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Sunshine Multi

Mr. Ranjith K, a 32-year-old male, was admitted to Sunshine Multi-Specialty Hospital following a high-impact road traffic accident resulting in a closed comminuted fracture of the right tibia. He underwent emergency surgery (ORIF) and required prolonged rehabilitation, with strict non-weight bearing advised for 12 weeks post-discharge. The patient was discharged stable, conscious, and requires assistance for mobility, along with a follow-up for outpatient physiotherapy.

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36 views1 page

Sunshine Multi

Mr. Ranjith K, a 32-year-old male, was admitted to Sunshine Multi-Specialty Hospital following a high-impact road traffic accident resulting in a closed comminuted fracture of the right tibia. He underwent emergency surgery (ORIF) and required prolonged rehabilitation, with strict non-weight bearing advised for 12 weeks post-discharge. The patient was discharged stable, conscious, and requires assistance for mobility, along with a follow-up for outpatient physiotherapy.

Uploaded by

deviprasadkukkaje07
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Sunshine Multi-Specialty Hospital

Discharge Summary

Patient Name: Mr. Ranjith K IP No: IP/2024/0110/367


Age/Gender: 32 / Male DOA: 10-Jan-2024
Contact no 8901736789 DOD: 20-Jan-2024
Diagnosis
Closed comminuted fracture of the right tibia with significant displacement

Chief Complaint:
Patient presented with excruciating pain, severe swelling, and deformity in the right leg following a
high-impact road traffic accident on 10-Jan-2024. Inability to bear weight on the affected limb.

Clinical Findings:
- Severe swelling, deformity, and bruising of the right leg extending to the knee and ankle
- Significant movement restriction due to severe pain and instability
- Vitals stable, but patient experiencing severe pain (VAS 8-9/10)
- Neurovascular assessment revealed decreased sensation in the right foot

Investigations:
- X-Ray (Right Leg): Comminuted and displaced fracture of right tibia with significant angulation
- CT Scan (Lower Limb): Confirmed comminuted tibial shaft fracture with evidence of soft tissue
injury and no vascular compromise

Course in the Hospital:


- Patient was stabilized and admitted for emergency surgical intervention
- Underwent Open Reduction and Internal Fixation (ORIF) with plating and possible bone grafting on
12-Jan-2024
- Post-op recovery was complicated with wound edema, managed conservatively
- Regular dressing and intensive physiotherapy sessions during hospital stay. Pain managed with IV
and oral analgesics

Outcome:
- Condition stabilized, but patient requires prolonged rehabilitation
- Patient advised strict non-weight bearing for 12 weeks
- Sutures to be removed in 14 days post-discharge
- Referred for follow-up and outpatient physiotherapy

Discharge Medications:
- Tab. Tramadol 50 mg – 1 tab twice a day for 7 days
- Tab. Pantoprazole 40 mg – 1 tab daily for 14 days
- Tab. Calcium + Vitamin D3 – 1 tab daily for 3 months
- Tab, Ceftriaxone 1.5g – 1 tab thrice daily for 7 days

Discharge Condition:
Stable and conscious, but requires assistance for mobility. Mobilized with walker with significant
support. Fit for discharge with home care and outpatient follow-up

Attending Physician:
Dr. Vishal Rao, M.S. (Orthopedics)

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