Fracture of calcaneus open Concussion with loss of consciousness of 30 minutes or less Other accidental fall from one level to another Postprocedural fever Dysthymic disorder Other chronic pain Backache unspecified
 
Name:  ___                      Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: ORTHOPAEDICS
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___
 
Chief Complaint:
Fall off ladder, presents with R foot pain and low back pain 
 
Major Surgical or Invasive Procedure:
___:  I&D right open calcaneus fracture with VAC placement
___:  I&D right open calcaneus fracture with VAC change
___:  I&D right open calcaneus fracture with ORIF and Split 
Thickness Skin Graft to wound.

 
History of Present Illness:
Mr. ___ is a ___ year old man who had a fall off a ladder 
(approx 12 feet)on ___.  He was taken to ___ 
___ and was found to have a Grade IIIb open right calcaneal 
fracture.  He was then transferred to the ___ for further 
evaluation and care.
 
Past Medical History:
Depression
Anxiety
Right foot fx (___) treated non-operatively
Low back injury (___) treated non-operatively
 
Social History:
___
Family History:
n/a
 
Physical Exam:
Upon admission

Alert and oriented
Cardiac:  Regular rate rhythm
Chest:  Lungs clear bilaterally
Abdomen:  Soft non-tender non-distended
Extremities:  RLE, SILT R foot/toes/plantar surface open 
fracture with large laceration medial to right ankle/heel
 
Pertinent Results:
___ 07:20PM   GENTA-1.2*
___ 07:20AM   GLUCOSE-143* UREA N-10 CREAT-0.9 SODIUM-141 
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-26 ANION GAP-13
___ 07:20AM   WBC-6.3 RBC-3.56* HGB-10.9* HCT-32.2* MCV-91 
MCH-30.5 MCHC-33.7 RDW-13.6
___ 07:20AM   PLT COUNT-162
___ 06:15PM   ___ PTT-25.5 ___
___:45PM   GLUCOSE-100 UREA N-11 CREAT-0.8 SODIUM-139 
POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-23 ANION GAP-13
___ 05:45PM   WBC-6.3 RBC-4.15* HGB-12.4* HCT-36.8* MCV-89 
MCH-29.9 MCHC-33.8 RDW-13.8
___ 05:45PM   NEUTS-78.8* LYMPHS-16.4* MONOS-4.1 EOS-0.3 
BASOS-0.4
___ 05:45PM   PLT COUNT-164
___ 05:45PM URINE  COLOR-Straw APPEAR-Clear SP ___
___ 05:45PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 
LEUK-NEG
 
Brief Hospital Course:
Mr. ___ presented to the ___ on ___ via transfer from 
___ with a right open calcaneal fracture.  He 
was admitted, consented, and taken to the operating room.  He 
underwent an I&D with VAC placement of his right calcaneal 
fracture wound.  He tolerated the procedure well, was extubated, 
transferred to the recovery room and then to the floor.  On 
___ he returned to the operating room and underwent a 
repeat I&D of his right calcaneal fracture with VAC change.  He 
tolerated the procedure well, was extubated, transferred to the 
recovery room and then to the floor.  On ___ he returned to 
the operating room and underwent an I&D of the right calcaneal 
wound with ORIF by orthopaedics and a split thickness skin graft 
to his wound by plastic surgery.  He tolerated the procedure 
well, was extubated, transferred to the recovery room and then 
to the floor.  He remained on bedrest per plastic surgery for 
graft protection.  His splint was changed on ___ to provide 
improved padding.  On ___ his VAC was removed by plastic 
surgery and his antibiotics were stopped.  On ___ he was 
taken off bedrest and worked with physical therapy, though was 
only allowed to dangle his leg (have it dependent for 15 minutes 
3 times a day).  On ___ he was able to start physical 
therapy and was cleared for home with ___.  Foley ___ was 
removed and he voided 500cc prior to discharge.

The rest of his hospital stay was uneventful with his lab data 
and vital signs within normal limits and his pain controlled.  
He is being discharged today in stable condition.
 
Medications on Admission:
Antidepressant - unknown med and dose
 
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a 
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours).  
4. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe 
Subcutaneous Q12H (every 12 hours) for 18 days.
Disp:*36 syringes* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3 
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Fall from ladder
Right open calcaneus fracture

 
Discharge Condition:
Stable/Good

 
Discharge Instructions:
Continue to be non-weight bearing on your right leg

Continue to take your lovenox injections as instructed

Please take all medication as prescribed

If you have any increased pain, swelling, and or numbness, not 
relieved with rest, elevation and or pain medication, or if you 
have any other concerning symptoms, please call the office or 
come to the emergency department

You have been prescribed a narcotic pain medication.  Please 
take only as directed and do not drive or operate any machinery 
while taking this medication.  There is a 72 hour ___ 
through ___, 9am to 4pm) response time for prescription refil 
requests.  There will be no prescription refils on ___, 
___, or holidays.  Please plan accordingly.    
 
Followup Instructions:
___

{'R foot pain': ['Fracture of calcaneus'], 'low back pain': ['Backache'], 'fall off ladder': ['Other accidental fall from one level to another']}