Unspecified derangement of joint hand Esophageal reflux Pain in limb Keloid scar Late effect of crushing Late effects of other accidents Accidents occurring in unspecified place
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: ORTHOPAEDICS
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
R wrist decreased AROM
 
Major Surgical or Invasive Procedure:
TENDON TRANSFER RIGHT WRIST EXTENSOR DIGITORUM CARPIALIS ___ TO 
___ DIGIT; EXTENSOR CARPIALIS RADIALIS BREVIS TO EXTENSOR 
CARPIALIS ULNARIS, EXTENSOR DIGITORUM QUINTI TO EXTENSOR CARPI 
ULNARIS ___ DIGIT; ___ EXTENSOR CENTRAL SLIP REPAIR; TENOLYISIS 
EXTENSOR DIGITORUM CARPIALIS TENDONS; ? REVISION DORSAL FOREARM 
8 X 3 CM EXTENSOR POLLICUS LONGUS REPAIR WITH TENDON ALLOGRAFT

 
History of Present Illness:
Mr. ___ is a ___ male
who sustained an open crush injury to the right forearm in a
lathe.  This is associated with right radial fracture.  He
underwent fasciotomies initially as well as ORIF of his distal
radius fracture and carpal tunnel release.  His debridement
unfortunately required dissections of the ECU and EPL tendons be
taken.  Since surgery, his postoperative course has been
complicated by pain requiring gabapentin use three times a ___ 
as
well as ongoing Vicodin use now over 10 weeks out from surgery. 
He reports that he is still making progress with physical 
therapy
and the physical therapist has sent a note along with him today,
which documents his MCP joint motion at the index finger is from
-9 to 66, The middle finger is ___, ring finger is 0 to 65 and
small finger is 0 to 50.  At the PIP joint of the index -___ to 
90
degrees, middle finger -5 to 96 degrees, ring finger -10 to 95
degrees and small finger -30 to 86 degrees.  At the DIP joint 
for
the index finger -15 to 59 degrees, middle finger is 0 to 62
degrees, ring finger -10 to 63 degrees and small finger -4 to 55
degrees, the thumb MP joint from -25 to 50 degrees, PIP joint 10
to 30 degrees with only 56 degrees of palmar abduction.  The
patient also indicates that he for the last several weeks has 
had
lateral epicondylitis of the left elbow and pain in the anterior
right shoulder consistent with bicipital tendonitis.  Though it
was recommended at his last visit with us that he consult with a
psychologist or psychiatrist in around his pain issues and 
coping
issues from surgery, he has not been interested so far in
pursuing that.
 
Past Medical History:
GERD, Gout
 
Social History:
___
Family History:
Non-contributory
 
Physical Exam:
GEN: Well appearing, NAD
AVSS

RUE: 
Splint c/d/i
EPL/FDS/FDP/DIO fire
SLT m/r/u
Fingers WWP
 
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service and 
was taken to the operating room for above described procedure. 
Please see separately dictated operative report for details. The 
surgery was uncomplicated and the patient tolerated the 
procedure well. Patient received perioperative IV antibiotics.

Postoperative course was remarkable for the following:

Otherwise, pain was initially controlled with oral pain 
medications with IV for breakthrough pain.  At the time of 
discharge the patient was tolerating a regular diet and feeling 
well.  The patient was afebrile with stable vital signs.  The 
patient's pain was adequately controlled on an oral regimen. The 
operative extremity was neurovascularly intact and the wound was 
benign. 

The patient's weight-bearing status is non weight bearing in 
splint until follow up.
 
Mr ___ is discharged to home in stable condition.

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY 

 
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain 
2. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN pain 
3. Omeprazole 20 mg PO DAILY 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
R arm crush injury

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

 
Discharge Instructions:
1. Please return to the emergency department or notify your 
physician if you experience any of the following: severe pain 
not relieved by medication, increased swelling, decreased 
sensation, difficulty with movement, fevers greater than 101.5, 
shaking chills, increasing redness or drainage from the incision 
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this 
admission and any new medications and refills.  
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do 
not drive, operate heavy machinery, or drink alcohol while 
taking these medications. As your pain decreases, take fewer 
tablets and increase the time between doses. This medication can 
cause constipation, so you should drink plenty of water daily 
and take a stool softener (such as colace) as needed to prevent 
this side effect.  Call your surgeons office 3 days before you 
are out of medication so that it can be refilled.  These 
medications cannot be called into your pharmacy and must be 
picked up in the clinic or mailed to your house.  Please allow 
an extra 2 days if you would like your medication mailed to your 
home.
5. You may not drive a car until cleared to do so by your 
surgeon.
6. Please keep your splint clean and dry until follow up.  You 
can shower, but make sure to keep your splint dry.
7. Please call Dr ___ office at ___ upon discharge to 
schedule a follow up for ___ days after surgery.
12. ACTIVITY: Non weight bearing in splint until follow up
 
Followup Instructions:
___

{'R wrist decreased AROM': ['Late effect of crushing'], 'pain': ['Pain in limb', 'Late effects of other accidents'], 'lateral epicondylitis': ['Pain in limb'], 'bicipital tendonitis': ['Pain in limb']}