TIRUNELVELI MEDICAL COLLEGE AND HOSPITAL

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

NAME : Velsamy IP NO : 67607 D.O.A : 8/8/22

AGE / SEX : 47/male D.O.S : 18/8/22

ADDRESS: s/o arumugam , 84,pray nagar , tuticorin D.O.D : 22/8/22

Diagnosis: chronic osteomyelitis Left proximal 3rd tibia

Procedure Done: bone curatage with tissue biopsy

HISTORY OF PRESENT ILLNESS

Pain , swelling pus discharge from upper 3rd L leg for past 6 yr

Pain dull aching / insidious in onset progressive in nature

H/o fever positive on & off

No H/o trauma

Patient was apparently normal 6 yr back after which he developed pain , swelling pus discharge
from proximal 3rd Left leg for 6year

I& D done in Thoothukudi medical College 5 years back .admitted & treated with iv antibiotics
for about 4 times

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 left lower limb : generalised mild swelling over anteromedial aspect of left
 tenderness+ warth +

Sinus discharge pus + over anteromedial spected of Left leg

No bony crepitus

No bony defromity

No abnormal

Distal pulses +

Active toe movements +

Examination of other long bone , supine pelvis - apper to be clinically normal

Other long bone clinically normal

INVESTIGATION :

BLOOD INVESTIGATION: RADIOLOGICAL INVESTIGATION :

WBC- 13900cells/mm3

DC : PP- 78% L 16% E-6% X ray left knee joint with leg: AP, lateral

RBC – 5.18million cells/ mm3 Chest xray

Hb- 14.38/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. Sinus along with
heat excised skin , S/C tissue incised & retracted, cavity identified necrotising tissue excised ,
bone curatage done, specimen sent for biopsy , thorough 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