Closed fracture of four ribs Traumatic hemothorax without mention of open wound into thorax Acute posthemorrhagic anemia Bipolar I disorder most recent episode (or current) depressed unspecified Accidental fall from bed Personal history of malignant neoplasm of breast Sciatica Disorder of bone and cartilage unspecified Mitral valve disorders Unspecified acquired hypothyroidism Irritable bowel syndrome Unspecified hearing loss
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: SURGERY
 
Allergies: 
Penicillins
 
Attending: ___.
 
Chief Complaint:
s/p Fall, rib fractures
 
Major Surgical or Invasive Procedure:
___ Right thoracostomy tube placement

 
History of Present Illness:
___ who presents after a fall out of bed. She does not remember 
the circumstances of the fall, but found herself on the floor 
with terrible pain in her right side. She denied head trauma. 

Her daughter reports a subacute decline over the past several 
months, with worsening confusion and occasional inappropriate 
behavior (walking around naked). She recently moved to a new 
___ living facility. The daughter is concerned that she 
is more depressed than she had previously been. 

She denies any palpitations, lightheadedness, dizziness, or 
other associated symptoms. In the ED, she was found to have 
multiple rib fractures, with other negative imaging. She was 
admitted for pain control. 

All systems were reviewed and are negative except as above. 
 
Past Medical History:
- Breast cancer
- Sciatica
- Dyspepsia
- Uterine prolapse
- T12 compression fracture
- Osteopenia
- Hypothyroidism 
- Depression/Bipolar disorder
- IBS
- Mitral valve prolapse
- Hearing loss
 
Social History:
___
Family History:
Noncontributory
 
Physical Exam:
Upon admission:
VITALS: T97.4F, BP 138/63, HR 72, RR 16, Sat 94%RA 
GENERAL: Well appearing, no acute distress
HEENT: EOMI, PERRL, OP clear without lesions
NECK: No cervical lymphadenopathy, no JVD, no carotid bruit
CARD: RRR, normal S1/S2, no m/r/g
RESP: CTA bilaterally, no wheezes/rales/rhonchi; ecchymoses and 
tenderness to light palpation over right-sided ribs bilaterally
ABD: Soft, nontender, nondistended, normoactive bowel sounds, no 
hepatosplenomegaly
RECTAL: Guaiac negative in ER
BACK: No spinal tenderness, no CVA tenderness 
EXT: No clubbing/cyanosis/edema, 2+ DP pulses
NEURO: CN II-XII, A&O x 3, Strength ___ in both upper and lower 
extremities bilaterally, no sensory deficits, gait not tested
PSYCH: Appropriate, normal affect
 
Pertinent Results:
___: 14.2  PTT: 30.0  INR: 1.2  
 
Na 141   K 3.8   Cl 105   HCO3 25   BUN 17   Creat 0.8   Gluc 
106

CK: 257  MB: 4  Trop-T: <0.01  

WBC 8.5
N:69.5 L:19.9 M:9.8 E:0.5 Bas:0.3
Hgb 12.4
Hct 38.1
Plt 237
MCV 95

U/A: SpecGr 1.018, tr leuk, tr bld, 15 ket, 6 WBC, 2 RBC, no 
bacteria  
 
STUDIES:
ECG: No prior for comparison. NSR at 77bpm. 

Head CT: 1. No intracranial hemorrhage, with global atrophy and 
mild chronic microvascular infarction. 2. No displaced skull 
fracture. 3. Opacified right maxillary sinus.

CXR: 1. Right-sided rib fractures. Consider dedicated rib 
series. 
2. No pneumothorax. 3. T12 compression deformity, age 
indeterminate, in the absence of prior films. Correlate 
clinically 

Hip films: This exam is WNL. There is no fracture or 
dislocation. Sacroiliac joints and hips are normal. There is no 
focal lytic or sclerotic lesion. The bones are mildly 
demineralized. There is no abnormal soft tissue calcification or 
radiopaque foreign body. 

