Partial traumatic transphalangeal amputation of left thumb initial encounter Chronic viral hepatitis C Contact with powered woodworking and forming machines initial encounter Other specified industrial and construction area as the place of occurrence of the external cause Cannabis use unspecified uncomplicated
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: ORTHOPAEDICS
 
Allergies: 
ibuprofen
 
Attending: ___.
 
Chief Complaint:
L thumb near complete amputation
 
Major Surgical or Invasive Procedure:
___ ___:
1. Irrigation and debridement down to necrotic bone.
2. Primary IP joint arthrodesis with autograft.
3. Repair of the radial digital nerve.
4. Repair of the ulnar digital nerve.
5. Repair of the ulnar digital artery with a 3 cm vein
    graft from the foot.
6. Full thickness skin graft measuring 5x1.5cm

 
History of Present Illness:
Mr. ___ is a ___ year old male with past medical history
significant for HCV who presents from outside hospital with a
near complete amputation of his left thumb at the 
interphalangeal
joint. Patient states he was using a table saw at work and cut
through his thumb. He denies any other injuries. He has no
sensation distal to the cut.
 
Past Medical History:
Hepatitis C virus                             

 
Social History:
___
Family History:
NC
 
Physical Exam:
NAD
No respiratory distress
RRR
splint c/d/i, decreased sensation in the distal thumb, some 
sensation over dorsal nailbed, cap refill ___
 
Brief Hospital Course:
The patient presented to the emergency department and was 
evaluated by the orthopedic Hand surgery team. The patient was 
found to have L thumb near complete amputation and was admitted 
to the orthopedic surgery service. The patient was taken to the 
operating room on ___ for:
1. Irrigation and debridement down to necrotic bone.
2. Primary IP joint arthrodesis with autograft.
3. Repair of the radial digital nerve.
4. Repair of the ulnar digital nerve.
5. Repair of the ulnar digital artery with a 3 cm vein
    graft from the foot.
6. Full thickness skin graft measuring 5x1.5cm

, 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 was monitored for 24hours there w/ q1h NV exams to 
his L thumb. After 24h he was transferred to the floor. The 
patient was initially given IV fluids and IV pain medications 
including a supraclavicular nerve catheter. He was initially 
kept NPO in case there was a need to potentially take him back 
to the OR for a revision. He progressed to a regular diet and 
oral medications by POD#2. The patient was given ___ 
antibiotics and anticoagulation per routine and antibiotics were 
continued while he was in house. The patient's home medications 
were continued throughout this hospitalization. The patient was 
discharged home with followup in 1 week. 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 
NWB on the LUE, and will be discharged on ASA 162mg for DVT 
prophylaxis. The patient will follow up in Hand Clinic 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:
Methadone
 
Discharge Medications:
1.  Acetaminophen 1000 mg PO Q8H  
2.  Aspirin 162 mg PO DAILY  
3.  Docusate Sodium 100 mg PO BID  
4.  Gabapentin 300 mg PO TID  
5.  OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain  
6.  Senna 8.6 mg PO BID  
7.  Methadone (Concentrated Oral Solution) 10 mg/1 mL 63 mg PO 
DAILY  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
L thumb near complete amputation

 
Discharge Condition:
Stable

 
Discharge Instructions:
- 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:
- Non weight bearing L upper 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 162mg 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.
- Splint must be left on until follow up appointment unless 
otherwise instructed
- Do NOT get splint wet

Physical Therapy:
NWB LUE
Treatments Frequency:
Wound monitoring
Pin care:
The initial dressing may have Xeroform wrapped at the pin site 
with surrounding gauze.
Often, the Xeroform is used in the immediate post-op phase to 
allow for control of the bleeding. The Xeroform can be removed 
___ days after surgery.
If the pin sites are clean and dry, keep them open to air. If 
they are still draining slightly, cover with clean dry gauze 
until draining stops.
If they need to be cleaned, use ___ strength Hydrogen Peroxide 
with a Q-tip to the site.

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

{'near complete amputation of left thumb': ['Partial traumatic transphalangeal amputation of left thumb'], 'decreased sensation in the distal thumb': ['Partial traumatic transphalangeal amputation of left thumb'], 'cut through thumb': ['Partial traumatic transphalangeal amputation of left thumb'], 'no sensation distal to the cut': ['Partial traumatic transphalangeal amputation of left thumb']}