Discharge Summary
DAT E ADMITTE D:
DATE DISCH A RGED:
DISCH ARGE ATTENDING: Dr.
DISCH ARGE DIAGNOSIS: Right-sided rib fractures 5 through II .
SECONDA RY DIAGNOSIS: Urinary retention due to BPH , right traum atic hemothorax, elder abuse
HISTORY OF PR ESENT ILLNESS: This is a 71-year-old male who was
assaulted by his son at home. He was found to have multiple new right-sided rib fractures
on imagin g in the emerge ncy departm ent and upgraded to a trauma III
at that time secondary to his rib fractures and advanced age.
He denies loss of consciousness or any other injuries or symptoms
other than pain and difficulty breathing.
HOSPITAL COURSE: The patient was admitted after his initial
workup in the Emergency Department. He was admitted for IV pain control,
and evaluation . His diet was advanced and he began transitioning to ora l pain medications.
Two days after admission it was attempted to discontinue the pati ent's Foley catheter,
however, he experienced urinary retention and it was necessary to replace
Discharge Summary
the Foley. On
, Flomax was started to help allev iate thi s
problem and the Foley was left in place until disch arge. Otherw ise, the
patient has been improvin g as expec ted, has weaned offof h is oxygen
requirement, and has ac hieved adequate pa in contro l with his oral
medications. He is bein g discharged ho me on Floxm ax 0.4 mg.
DISPOSITI ON : Informati on provid ed to the patient: He is to be d ischarge d
hom e with a regul ar diet. His ac tivity is as tolerated . He is to
fo llow up with his primary care prov ider for a GU evaluation as the patient is being
discharged with his Foley catheter in place for urinary retention. The
plan is to remove the cathe ter in Trauma C linic on
, however, he
still wo uld benefit from a foll owu p with his primary care pro vider. Th e
patient is also be ing discharged with his incenti ve spirometer, to be used
10 time s per hour g iven his multipl e rib frac tures and high likelih ood of
a deterioration in his resp iratory status ifn ot used regul arl y. For pain
management, he is being disch arged hom e with oxycodo ne 5 mg to be taken
every 4 hours as needed for pain.
History and Physical
Adm is sion Infonnation
Report date and time
Chief Complaint
Trauma III upgrade: assau lted by son. Found to have mu ltiple rib fx
History of Present Illness
Other.
71 yo M assaulted by son. Wa s found to have multiple new R sided rib fx on imaging . Upgraded to a trauma III 2/2 rib fx
with old age . Abuse reported to au thorities.
Past Medical Hi story
Past Medical History
Allergy: .
Allerg ic Reactions (all) None.
Illness: BPH.
Surgical procedure s: none
Fami ly History: None reported.
Social History
Race: Whi te.
Alcohol use: Denied.
Tobacco use: Denied.
C urrent Substance Abuse: Denied.
Review of Systems
Constitutional: Negative.
Eyes: Negative.
ENT: Negative .
Cardia: Negative.
History and Physical
Respiratory: Neg ati ve.
GI: Negative.
GU : Neg at ive.
Muscul oskelatal : R rib pain: 10/10 .
Skin/Breast: Negati ve.
Neurologic: Negati ve.
Psychi atric : Neg ati ve.
Primary Assessment
A irway
speaking
Breath Sou nds
Equal bilaterally
Ci rculation
Pulse s
Radial
2+
Femoral
2+
Dorsalis Pedalis
2+
Disability & Level Of C onsci ousness
Alert and oriente d x3
Able to move all extremities
Expose Examine Evaluate
Resusciation
peripheral IV
Physical Examination
History and Physical
Oxygen therapy
Nasal canu la
Chemically paralyzed
No
Glasgow Coma Score
Int ubated
No
Total: 15
Head & General Appearance
Pupils Equal, Round, Reactive to Light and Accom modation (PERRLA)
Extraocular movement intact
No abnormalit ies fou nd
Neck
C-collar present
Back
T horacic spine cleared
No
Lumbar spine cleared
No
Chest
TIP R low er ribs
Cardiovascular
Rhyt hm
Reg ular
Rate
Reg ular
5152
Heart Sounds Normal
Respiratory
Clear to ascultation bi laterally
Abdomen
Tenderness
Guarding
Pelvis
No abnorma lities found
History and Physical
Impression and Plan
Problems/Injuries Identified
71 yo M assaulted by son found to have R rib 5-1 1 fx
-Admit to IMCU
-Pain: Maxim ize IV pain contro l, consult APS:
-Spine s: Full precautions, flu CT of CTL spines
-N PO, IVF : LR
-Serial abd /hct q6hr
-sco'e, IS
Emergency Department Record
Assault
Basic Information
Time seen: Date & time
History source: Patient, EMS.