Shoulder films: There is no fracture or dislocation of the 
shoulder. There are degenerative changes at the 
acromioclavicular joint. There is mild demineralization. There 
is no focal lytic or sclerotic lesion. A tubular structure is 
seen overlying the right upper chest probably artifact on skin. 
No abnormal periarticular soft tissue calcification. The right 
lung is normal. 

Rib films: Multiple rib fractures.

___ 08:10AM   CK(CPK)-254*
___ 08:10AM   cTropnT-<0.01
___ 04:50AM   ___ PTT-30.0 ___
___ 03:00AM   GLUCOSE-106* UREA N-17 CREAT-0.8 SODIUM-141 
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
___ 03:00AM   CK(CPK)-257*
___ 03:00AM   WBC-8.5 RBC-4.04* HGB-12.4 HCT-38.1 MCV-95 
MCH-30.7 MCHC-32.5 RDW-15.3
___ 03:00AM   PLT COUNT-237
 
Brief Hospital Course:
She was admitted initially to the Medicine service on ___. A 
Trauma consult was obtained on ___ because questionable 
hemothorax, right pleural effusion and hematocrit drop from 38.5 
to 29.7. A right thoracosotmy was placed by Surgery and remained 
in for several days. The chest tube was pulled on ___ in the 
late afternoon. Post removal films showed peristent right apical 
pneumothorax. A repeat chest film was obtained which showed 
virtually the same findings. She is on nasal oxygen at 2 liters; 
her saturations have been in mid 90's. 

She was noted intermittently with elevated blood pressure felt 
likley due to pain from her rib fractures. Her pain was managed 
with standing Tylenol and prn Oxycodone; a Lidoderm patch was 
also added. This regimen appeared to be effective.
She was started on a bowel regimen. 

Her home medications were restarted. She was started on a 
regular diet and tolerated this. She was evaluated by Physical 
therapy and is being recommended for rehab after her acute 
hosital stay.

 
Medications on Admission:
- Levothyroxine 75mcg daily
- Omperazole 20mg BID
- Gabapentin 300mg TID
- Dorzolamide-timolol 1 gtt ___ BID
- Depakote 750mg QHS
- Citalopram 20mg daily
- Multivitamin daily
- Calcium, vitamin D
- Alendronate 70mg weekly ___
 
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000  
Injection TID (3 times a day).  
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 
times a day).  
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO BID (2 times a day).  
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).  
6. Dorzolamide-Timolol ___ % Drops Sig: One (1) Drop 
Ophthalmic BID (2 times a day): ___.  
7. Divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: Three 
(3) Tablet, Delayed Release (E.C.) PO DAILY (Daily).  
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
9. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) 
Tablet, Chewable PO TID (3 times a day).  
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) 
Tablet PO DAILY (Daily).  
12. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every 
___.  
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: 
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).  
14. Tylenol ___ mg Tablet Sig: Two (2) Tablet PO every ___ 
hours.  
15. Oxycodone 5 mg/5 mL Solution Sig: Five (5) ML's PO Q4H 
(every 4 hours) as needed for pain.  
16. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).  

17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) 
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for 
constipation.  

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
s/p Fall
Multiple right rib fractures
Right hemothorax
Pneumothorax
 
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain 
adequately controlled.
 
Followup Instructions:
___

{'terrible pain in her right side': ['Closed fracture of four ribs'], 'subacute decline': ['Bipolar I disorder', 'most recent episode (or current) depressed'], 'worsening confusion': ['Bipolar I disorder', 'most recent episode (or current) depressed'], 'inappropriate behavior': ['Bipolar I disorder', 'most recent episode (or current) depressed'], 'multiple rib fractures': ['Closed fracture of four ribs'], 'right hemothorax': ['Traumatic hemothorax without mention of open wound into thorax'], 'pneumothorax': ['Pneumothorax'], 'elevated blood pressure': ['unspecified'], 'pain from her rib fractures': ['Closed fracture of four ribs'], 'constipation': ['unspecified']}