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    All India Institute of Medical Sciences, Patna: Department of Orthopaedics Discharge Summary

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    Manindra Nayak
    1. The patient, a 20-year-old female, was admitted to the hospital with fractures of the left elbow bone and right forearm bone following an assault. 2. She underwent surgery to repair the fractures, involving the insertion of plates, screws, and wires. 3. Her post-operative recovery was uneventful, and she was discharged with instructions to follow-up in 3 weeks and continue various medications and physiotherapy exercises.

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    All India Institute of Medical Sciences, Patna: Department of Orthopaedics Discharge Summary

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    Manindra Nayak
    56 views2 pages
    1. The patient, a 20-year-old female, was admitted to the hospital with fractures of the left elbow bone and right forearm bone following an assault. 2. She underwent surgery to repair the fractures, involving the insertion of plates, screws, and wires. 3. Her post-operative recovery was uneventful, and she was discharged with instructions to follow-up in 3 weeks and continue various medications and physiotherapy exercises.

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    1. The patient, a 20-year-old female, was admitted to the hospital with fractures of the left elbow bone and right forearm bone following an assault. 2. She underwent surgery to repair the fractures, involving the insertion of plates, screws, and wires. 3. Her post-operative recovery was uneventful, and she was discharged with instructions to follow-up in 3 weeks and continue various medications and physiotherapy exercises.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    56 views2 pages

    All India Institute of Medical Sciences, Patna: Department of Orthopaedics Discharge Summary

    Uploaded by

    Manindra Nayak
    1. The patient, a 20-year-old female, was admitted to the hospital with fractures of the left elbow bone and right forearm bone following an assault. 2. She underwent surgery to repair the fractures, involving the insertion of plates, screws, and wires. 3. Her post-operative recovery was uneventful, and she was discharged with instructions to follow-up in 3 weeks and continue various medications and physiotherapy exercises.

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    of 2

    R DEPARTMENT OF ORTHOPAEDICS

    ALL INDIA INSTITUTE OF MEDICAL SCIENCES, PATNA


    Discharge Summary
    Date of admission: 13/11/19
    Name: LALAN KUMAR
    Date of operation: 26/11/19
    Age/Sex: 20/F
    Consultant in charge: DR ANUP KUMAR Date of discharge: 7/12/19
    DR SUDEEP KUMAR IPD No: 109112019019571
    CR No: 109111902305684
    Address.DARBHANGA, BIHAR
    MOB : 8409896552

    Diagnosis: FRACTURE LT OLACRANON AND FRACTURE RT SHAFT OF ULNA

    CLINICAL SUMMARY:patient came with c/o pain in lt elbow and pain in rt forearm for 8
    days
    Patient was allegedly involved in assualt and was beaten with log following which he
    attained injury on 4/11/19 at 11 am

    ON EXAMINATION (at the time of admission):


    Patient is conscious and well oriented to time, place and person. Vitals stable.

    LOCAL EXAMINATION:
    Rt forearm- a/e slab present, dnvs- intact
    Lt arm- mild swelling present, tenderness present, rom-restricted d/t pain, dnvs- intact

    BLOOD INVESTIGATION:
    Hb%:14.2 TLC:8.77 thousand/ microlitre PLATELETS:125 thousand/ microlitre
    VIRAL MARKERS: NON REACTIVE.
    KFT: UREA:29.4, CREATININE :0.72, Na+ :134.57, K+ :3.70
    LFT: Total bilirubin:2.43, Direct:0.92, Indirect:1.51,ALT :55.1,AST:37, ALP-
    98.3,Albumin:3.86,Globulin :2.56
    PT: INR: 20.9/1.82

    RADIOLOGY: FRACTURE LT OLACRANON AND FRACTURE RT SHAFT OF ULNA


    Final diagnosis- FRACTURE LT OLACRANON AND FRACTURE RT SHAFT OF ULNA

    OPERATION- TBW LT OLACRANON, PLASTRY OF RT ULNA


    IMPLANT:SYNTHES
    RIGHT SIDE:1/3RD TUBULAR LOCKING PLATE 6 HOLED
    3.5MM CORTICAL LOCKING SCREWS 14MM-4
    16MM-1
    LEFT SIDE:TBW
    1MM DIAMETER SS WIRE
    2 K WIRES
    POST OP HOSPITAL STAY: Uneventful

    AT THE TIME OF DISCHARGE: Patient conscious, oriented, afebrile,no wound


    soakage,wound healthy,sutures removed, no distal neurovascular deficit.

    DISCHARGE ADVICE:
    1. T.SIGNOFLAM 1 TAB BD FOR 3 DAYS AND THEN SOS
    2. T.PANTOP 40MG 1 TAB BEFORE BREAKFAST FOR 3 DAYS
    3. T.VITAMIN-C 500MG 1 TAB BD FOR 1 MONTH
    4. C.B-COMPLEX 1 TAB OD FOR 1 MONTH
    5.T.CALCIUM 500MG OD FOR 1 MONTH

    PHYSIOTHERAPY EXERCISES: left shoulder abduction and adduction excercises, passive


    flexion and extension exercises of both upper limbs

    NOTE: In case any fever, increase in pain, swelling and discolouration, immediately report
    to orthopaedic OPD /ward / emergency.

    FOLLOW UP:
    Review in orthopaedics opd after 3 weeks in Ortho OPD (MON/WED)

    JUNIOR RESIDENT SENIOR RESIDENT CONSULTANT IN CHARGE

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