Displaced trimalleolar fracture of right lower leg initial encounter for closed fracture Fall (on) (from) other stairs and steps initial encounter Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
right ankle fracture dislocation
 
Major Surgical or Invasive Procedure:
right ankle surgical fixation

 
History of Present Illness:
___ healthy female who sustained a right ankle injury 
following a mechanical slip and fall down stairs.  She states 
she was packing to fly home tomorrow morning when she was going 
to load up her suitcase down stairs, slipped on the last step, 
twisting and injuring her ankle.  Denied head strike or loss of 
consciousness.  She is not currently on anticoagulation.  She 
denies any numbness or paresthesias in the right foot.  She 
denies any previous injury to the right ankle.  Notably she is 
currently in town visiting her son.  She lives in ___ 
currently.  She is here with her husband and son.

 
Past Medical History:
none
 
Social History:
___
Family History:
noncontributory
 
Physical Exam:
Right lower exam
-splint c/d/I
-grossly moves exposed toes
-silt in exposed toes
-toes WWP 
 
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 ankle fracture dislocation and was admitted to 
the orthopedic surgery service. The patient was taken to the 
operating room on ___ for open reduction internal fixation of 
right ankle fracture, 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 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 
nonweightbearing in the right lower extremity in a splint, and 
will be discharged on Lovenox for DVT prophylaxis. The patient 
will follow up with Dr. ___ routine.  Alternatively, 
since she is from ___ she may choose to follow-up 
with an orthopedic provider ___.  She was instructed to 
follow-up in 2 weeks.  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 1000 mg PO Q6H  
2.  Docusate Sodium 100 mg PO BID  
3.  Enoxaparin Sodium 40 mg SC QHS 
RX *enoxaparin 40 mg/0.4 mL ___t bedtime Disp #*28 
Syringe Refills:*0 
4.  OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain 
don't drink or drive while taking 
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours 
PRN Disp #*30 Tablet Refills:*0 
5.  Senna 8.6 mg PO BID  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
right ankle 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:
Discharge Instructions:

INSTRUCTIONS AFTER ORTHOPAEDIC 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.

ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing right lower extremity in splint

MEDICATIONS:
  1)  Take Tylenol ___ every 6 hours around the clock. This is 
an over the counter medication.
  2)  Add oxycodone as needed for increased pain. Aim to wean 
off this medication in 1 week or sooner.  This is an example on 
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days, 
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.  
Then continue with Tylenol for pain.
  3)  Do not stop the Tylenol until you are off of the narcotic 
medication.
  4)  Per state regulations, we are limited in the amount of 
narcotics we can prescribe. If you require more, you must 
contact the office to set up an appointment because we cannot 
refill this type of pain medication over the phone. 
  5)  Narcotic pain relievers can cause constipation, so you 
should drink eight 8oz glasses of water daily and continue 
following the bowel regimen as stated on your medication 
prescription list. These meds (senna, colace, miralax) are over 
the counter and may be obtained at any pharmacy.
  6)  Do not drink alcohol, drive a motor vehicle, or operate 
machinery while taking narcotic pain relievers.
  7)  Please take all medications as prescribed by your 
physicians at discharge.
  8)  Continue all home medications unless specifically 
instructed to stop by your surgeon.
      
ANTICOAGULATION:
- Please take Lovenox 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.
- Incision may be left open to air unless actively draining. If 
draining, you may apply a gauze dressing secured with paper 
tape.
- If you have a splint in place, splint must be left on until 
follow up appointment unless otherwise instructed. Do NOT get 
splint wet.

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

THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB

 
Followup Instructions:
___

{'right ankle fracture dislocation': ['Displaced trimalleolar fracture of right lower leg'], 'mechanical slip and fall down stairs': ['Fall (on) (from) other stairs and steps'], 'twisting and injuring ankle': ['Displaced trimalleolar fracture of right lower leg'], 'denied head strike or loss of consciousness': [], 'denies any numbness or paresthesias in the right foot': [], 'denies any previous injury to the right ankle': []}