Closed fracture of upper end of fibula alone Fall from other slipping tripping or stumbling Closed fracture of shaft of tibia alone
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: ORTHOPAEDICS
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
left distal tibia and proximal fibular fracture
 
Major Surgical or Invasive Procedure:
Tibia ORIF with intramedullary nail 

 
History of Present Illness:
This is a ___ year-old man in her USOH until yesterday afternoon
when he sustained a syncope and sustained a torsional fall from
standing. He was transferred from an ___ with a splint
in place. He denies headstrike and LOC. He also denies, neck or
chest pain.  He presented to ___ ED with films demonstrating a
distal tibia shaft fracture as well as a fibula fracture.

 
Past Medical History:
PMH: none
PSH:  L patellar tendon repair with anterior incision extending
to tibial tubercle

 
Social History:
___
Family History:
NC
 
Physical Exam:
On Admission: 
A&O x 3 
Calm and comfortable 
  
___
Pelvis stable to AP and lateral compression.  
RLE skin clean and intact 
Tenderness over L tibia and obvious deformity however no
erythema, edema, induration or ecchymosis.
There is a small abrasion over anterior aspect of 
Thighs and leg compartments soft 
No pain with passive motion 
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT 
___ ___ TA Peroneals Fire 
1+ ___ and DP pulses 

On Discharge: A+Ox3, calm/comfortable
RLE skin clean and intact 
Dressing c/d/i, incision healing well
No pain with passive motion 
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT 
___ ___ TA Peroneals Fire 
2+ ___ and DP pulses 

 
Pertinent Results:
XR Tibia/Fibula ___: 
FINDINGS:  ___ spot fluoroscopic images of the left tibia 
were 
submitted for archival in order to document lateral fixation 
plate and screw 
placement across a comminuted distal tibial fracture.  For 
further details, 
please refer to the operative note.  Total operative 
fluoroscopic time was 
141.2 seconds. 

 
Brief Hospital Course:
On ___ the patient was admitted to the ortho trauma service and 
noted to have a closed, distal spiral tibial shaft fracture 
which was reduced and splinted
without signs of compartment syndrome or neurovascular 
compromised. 

On ___ the patient underwent ORIF intramedullary rod fixation 
of left tibia fracture. 

On ___ the patient continued to recover well from surgery. His 
dressings were changed on post-op day 2 the incision was noted 
to be healing well. He was discharged home on lovenox for DVT 
prophylaxis with instructions to follow-up with Dr. ___ in 
clinic. 

 
Discharge Medications:
1. Aspirin 325 mg PO DAILY 
2. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN Pain 
RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp 
#*140 Tablet Refills:*0
RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp 
#*140 Tablet Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
fracture left tibia

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

 
Discharge Instructions:
MEDICATIONS:

- Please take all medications as prescribed by your physicians 
at discharge.

- Continue all home medications unless specifically instructed 
to stop by your surgeon.

- Do not drink alcohol, drive a motor vehicle, or operate 
machinery while taking narcotic pain relievers.

- Narcotic pain relievers can cause constipation, so you should 
drink eight 8oz glasses of water daily and take a stool softener 
(colace) to prevent this side effect.

 

ANTICOAGULATION:

- Please take aspirin 325mg daily for 2 weeks/until your 
follow-up appointment
 

WOUND CARE:

- You can get the wound wet/take a shower starting 3 days after 
your surgery.  You may wash gently with soap and water, and pat 
the incision dry after showering.  

- No baths or swimming for at least 4 weeks.

- Any stitches or staples that need to be removed will be taken 
out at your 2-week follow up appointment.

- No dressing is needed if wound continues to be non-draining.

 

ACTIVITY AND WEIGHT BEARING:

touch-down weight bearing LLE
 
Followup Instructions:
___

{'syncope': ['Fall from other slipping', ' tripping', ' or stumbling'], 'torsional fall': ['Fall from other slipping', ' tripping', ' or stumbling'], 'distal tibia shaft fracture': ['Closed fracture of shaft of tibia alone'], 'fibula fracture': ['Closed fracture of upper end of fibula alone']}