TIRUNELVELI MEDICAL COLLEGE AND HOSPITAL

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

NAME : Karthik Raja IP NO : 68995 D.O.A : 12/8/22

AGE / SEX : 24/male D.O.S : 16/8/22

ADDRESS: s/o gurusamy ,791 dulasing nagar , manthithoppu D.O.D : /8/22

Perumal Kovil street , kovilpatti, Thoothukudi

Diagnosis: Non union both bone leg fracture

Procedure Done: CRIF with ILIM nailing

HISTORY OF PRESENT ILLNESS

24 yr old male came to hospital with

C/o pain in Right leg for past 3 month

No H/o fever

No H/o swelling

No H/o pus discharge

Pt apparatus normal 3month back sustained RTA on 5/05/22 , got admitted in madurai medical
College ,was diagnosed as compound grade 3A both bone Right leg , treated with external
fixator with flap cover on Right leg.

Patient also had sustained injury to Left leg & was diagnosed as closed both bone left leg &
treated with CRIF with ILIM nailing on 05/05/22

External fixator was removed on 22/7/22 in tvmch AK slab applied.

No H/o suggestive of head injury, chest injury, abdomen injury

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 :

Flap cover seen in medial aspect of distal 3rd of Right leg necrosed skin tissue seen over medial
aspect of Right heel .

No Tenderness

No Swelling

bony crepitus +

Bony deformity +

abnormal mobility +

Distal pulse +

Active toe movement+

ROM full

B/l clavicle & other long bone clinically normal

PDT , PCR negative

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

Other long bone clinically normal

Non union both bone middle 3rd - right leg

INVESTIGATION :

BLOOD INVESTIGATION: RADIOLOGICAL INVESTIGATION :

WBC-13100cells/mm3 Xray of knee joint with leg : AP/lateral

DC : PP- 76% L 14% E-10% Xray of leg with ankle joint & foot:
AP/lateral/oblique.
RBC – 4.66million cells/ mm3

Hb- 7.2/dl,

PCV – 27.9%

Platelets – 2.90 lacs

RBS – 82mg/dl
Urea – 23mg/dl

Creatinine- 0.8mg/dl

Sodium – 137meq/l

Potassium – 3.9meq/l

COVID -NEG

HBsAg Negative

HCV Negative

HIV Non-Reactive

Blood group :-0 postive

Operative notes

Under SAP , under spinal anesthesia patient in supine position, pt is painted & draped ,

Incision of size 6cm made over lateral aspect of middle 3rd of right leg , fibulectomy done .
Incision of size 8cm made from inferior pole of patella to tibial tubercle .patell patella tendon
split . Entry point made. Sequential renaming done tibial nail of size 10*34cm inserted & fixed
distally with 2 screw 4.5 mm cortical bone & proximal with two 4.5mm cortical both fracture
end were freshened . Bone graft were filled in the fracture gap. After complete hemostasis,
wound closed in layer. Sterile dressing done. Distal pulse dorsalis pedis , posterior tial felt at the
end of the procedure.

Condition at discharge:

Post – operative Period

Post operative Period uneventful

Wound healthy

No discharge

Regular cleaning and dressing done

ADVICE ON DISCHARGE :

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