DISCHARGE SUMMARY

PATIENT NAME
Jack Richardson

PATIENT ID
157900

ADMITTED
07/04/2024

DISCHARGED
07/16/2024

ADMITTING PHYSICIAN
Jason Karns, MD

PROCEDURES
Open reduction, internal fixation of fractures.

COMPLICATIONS
None.

ADMITTING DIAGNOSIS
Multiple trauma from motor vehicle accident, brought in through emergency
room.

HISTORY
The patient is a 31-year-old Caucasian male who was involved in an MVA
approximately 2 hours prior to admission. On admission he was noted to
have an unstable pelvis and a traumatic laceration through the left
perineum, indicative of an open fracture. The patient also had a left femoral
head dislocation. X-rays of the left foot and ankle revealed a severe fracture,
left ankle. Patient was admitted to general surgery service to rule out intra-
abdominal injury.

HOSPITAL COURSE
The day following admission, the patient underwent open reduction, internal
fixation of his fractured pelvis, and ankle fracture. He did well following
surgery and was ambulating on postoperative day 2. He began rehabilitation
in the physical therapy department and will continue physiotherapy following
discharge. He remained afebrile throughout his hospital stay. On discharge,
all wounds were healing without complication and were clean and dry. There
were no signs of infection. A short leg cast was applied to the left leg prior to
discharge.

(Continued)
DISCHARGE SUMMARY

Patient Name: Jack Richardson

Patient ID: 157900
Discharged: 07/16/2024
Page 2

DISCHARGE MEDICATION
Tylenol NO. 3, one p.o., q. 4-6 h.

DISCHARGE INSTRUCTIONS
Patient is to be seen in orthopedic clinic in 1 week for wound check and x-
rays of the pelvis and left ankle. He will be seen in general surgery service in
2 weeks. Activities as tolerated, elevate the leg, call if he has any problems
prior to his follow-up visit.

DISCHARGE DIAGNOSES
1. Fracture, left ankle.
2. Fractured pelvis.

Jason Karns, MD
Family Practice

JK:rf
D: 08/02/2024
T: 08/03/2024