Closed dislocation of metacarpophalangeal (joint) Sprain of interphalangeal (joint) of hand Fall from other slipping tripping or stumbling Diabetes mellitus without mention of complication type II or unspecified type not stated as uncontrolled Unspecified essential hypertension Osteoarthrosis unspecified whether generalized or localized site unspecified Diverticulosis of colon (without mention of hemorrhage) Acquired absence of intestine (large) (small)
 
Name:  ___              Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
Penicillins
 
Attending: ___.
 
Chief Complaint:
left ___ digit MCP dislocation
 
Major Surgical or Invasive Procedure:
Open reduction of left ___ digit dislocation at MCP  Joint

 
History of Present Illness:
___ y/o p/w irreducible dorsal dislocation of SF MPJ. Pt. now s/p 
open reduction of MCP fracture. Pt being admitted O/N for 
monitoring. 

 
Past Medical History:
PMH:
HTN
DMT2 - no insulin required
diverticulosis
hemrrhoids
.
PSH: 
TAH - for "benign tumor"
Partial L colectomy ___ for acute GI bleed
Breast Bx -benign
L wrist surgery - "cyst"
Central back area infected "cyst" s/p I&D 

 
Social History:
___
Family History:
sister- h/o diverticulosis, GI bleeding, no surgeries required

 
Physical Exam:
GEN - Alert, oriented, no acute distress  
HEENT - NCAT, MMM, EOMI, sclera anicteric, OC/OP clear  
NECK - supple, no JVD, no LAD  
PULM - CTAB,
CV - RRR, 
ABD - soft, NT/ND, normoactive bowel sounds, no guarding or 
rebound
EXT - WWP, no c/c/e, 2+ pulses palpable bilaterally
MSK- splint in place, no paresthesias, sensation intouch to 
light touch, warm well perfused. Motion limited by splint 
application
SKIN - no ulcers or lesions  

 
Brief Hospital Course:
The patient was admitted to the plastic surgery service on 
___ and had a open reduction of left ___ digit MCP 
dislocation.  The patient tolerated the procedure well. 
.
Neuro: Post-operatively, the patient was transitioned to oral 
pain medications and tolerated it well . 
.
CV: The patient was stable from a cardiovascular standpoint; 
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint; 
vital signs were routinely monitored.
.
GI/GU: Post-operatively, the patient was given IV fluids until 
tolerating oral intake.  Intake and output were closely 
monitored. 
.
Prophylaxis: The patient received subcutaneous heparin during 
this stay, and was encouraged to get up and ambulate as early as 
possible. 
.
At the time of discharge on POD#1, the patient was doing well, 
afebrile with stable vital signs, tolerating a regular diet, 
ambulating, voiding without assistance, and pain was well 
controlled
 
Discharge Medications:
1. Atenolol 50 mg PO DAILY 
2. GlyBURIDE 5 mg PO DAILY 
3. Hydrochlorothiazide 25 mg PO DAILY 
4. Prazosin 2 mg PO BID 
5. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN pain 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
left ___ digit dislocation at MCP joint with volar plate 
interposition

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

 
Discharge Instructions:
keep hand in splint until follow up on ___. Do not change 
dressing
NWB left upper extremity
Keep splint dry
OK to shower tomorrow
please resume all home medication
take pain medication as indicated
 
Followup Instructions:
___

{'irreducible dorsal dislocation': ['Closed dislocation of metacarpophalangeal (joint)'], 'HTN': ['Unspecified essential hypertension'], 'DMT2': ['Diabetes mellitus without mention of complication', 'type II or unspecified type', 'not stated as uncontrolled'], 'diverticulosis': ['Diverticulosis of colon (without mention of hemorrhage)']}