Injury to median nerve Closed fracture of navicular [scaphoid] bone of wrist Closed fracture of other bone of wrist Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: ORTHOPAEDICS
 
Allergies: 
Penicillins
 
Attending: ___.
 
Chief Complaint:
R transscaphoid perilunate fracture dislocation
 
Major Surgical or Invasive Procedure:
___ Dr. ___, MD
1. Open reduction internal fixation right scaphoid
    fracture.
2. Open reduction internal fixation triquetral fracture.
3. Open release of the right carpal tunnel.
4. Open reduction internal fixation of a wrist perilunate
    dislocation

 
History of Present Illness:
HPI: ___ yo RHD M who was skateboarding on ___ when he was
struck from behind on the R side by a car. Pt was taken to
___ where trauma workup was negative except
for a R transscaphoid perilunate fracture dislocation. Pt was
transferred to ___ ED & orthopaedics was consulted.  At time 
of
initial eval pt had median nerve symptom w/ numbness at tingling
of fingertips of the first 3 digits w/ associated slight
diminished sensation in those digits. Closed reduction was
performed under conscious sedation & pt was placed in a splint.
Pt median nerve symptoms improved with resolution of 
paresthesias
and only slight diminished sensation over the thumb.  Pt was
discharged home, and now returns for planned surgical fixation. 
Pt reports had some tingling in median nerve distribution upon
waking this morning, but this has resolved.  No other interval
changes. ROS otherwise negative.

 
Past Medical History:
h/o B ankle fx
h/o metacarpal fracture
s/p tonsillectomy as a child

 
Social History:
___
Family History:
Noncontributory
 
Physical Exam:
PEX on admission
A&O x 3
Calm and comfortable 
RUE: splint c/d/i
Sensation to light touch slightly diminished thumb as compared 
to
other side, otherwise SILT in R M U distibutions
EPL FPL EIP EDC FDP fire
Digits WWP

 
Pertinent Results:
N/A
 
Brief Hospital Course:
The patient was admitted to the Orthopaedic  Service for repair 
of a R transscaphoid perilunate fracture dislocation & 
triquetral fracture.  The patient was taken to the OR and 
underwent ORIFR transscaphoid perilunate fracture dislocation & 
triquetral fracture as well as carpal tunnel release. The 
patient tolerated all procedures without difficulty and was 
transferred to the PACU in stable condition. Please see 
operative report for full details.  The patient transferred to 
the floor in the usual fashion.  Postoperatively, pain was 
controlled with a PCA with a transition to PO pain meds as 
tolerated.  Diet was advanced without complication. Pt noted 
persitent numbness in the median nerve distribution which was 
improved w/ strict hand elevation.  At time of discharge states 
has mild slight residual "pins & needles" senstion involving the 
thumb.  The hospitalization has otherwise been uneventful and 
the patient has done well.  

**** 

At discharge, vital signs are stable, the patient is alert and 
oriented, afebrile, tolerating pos, voiding qshift and pain is 
well controlled.  Splint is c/d/i. Pt has very mild decreased 
senstion to light touch over the R thumb, similar to 
pre-operative exam.  Digits are WWP. Fires EPL/FPL/FDP/EDC.  The 
extremities are neurovascularly intact distally throughout.  All 
incisions are clean, dry and intact without evidence of 
infection, hematoma or seroma.  

**** 

The patient is discharged to home in stable condition.  
Intructions given. 

 
Medications on Admission:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) 
as needed for pain.  
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 
4 hours).  
3. Senna Concentrate 8.6 mg Tablet Sig: One (1) Tablet PO twice 
a ___: Take while on narcotic to prevent constipation.  

 
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q3H (every 3 hours) 
as needed for pain.  
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 
4 hours).  
3. Senna Concentrate 8.6 mg Tablet Sig: One (1) Tablet PO twice 
a ___: Take while on narcotic to prevent constipation.  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
R transscaphoid perilunate fracture dislocation s/p ORIF & 
carpal tunnel release

 
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 MD if you 
experience: increasing pain not relieved by medication, 
increased swelling, decreased sensation, difficulty with 
movement, fevers >101.5, shaking chills, redness or drainage at 
the incision site, chest pain, shortness of breath or other 
symptoms of concern.

2. Please follow up with your PCP regarding this admission and 
any new medications and refills. 

3. Resume your pre-hospitalization medications unless otherwise 
instructed. 

4. You have been given medications for your pain control.  As 
your pain improves, decrease your pain medication by taking 
fewer tablets and/or increasing the time interval between doses. 
 Do not drink, drive or operate machinery while taking 
narcotics.  Take a stool softener to prevent constipation.  

5. Do not drive until cleared to do so by your surgeon or your 
primary MD. 

6. Please keep splint clean and dry

7. WB Status: non-weightbearing right upper extremity

8. Please keep right upper extremity maximally elevated at all 
times to help w/ swelling and pain

9. Antibiotics: 

Physical Therapy:
Non-weightbearing right upper extremity
Treatments Frequency:
Please continue splint. Keep clean and dry
 
Followup Instructions:
___

{'numbness at tingling of fingertips': ['Injury to median nerve'], 'slight diminished sensation': ['Injury to median nerve'], 'paresthesias': ['Injury to median nerve'], 'R transscaphoid perilunate fracture dislocation': ['Closed fracture of navicular [scaphoid] bone of wrist', 'Closed fracture of other bone of wrist'], 'triquetral fracture': ['Closed fracture of other bone of wrist'], 'carpal tunnel release': ['Injury to median nerve']}