Nonunion of fracture Other and unspecified alcohol dependence unspecified
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: ORTHOPAEDICS
 
Allergies: 
Hayfever / Adhesive Tape / Latex
 
Attending: ___.
 
Chief Complaint:
Right humerus nonunion
 
Major Surgical or Invasive Procedure:
___:  ORIF Right humerus ___

 
History of Present Illness:
Mr. ___ is a gentleman who had a fall and
sustained a proximal humerus and humeral shaft fracture about
9 months ago.  This was initially treated with closed
management.  However, he has gone on to develop a nonunion of
his humeral shaft fracture.  He has had a CT scan that shows
a nonunion and has failed a bone stimulator.  At this point,
given the pain and deformity he is having, a decision was
made to proceed with operative intervention
 
Past Medical History:
Right Distal Humeral Fracture in ___  
Alcoholism  

 
Social History:
___
Family History:
Non-contributory  
 
Physical Exam:
Upon admission
Alert and oriented
Cardiac:  Regular rate rhythm
Pulm:  Lungs CTA ___
Abdomen:  Soft, NT, ND 
Extremities: + sensation/movement, + pulses, skin intact

 

 
Pertinent Results:
___ 01:59PM   WBC-7.0# RBC-2.99* HGB-10.4* HCT-31.2* 
MCV-104* MCH-34.8* MCHC-33.4 RDW-17.7*
___ 01:59PM   PLT COUNT-84*
 
Brief Hospital Course:
Mr ___ admitted to ___ on ___ s/p ORIF R Humerus 
___. On ___ pt was taken to the operating room and 
underwent an ORIF of his fracture. He tolerated the procedure 
and anesthesia well and was transferred to the recovery room, 
and then to the floor. Pt was given ancef x 24hours post-op. He 
was to remain ___ RUE
.
The rest of his hospital stay was uneventful with his lab data 
and vital signs within normal limits and pain well controlled.  
He is being discharged today in stable condition
 
Medications on Admission:
Pantoprazole 40mg QD
 
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One 
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).  
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QOD ().  
4. Fluocinonide 0.05 % Cream Sig: One (1) Appl Topical BID (2 
times a day).  
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as 
needed for Constipation.
Disp:*50 Tablet(s)* Refills:*1*
6. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal 
HS (at bedtime) as needed for constipation.
Disp:*20 Suppository(s)* Refills:*1*
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO ONCE 
(Once) for 1 doses.  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Right humerus ___

 
Discharge Condition:
Stable

 
Discharge Instructions:
Continue to be non-weight bearing on your right arm, wear your 
sling for comfort

Please take all medication as prescribed

If you have any increased redness, drainage, or swelling, or if 
you have a temperature greater than 101.5, please call the 
office or come to the emergency department.

You have been prescribed a narcotic pain medication.  Please 
take only as directed and do not drive or operate any machinery 
while taking this medication.  There is a 72 hour ___ 
through ___, 9am to 4pm) response time for prescription refil 
requests.  There will be no prescription refils on ___, 
___, or holidays.  Please plan accordingly.    
 
Followup Instructions:
___

{'pain': ['Nonunion of fracture'], 'deformity': ['Nonunion of fracture']}