Arrival mode: Ambulance.
Vital signs: Vital signs,
Temperature Tempo ral Arte ry
Heart Rate Monitored
70 bpm
Systolic Blood Pressure
157 mmHg
Diastolic Blood Pressure 90 mmHg
Mean Ar t e rial Pressure
112 mmHg
Respiratory Rat e
14 br/min
satura tion : Oxygen Th e r a p y and Oxygenation Info .
Oxygen Saturation
99 % No r ma l
36 .7 DegC
Oxygen
Allergies: .
Allergic Reactions (all)
codeine
History limitation: None.
History of Present Illness
The patient is a 71 years old Male who presents with a complaint of assault and pt reports being assulted . Complains
of pain at R side of chest, abdomen . . The occurrence was 1 hour(s) prior to arrival. The course of pain is constant.
Location of pain : Chest abdomen . Location of bleeding : Chest abdomen. Location of laceration : Chest abdomen. The
degree of headache is negative. The other degree of pain is moderate. The degree of bleeding is negative. There are
pain exacerbating factors including jarring and movement. The mechanism of injury was hit with fist(s). Intoxication :
negative:-E xisting injuries prior to trauma : none.
Associated Symptoms
Constitutional symptoms: Negative.
ENT: Negative.
Cardiovascular symptoms: Negative.
Respiratory symptoms: Negative.
Other gastrointestinal symptoms: Negative.
Neurologic symptoms: Negative
Loss of consciousness: Negative.
Emergency Department Record
Review of Systems
Eye symptoms: Negative
ENT: Negative
Cardiovascular symptoms: Negative.
Respiratory symptoms: Negative.
Gastrointestinal symptoms: Difficult urinating.
Other significant review of systemsAIl other systems reviewed and otherwise negative
Past Medicall Familyl Social History
Medical history: Additional significant medical history: BPH
Surgical history: Not significant.
Family history: Not significant.
Social history: Alcohol: None. Tobacco: None. Drugs : Denies drug
use.
Physical Examination
General appearance: Mild distress .
Skin: Warm. Dry.
Head: Within normal limits.
Chest wall: diffu se tenderness
Pelvis: No tenderness. No instability.
Back: Nontender. Normal range of motion . Normal alignment.
Extremity: Normal range of motion . No swelling.
Neck: Supple , trachea midline, no tenderness, full ROM without pain.
Eye: Pupils equal , round , and reactive to light. Extraocular movements intact.
Ears, nose, mouth and throat: Oral mucosa moist
Heart: Regular rate and rhythm , no extra heart sounds, no murmurs.
Perfusion : Within normal limits.
Respiratory: t.ungs clear to auscultation bilaterally. Respirations nonlabored.
Abdominal: Soft. Non distended . Normal bowel sounds . No organomegaly. diffusely tender.
Neurological: Alert and oriented times 3. No focal neuro deficits.
Psychiatric: Appropriate .
IMPRESSION AND PLAN :
Admit to Inpatient Unit, Trauma 3 due to multip l e rib fx and age .
Diagnosis : Mu ltipl e rib fractur es, right hemothorax .
CT SCAN
Computed tomography (CT):
CTA CHEST W CONT
INDI CATI ON : Chest p ain, trauma
EXAM I NATI ON : CT a ngiogram o f t he thorax
COMPARISON : None avai lab le
F INDI NGS ,
The pulmona r y a rt e ri e s a r e we l l o pacified wit h con t r ast wi t h o u t evi de n ce o f filling
d ef e c t to s ugg est pul monary embo l i s m.
Th e aorta is n o r mal i n ca li ber without evi dence of aneury s m or d i ss e c ti on .
Hear t size i s no rma l. No peri c a rd i a l effus ion .
Limi t ed eval uat ion o f the thyroid demon s t r a tes n o abnormal i t i e s .
No p a t h o l ogi c all y e n larged a x i l lary or media s tinal lymph n ode s.
The e sop hagu s i s wi th in n ormal limits .
No
pne umotho r ax.
I MPRESS ION ,
1 . Mul ti p le right - sided ri b f ractu res a re pre s ent invo lv i n g t he
right ribs 5 thr o u gh 11 a n d sma ll eff u sion tha t rep r e sen t s a he mot hora x