Other fracture of shaft of left tibia initial encounter for closed fracture Pressure ulcer of left heel stage 1 Fall on same level due to ice and snow initial encounter Unspecified place or not applicable Unspecified fracture of shaft of left fibula initial encounter for closed fracture
 
Name:  ___                     Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
latex
 
Attending: ___.
 
Chief Complaint:
left tibial shaft fracture
 
Major Surgical or Invasive Procedure:
Placement of left tibial intramedullary nail on ___

 
History of Present Illness:
___ w Left distal ___ tib/fib shaft fx on ___ while ice
skating presents for left heel pain x 2 days. She was seen at 
___
originally but followed with Dr. ___ in clinic on ___
and had long leg cast applied and wedged. For the past 2 days 
she
has had increasing pain at the heel and tightness of the toes,
enough now that the pain is waking her from sleep despite pain
meds and elevation. She called the answering service and I
advised her to come in due to the possibility of a heel sore. 
The
patient is scheduled to see Dr. ___ on ___ to likely
plan IM nailing of the tibia which she is more amenable to now
given the difficulty getting around with the long leg cast.  She
denies any numbness or tingling.  She has not taken oxycodone 
for
several days but continues to take Tylenol around-the-clock. 
Otherwise feels well and denies any fevers, chills, chest pain,
or shortness of breath. Of note, patient reports that she had a
CT scan of the ankle at ___ and it was on the disc that she
brought to clinic.
The patient was evaluated in clinic on ___ and decided that 
she would no longer like to pursue closed treatment and elected 
for surgical intervention. The risks, benefits, indications for 
surgery were thoroughly discussed with the patient, and she 
elected to undergo surgery, which was scheduled for ___.

 
Past Medical History:
Migraines, PVCs   
 
Social History:
___
Family History:
NC
 
Physical Exam:
Upon Admission:
___
General: Well-appearing female in no acute distress.
Left lower extremity:
-Long-leg cast clean dry and intact without skin breakdown at 
the
edges.
-I bivalved the entire long-leg cast and reinforced the cast 
with
tape.  I also removed the entire heel portion of the cast,
exposing the skin to reveal a 2 x 2 cm stage I pressure ulcer
without a break in the skin or surrounding erythema or drainage.
- wiggles exposed toes
- SILT exposed toes
- Toes wwp with BCR 

Upon Discharge:

General: Well-appearing, breathing comfortably on RA
Detailed examination of LLE:
-ace dsg CDI
-Fires FHL, ___, TA, GCS
-SILT ___ n distributions
-WWP distally
 
Pertinent Results:
please see OMR for pertinent labs and studies
___ 05:45AM BLOOD WBC-10.1* RBC-3.58* Hgb-9.3* Hct-30.1* 
MCV-84 MCH-26.0 MCHC-30.9* RDW-12.9 RDWSD-39.5 Plt ___
___ 05:45AM BLOOD Glucose-100 UreaN-10 Creat-0.6 Na-144 
K-4.2 Cl-108 HCO3-22 AnGap-14
___ 05:45AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1
 
Brief Hospital Course:
The patient presented as a same day admission for surgery. The 
patient was taken to the operating room on ___ for placement 
of left intramedullary nail, which the patient tolerated well. 
For full details of the procedure please see the separately 
dictated operative report. The patient was taken from the OR to 
the PACU in stable condition and after satisfactory recovery 
from anesthesia was transferred to the floor. The patient was 
initially given IV fluids and IV pain medications, and 
progressed to a regular diet and oral medications. The patient 
was given ___ antibiotics and anticoagulation per 
routine. The patient's home medications were continued 
throughout this hospitalization. The patient worked with ___ who 
determined that discharge to home was appropriate. The ___ 
hospital course was otherwise unremarkable.

At the time of discharge the patient's pain was well controlled 
with oral medications, incisions were clean/dry/intact, and the 
patient was voiding/moving bowels spontaneously. The patient is 
weight bearing as tolerated in the left lower extremity, and 
will be discharged on aspirin 325mg daily x4weeks for DVT 
prophylaxis. The patient will follow up with Dr. ___ 
routine. A thorough discussion was had with the patient 
regarding the diagnosis and expected post-discharge course 
including reasons to call the office or return to the hospital, 
and all questions were answered. The patient was also given 
written instructions concerning precautionary instructions and 
the appropriate follow-up care. The patient expressed readiness 
for discharge.
 
Medications on Admission:
None
 
Discharge Medications:
1.  Acetaminophen 650 mg PO Q6H 
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times daily 
Disp #*60 Tablet Refills:*0 
2.  Aspirin 325 mg PO DAILY 
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*28 Tablet 
Refills:*0 
3.  Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 
RX *bisacodyl 5 mg 1 tablet(s) by mouth daily Disp #*50 Tablet 
Refills:*0 
4.  Calcium Carbonate 1250 mg PO TID 
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by 
mouth daily Disp #*30 Tablet Refills:*0 
5.  Docusate Sodium 100 mg PO BID 
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp 
#*50 Tablet Refills:*0 
6.  Multivitamins 1 TAB PO DAILY  
7.  OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain 
RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4) 
hours Disp #*30 Tablet Refills:*0 
8.  Senna 8.6 mg PO DAILY 
RX *sennosides [senna] 8.6 mg 1 tab by mouth daily Disp #*50 
Tablet Refills:*0 
9.  Vitamin D 800 UNIT PO DAILY 
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth 
daily Disp #*60 Tablet Refills:*0 

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
___ Diagnosis:
Left tibial shaft fracture

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).

 
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:

- You were in the hospital for orthopedic surgery. It is normal 
to feel tired or "washed out" after surgery, and this feeling 
should improve over the first few days to week. 
- Resume your regular activities as tolerated, but please follow 
your weight bearing precautions strictly at all times.

ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated to the left lower extremity

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 4 weeks

WOUND CARE:
- You may shower. 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.
- Please remain in your dressing and do not change unless it is 
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless 
otherwise instructed
- Do NOT get splint wet

DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the 
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning 
changes in your incision
- Persistent or increasing numbness, tingling, or loss of 
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid, 
medications down
- Any other medical concerns

THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB

Physical Therapy:
Weightbearing as tolerated to left lower extremity
Treatments Frequency:
Any staples or superficial sutures you have are to remain in 
place for at least 2 weeks postoperatively.  Incision may be 
left open to air unless actively draining.  If draining, you may 
apply a gauze dressing secured with paper tape.  You may shower 
and allow water to run over the wound, but please refrain from 
bathing for at least 4 weeks postoperatively.

Please remain in the splint until follow-up appointment.  Please 
keep your splint dry.  If you have concerns regarding your 
splint, please call the clinic at the number provided.

Call your surgeon's office with any questions.
 
Followup Instructions:
___

{'left heel pain': ['Other fracture of shaft of left tibia', 'Pressure ulcer of left heel'], 'increasing pain at the heel': ['Other fracture of shaft of left tibia', 'Pressure ulcer of left heel'], 'tightness of the toes': ['Other fracture of shaft of left tibia', 'Pressure ulcer of left heel'], 'numbness or tingling': [], 'fevers, chills, chest pain, or shortness of breath': []}