DISCHARGE SUMMARY

Date : 14 Jul 2020

Sex : Male

Thank you for continuing care of our patient, xxxxx, a 28-year-old male, xxxxx

DATE OF ADMISSION: 14 April 2018 DATE OF DISCHARGE: 15 April 2018

ADMISSION DIAGNOSIS:

S 22.4 Multiple fractures of left ribs (5th and 6th)

BRIEF HPI:

05.40 p.m. He came to ER straight away due to pain on left ribs and difficulty breathing. He was surfing but
then bump to the ground on left chest and face. He felt pain 7-8 out of 10 painscale, which aggravated by taking
deep breath, and lift up left arm. Denied loss of consciousness.

PAST MEDICAL HISTORY:

He denied having any known drug allergy, any significant past medical history, or using any regular
medications.

HOSPITAL COURSE:

Upon initial examinations, he was haemodynamically stable. On the chest, hyperemic was noted on left ribs 5th-
6th-7th with deformity but breath sound was clear, chest expansion was symmetrical. Other physical
examinations were within normal limit. Chest x-ray was suspicious of ribs fracture and chest CT- scan
confirmed the fracture: left 5th and 6th ribs, non-displaced but no findings of hemo or pneumothorax. Patient
was admitted for pain management and started on painkiller drip. Blood test revealed leukocytosis but urine
analysis was unremarkable with no sign of urine infection. His medications were adjusted during
hospitalization, including tapering down of painkiller drip and administration of muscle relaxant. Gradually, his
condition's better and he was able to be discharged to continue treatment as an outpatient on 15 April 2018.

CONSULTATIONS:

None

PROCEDURES (imaging and results are as attached):

Laboratories
14 April 2018 p.m.
- CBC: Hgb 15.5 g/dL , Hct 43.8% , WBC 15.200*/uL (H) (Neu 81.8*% (H)) , PLT 286.000/uL - Urine
analysis: unremarkable, no sign of infection

Imagings

14 April 2018 Radiologist (dr Made Dwija Putra Ayusta, SpRad) impression of:
- XR-Thorax PA/Oblique view: No acute cardiopulmonary disease. No fracture is seen - CT-Thorax without IV
contrast: Non displaced fractures of left 5th and 6th ribs

RE :
Patient Number : xxxxx
Patient Name Age Nationality

: xxxxx
: 28 years, 8 month : xxxxx

To whom it my concern,

Dear Sir / Madam

DISCHARGE DIAGNOSIS:

S 22.4 Close fracture of 5th and 6th ribs, left, non-displaced

DISCHARGE CONDITION:

Haemodynamically stable with no fever, good oral intake, able to mobilize independently (bur very slowly) with
no significant problem, and improving general condition.

DISCHARGE PHYSICAL EXAMINATION:

Vital sign
Level of Consciousnes

Blood Pressure

Pulse General state

: alert
: 110/70 mmHg : 82 x/min

Respiratory Rate Temperature

O2 Saturation

: 18 x/min
: 36.5 °C
: 97 % on RA
General appearance: in discomfort, very slowly in mobilization; GCS 4-5-6
Head, neck: non-tender, no sign of injury, stable
Back, spine: no obvious injury, no step off, no increasing tenderness during midline and paraspinal palpation, no
crepitation, no CVA tenderness
Chest: tender (+) on left anterolateral, ribs level 5th-6th, crepitation was not attempted
Heart: adynamic precordium, normal rate regular rhythm
Lungs: symmetric chest expansion, clear breath sound, no rales, no wheezes
Abdomen: soft, no bruise, no obvious sign of injury, normal bowel sound, no hepatosplenomegally, no
tenderness, no defans

ACTIVITY:

As tolerated but have enough rest, avoid strenuous activity, and avoid over exhausting yourself

DIET:

As tolerated but have plenty of fluid

MEDS:

- Pantozol 40mg. 1 tablet, once daily , Gastric acid regulator (Pantoprazole)

- Torasic 10mg. 1 tablet, 3x daily , Pain killer / Anti-inflammatory (Ketorolac)
- Ultracet. 1 tablet, 3x daily , Strong Painkiller (Paracetamol 325mg+ Tramadol 37.5mg)
- Myores 2mg. 1 tablet, 3x daily , Muscle relaxant (Tizanidine)
- Valisanbe 5mg. 1 tablet, once daily bedtime , Muscle relaxant (Diazepam), can cause sleepiness

FOLLOW-UP:

None unless developing worsening conditions. However if you start to develop worse pain on the back or the
left chest, or developing shortness of breathe, please come back to hospital for follow-up

DISCHARGE INSTRUCTIONS:

- Take medications as prescribed. If you develop any allergic reaction (e.g. skin rash, itchiness, shortness of
breath, etc.) after taking medications, STOP the medications and seek medical attention ASAP.
- You might be recommended to repeat chest CT-scan if you start to develop shortness of breath or worsening
chest pain

- If there is any worsening condition or any other concerns, please have follow-up or seek medical attention
immediately

FIT TO FLY STATEMENT:

Currently, he is fit to fly with commercial flight, regular seat with wider space on his left side, and unescorted
with luggage assistance. However, should his clinical condition deteriorates (e.g. worsening chest/back pain,
developing shortness of breath), the fit to fly statement can be revoked

Should you need further information, please do not hesitate to contact us again at the address below: Website : www.bimcbali.com
Tel : +62-361-761263
Fax : +62-361-764345

E-mail : admin@bimcbali.com

Thank you for your attention.

Regards,
Dr. xxxxx