Closed fracture of acetabulum Pedal cycle accident injuring pedal cyclist Accidents occurring in unspecified place
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: ORTHOPAEDICS
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
right acetabular fracture
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
HPI: ___ male presents with right hip pain. Patient was 
biking at about 3 pm today, got into an accident, went over the 
handlebars. He reports head strike while wearing helmet, no loss 
of consciousness. No head, neck, or back pain. Right hip pain 
with difficulty walking. He limped back home and was taken to 
urgent care where he underwent x-rays showing acetabular 
fracture. He was transferred to ___ for further care.

 
Past Medical History:
None
 
Social History:
___
Family History:
Non-contributory.
 
Physical Exam:
Exam on discharge:
Right lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
 
Pertinent Results:
___ 06:33PM   WBC-10.9 RBC-4.83 HGB-14.6 HCT-41.7 MCV-86 
MCH-30.1 MCHC-34.9 RDW-13.2
 
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 right acetabular fracture and was admitted to the 
orthopedic surgery service. The patient was given a trial of 
non-operative management and worked with physical therapy. 
Repeat XRs were performed after mobilization with ___. The 
patient's home medications were continued throughout this 
hospitalization. The patient worked with ___ who determined that 
discharge to home was appropriate. 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 in the right lower extremity. The patient will follow up 
with Dr. ___ 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:
None
 
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H 
Do not exceed 4g/day. 
2. Diazepam 5 mg PO Q6H:PRN muscle spasm 
Do not drink alcohol, drive, or use heavy machinery while 
taking. 
3. Docusate Sodium 100 mg PO BID 
4. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN Pain 
Do not drink alcohol, drive, or use heavy machinery while 
taking. 

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Right acetabular 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 ORTHOPAEDIC SURGERY:

- You were in the hospital for an Orthopaedic injury. It is 
normal to feel tired or "washed out", 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:
- Touchdown weight bearing right lower 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 lovenox 40mg daily for 2 weeks

DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the 
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning 
changes in your incision
- Persistent or increasing numbness, tingling, or loss of 
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid, 
medications down
- Any other medical concerns

 
Followup Instructions:
___

{'right hip pain': ['Closed fracture of acetabulum'], 'head strike': ['Pedal cycle accident injuring pedal cyclist'], 'difficulty walking': ['Closed fracture of acetabulum']}