Closed fracture of shaft of fibula with tibia Chronic airway obstruction not elsewhere classified Accidental fall on or from other stairs or steps Tobacco use disorder Anxiety state unspecified
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
naproxen
 
Attending: ___.
 
Chief Complaint:
left leg pain
 
Major Surgical or Invasive Procedure:
open reduction internal fixation of the right tibia/fibula 
fracture by Dr. ___ on ___

 
History of Present Illness:
___ yo F who was drinking ___ earlier tonight when she
stumbled on the stairs. She twisted her left leg awkwardly and
heard a crack. immediate pain and unable to bear weight.
ambulance transported to ___ where xrays showed a 
distal
tib/fib fracture. transferred for further care.

no numbness or tingling in feet. no other injuries. did not 
fall.
did not hit head. no other complaints. pain tolerable in splint

 
Past Medical History:
anxiety
COPD

 
Social History:
___
Family History:
NC
 
Physical Exam:
NAD
Breathing comfortably

___ fire
+SILT SPN/DPN/TN distributions
___ pulses, foot warm and well-perfused
In ACB
 
Pertinent Results:
___ 05:05AM   ___ PTT-28.0 ___
___ 03:30AM   GLUCOSE-102* UREA N-16 CREAT-0.6 SODIUM-138 
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17
___ 03:30AM   estGFR-Using this
___ 03:30AM   WBC-10.4 RBC-4.35 HGB-13.8 HCT-40.7 MCV-94 
MCH-31.6 MCHC-33.8 RDW-14.2
___ 03:30AM   NEUTS-77.3* LYMPHS-17.3* MONOS-4.7 EOS-0.5 
BASOS-0.2
___ 03:30AM   PLT COUNT-188
___ 02:50AM URINE  HOURS-RANDOM
___ 02:50AM URINE  HOURS-RANDOM
___ 02:50AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 
LEUK-NEG
___ 02:50AM URINE  COLOR-Yellow APPEAR-Clear SP ___
___ 02:50AM URINE  GR HOLD-HOLD
 
Brief Hospital Course:
The patient presented to the emergency department and was 
evaluated by the orthopedic surgery team. The patient was found 
to have a left tibia/fibula fracture and was admitted to the 
orthopedic surgery service. The patient was taken to the 
operating room on ___ for ORIF left tibia/fibula 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 by POD#1. 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 c 
home ___ was appropriate. She was placed in an aircast boot on 
POD1. 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 
TDWB LLE in aircast boot, and will be discharged on lovenox x 2 
weeks for DVT prophylaxis. The patient will follow up in two 
weeks with Dr. ___ per 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:
Prozac
 
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H 
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 
3. Docusate Sodium 100 mg PO BID 
4. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Doses 
Start: Today - ___, First Dose: Next Routine Administration 
Time 
RX *enoxaparin 40 mg/0.4 mL 1 syringe SC once a day Disp #*14 
Syringe Refills:*0
5. Lorazepam 0.5 mg PO Q8H:PRN Anxiety 
6. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN Pain 
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6H Disp #*80 Tablet 
Refills:*0
7. Senna 8.6 mg PO BID 

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
left distal tibia/fibula 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 Orthopedic 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.
 
Medicines
 
- Resume taking your home medications unless specifically 
instructed to stop by your surgeon. Please talk to your primary 
care doctor within the next ___ weeks regarding this 
hospitalization and any changes to your home medications that 
may be necessary.
- Do not drink alcohol, drive, or operate machinery while you 
are taking narcotic pain relievers (oxycodone/dilaudid).
- As your pain lessens, decrease the amount of narcotic pain 
relievers you are taking. Instead, take acetaminophen (also 
called tylenol). Follow all instructions on the medication 
bottle and never take more than 4,000mg of tylenol in a single 
day.
- If you need medication refills, call your surgeon's office 
3-to-4 days before you need the refill. Your prescriptions will 
be mailed to your home.
- Please take lovenox for 2 weeks to help prevent the formation 
of blood clots.
 
Constipation
 
- Both surgery and narcotic pain relievers can cause 
constipation. Please follow the advice below to help prevent 
constipation.
- Drink 8 glasses of water and/or other fluids like juice, tea, 
and broth to stay well hydrated.
- Eat foods that are high in fiber like fruits and vegetables.
- Please take a stool softener like docusate (also called 
colace) to help prevent constipation while you are taking 
narcotic pain relievers. 
- You may also take a laxative such as senna (also called 
Senokot) to help promote regular bowel movements. 
- You can buy senna or colace over the counter. Stop taking them 
if your bowel movements become loose. If your bowel movements 
continue to stay loose after stopping these medications, please 
call your doctor.
 
Incision
 
- Please return to the emergency department or notify your 
surgeon if you experience severe pain, increased swelling, 
decreased sensation, difficulty with movement, redness or 
drainage at the incision site.
- You can get the wound wet/take a shower starting 3 days after 
surgery. Let water run over the incision and do not vigorously 
scrub the surgical site. Pat the area dry after showering.
- No baths or swimming for at least 4 weeks after surgery.
- Your staples/sutures will be taken out at your 2-week follow 
up appointment. No dressing is needed if your wound is 
non-draining. 
- You may put an ice pack on your surgical site, but do not put 
the ice pack directly on your skin (place a towel between your 
skin and the ice pack), and do not leave it in place for more 
than 20 minutes at a time.
 
Activity
 
- Your weight-bearing restrictions are: touich down weight 
bearing in the left lower extremity.
- You should wear your Aircast boot at all times.
 

Physical Therapy:
TDWB LLE in aircast boot with assistive devices
ROMAT at all joints
Treatments Frequency:
Sutures/staples to be removed upon clinic follow up appointment 
in 2 weeks
Daily dressing changes until no drainage, then leave open to air 
in aircast boot
 
Followup Instructions:
___

{'left leg pain': ['Closed fracture of shaft of fibula with tibia'], 'anxiety': ['Anxiety state'], 'COPD': ['Chronic airway obstruction']}