TIRUNELVELI MEDICAL COLLEGE AND HOSPITAL

DEPARTMENT OF ORTHOPAEDICS
DISCHARGE SUMMARY
UNIT : ORTHO-1 UNIT CHIEF : Prof. Dr. Manikandan (MS ORTHO)

NAME : murugan IP NO : 58821 D.O.A : 11/7/22

AGE / SEX : 38/male D.O.S : 22/7/22

ADDRESS: s/o vel , Indra colony , sennikulam , sanuaronuovil tenkasi D.O.D : 22/8/22

Diagnosis: Right compound Grade 3 both bone leg fracture

Procedure Done: TENS nail for fibula

HISTORY OF PRESENT ILLNESS

Alleged H/O RTA

History & nature of injury noted as per AR

Past history-

N/ k/c/o Hypertension/ Coronary arterial disease/Diabetes mellitus/ Tuberculosis / Epilepsy/

Bronchial asthma/ seizure disorder

CLINICAL EXAMINATION FINDING :

General Examination : Conscious, oriented, Afebrile,

L/E of Right lower limb : laceration made of size 7*3*3cm over anterior aspect of leg

Tendon muscle exposed

3*3 cm over Right foot

DP +

abnormal movements
 Distal pulse +

Active foot movements+

B/L clavicle clinically normal

PCT, PDT negative

Other long bone clinically normal

INVESTIGATION :

BLOOD INVESTIGATION: RADIOLOGICAL INVESTIGATION :

WBC- 12100cells/mm3

DC : PP- 81% L 9% E-10% X ray Right knee joint with leg: AP, lateral

RBC – 3.61million cells/ mm3 Chest xray

Hb- 10.8/dl, X ray of leg with angle joint: AP, lateral

PCV – 30.3%

Platelets – 4.12 lacs

RBS – 74mg/dl

Urea – 17mg/dl

Creatinine – 0.6mg/dl

Sodium – 141meq/l

Potassium – 4.1 meq/l

COVID -NEG

HBsAg Negative

HCV Negative

HIV Non-Reactive

Blood group :- O positive

Operative notes

Under SAP under SA patient in supine position parts painted and draped. 3.5 mm TENs nail
inserted from fibula after achieving reduction with bone clamp . A 400mm LRS rail fixed to their
& 2 schanz pin inserted proximally . Another 2 schanz pin inserted proximally to fracture & 3
schanz pin inserted distal to fracture. Fracture reduced found to be satisfactory . Compound site
suture removed & wound wash given using saline , betadine & hydrogen peroxide. After
completed hemostasis wound closed in layers ,sterile dressing applied.

Condition at discharge:

Post – operative Period

Post operative Period uneventful

Wound healthy

No discharge

Regular cleaning and dressing done

ADVICE ON DISCHARGE :

Continue Lumbo-sacral belt

Avoid twisting, turning, bending forward movements

Avoid lifting, pushing, pulling heavy weight

Review in ortho1 OPD after 3 weeks on monday

Continue

T. Linezolid 600 mg 101

T Cipro 500 mg. 101

Tab Paracetamol 500mg 1 1 1

Tab Ranitidine 150 mg 101 2 Weeks

Tab Vit B complex 101

Tab.Cal 010

Tab.Vit c 10 1

C pregabalin 75 mg 1 hs
Advice to get medicine nearby PHC or GH.

PREPARED BY : Dr karthikeyan

CHECKED BY : Dr Abdul