing epistaxis. CT scan from 
that hospital demonstrated nasal bone and septal fractures. The 
Rhinorockets were maintained while inpatient and discontinued 
prior to discharge. He was encouraged to use oxymetolazone nasal 
spray and hold pressure should bleeding reoccur. 

#NSTEMI
Patient found to have mild elevation of troponin in the ED. This 
was trended and eventually rose to 1.5, though MB component 
downtrended during course of admission. The patient was without 
chest pain or other cardiac symptoms. Cardiology was consulted 
who thought that this was most likely secondary to demand 
ischemia (type II MI) secondary to his fall. An echocardiogram 
demonstrated aortic stenosis and likely distal LAD disease based 
on wall motion abnormalities. The patient's metoprolol was 
uptitrated, his pravastatin was converted to atorvastatin, his 
clopidogrel was maintained, and he was started on aspirin.

#Hypoxemia/L basilar consolidation
Patient reported to be mildly hypoxic in the ED, though he 
maintained normal oxygen saturations on room air. He denied 
shortness of breath or cough, fevers, or other infectious 
symptoms and had no leukocytosis. A CXR revealed consolidation 
in left lung, thought to be possibly related to aspirated blood. 
-monitor O2 saturation, temperature, trend WBC. He was convered 
with antibiotics while inpatient as he required prophylaxis for 
the Rhinorockets, but this was discontinued upon discharge.

#Acute kidney injury
Patient presented with creatinine of 1.5 with last creatinine at 
PCP 1.8. Patient was unaware of a history of kidney disease. The 
patient was discharged with a stable creatinine.

#Peripheral vascular disease
Patient had a history of AAA repair in ___ without history of 
MI per PCP. Patient denied history of CABG or cardiac/peripheral 
stents. A cardiac regimen was continued, as above.

TRANSITIONAL ISSUES
-Outpatient stress echo for futher evaluation distal LAD disease 
(possibly a large myocardial territory at risk). 
-Repeat echocardiogram in ___ years to monitor mild AS/AR.
-If epistaxis returns, can use oxymetolazone nasal spray.
-Repeat chest x-ray in ___ weeks to ensure resolution of the LLL 
infiltrative process.
-Consider follow-up with ENT or Plastic Surgery for later 
evaluation of nasal fractures.
-Repeat CBC in one week to ensure stability of HCT and 
platelets.
-Consider conversion of metoprolol tartrate to succinate for 
ease-of-administration.
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY 
2. Metoprolol Tartrate 50 mg PO TID 
3. Pravastatin 80 mg PO QPM 

 
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY 
2. Acetaminophen 650 mg PO Q8H:PRN pain 
Please avoid NSAID medications like ibuprofen given your 
bleeding. 
3. Aspirin 81 mg PO DAILY Duration: 30 Days 
4. Metoprolol Tartrate 75 mg PO TID 
RX *metoprolol tartrate 25 mg 3 tablet(s) by mouth three times 
daily Disp #*270 Tablet Refills:*0
5. Atorvastatin 40 mg PO QPM 
RX *atorvastatin 40 mg 1 tablet(s) by mouth every evening Disp 
#*30 Tablet Refills:*0
6. Oxymetazoline 1 SPRY NU BID:PRN nosebleed 
This can be purchased over-the-counter, the brand name is ___. 


 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Nasal fracture
Epistaxis
NSTEMI

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

 
Discharge Instructions:
Mr. ___,
You were admitted after you fell and broke your nose. You had 
nose bleeds that were difficult to control, thus plugs were 
placed in your nose to stop the bleeding. During your hospital 
course, you were found to have high troponins, a blood test for 
the heart. A ultrasound of your heart was performed. You should 
follow-up with your PCP to discuss stress test.

It was a pleasure participating in your care, thank you for 
choosing ___.
 
Followup Instructions:
___

{'Epistaxis': ['Epistaxis'], 'NSTEMI': ['Subendocardial infarction', 'Coronary atherosclerosis of native coronary artery'], 'Hypoxemia/L basilar consolidation': ['Hypoxemia'], 'Acute kidney injury': ['Acute kidney failure'], 'Peripheral vascular disease': ['Peripheral vascular disease']}