DISCHARGE SUMMARY
Patient Name : Mr Vivek Vodluri Age/Sex :22 yrs /Male
Date of Admission : 12/03/2025 Date of Discharge : 17/03/2025
Consultant : Dr. Piyush Nashikkar
History of Present Illness:
A 22 yr old male patient brought by relative with history of RTA on 11/03/2025 at Subedari
Hyderabad . primary treatment taken at shri chakra superspeciality hospital hanamkonda . now
patient admitted at Rajgire Hospital for further management .
Local Examination: Left Lower Limb
Skin 10cm long sutured CLW with serous discharge present over lateral aspect
of distal tibia. Skin anterior to it shows degloving type of injury with 7x5xm abrasion with skin
blackening.
Swelling Present
Tenderness Present
Deformity No
Crepitus. Present over fibula Shaft
Rom. Normal
Dnvd No
Diagnosis: Open 3b fibula fracture
Surgery : Debridement and VAC dressing
Date : 16/03/2025
Surgeon : Dr. Piyush Nashikkar
Anesthesia : Spinal
Hospital stay: A 22 yr old male patient brought by relative with history of RTA on 11/03/2025 .
patient taken primary treatment at shri chkara hospital hanamkoda , now patient get admitted at
Rajgire Hospital for further management . Here patient was examined by orthopedic surgeon Dr.
Piyush Nashikka and diagnosed with open 3b fibula fracture. Primary debridement and re-
sururing was done on day1 and daily dressing was done to seeflapskin survival. D
Plastic surgeon (Dr. SHRIKANT Perka) opinion was taken and Patient was advised for
Debridement and VAC dressing. The procedure was performed on 16/03/2025. whole procedure
was uneventful. During hospital stay patient was treated with antibiotic , antiemetics , antiacids ,
analgesics and other needfull treatment . now patient is vitally stable and symptomatically
better . so patient is being discharged in stable condition with VAC dressing in situ.
Condition at discharge:
GC fair, Afebrile, Vitals stable
Wound healthy, no soakage
Advice on Discharge:
Tab DiasdacMR 1 tab twice daily (10am & 10pm) x 7 days, after meals
Tab Pantop 1 tab once a daily x 7 days (empty stomach)
Tab CalbonaXT 1 tab once daily for 3 months , after meals
Tab Enzotrip 1 tab thrice daily (10am , 4 pm and 10pm) for 7 days , before meals
Tab Dcode 60k 1 tab once a week for 3 months .
Tab linid 600 1 tab twice daily for 7 days
Other Advice:
Strict non weight bearing
Activities movement
Active finger movements
Ice packs as and when required
Do not wet the dressing
In case of fever, soakage, bleeding or any other complication/ query contact immediately
Review with Dr. Piyush Nashikkar on 20/03/2025 with prior appointment on +91
9096038334 / 9209298334 (Mr. Manoj Kakade)/ 9209298334 (Rajgire Hospital Reception) /
9225538334 (Orthosports Reception)
For Physiotherapy related queries please contact Dr. Shubham Jaiswal (7304446969)
Dr. PIYUSH NASHIKKAR
Orthopedic & Sports Medicine surgeon
MS Ortho (KEM, Mumbai), DNB, MNAMS, FAOA
Fellowship in Shoulder and Knee
Arthroscopy, Sports Medicine, Joint Replacement & Osseointegration (Australia & S. Korea)
