|| Jai Sri Gurudev II
Adichunchanagiri Hospital & Research Centre
B.G. NAGARA – 571448. Nagamangala Taluk, Mandya District
DEPARTMENT OF ORTHOPAEDICS
DISCHARGE SUMMARY
NAME: Mr.PRASHANT SAGAR IP. NUMBER 24-36760
AGE: 31 years DATE OF ADMISSION: 16/12/2024
SEX: Male DATE OF DISCHARGE: 23/12/2024
BED NO: 3 ADDRESS : S/O SIDDAPPA
KARDHYAL BIDAR(D)
UNIT : ORTHO C UNIT CHIEF: DR. Harish K
ORTHO - C ( OPD : Wednesday/Saturday)
DR. Harish K (Professor)
Dr. Bellad S H (Associate Professor)
Dr. Guruprasad shivanna ( AssistantProfessor)
Dr.Sahil (Senior Resident)
Dr.Kiran (Senior Resident)
BUCKET HANDLE TEAR OF LATERAL MENISCUS OF RIGHT SIDE WITH 2YR OLD UNITED
DIAGNOSIS OPERATED DISTAL END FIBULA FRACTURE OF RIGHT SIDE
DIAGNOSTIC ARTHROSCOPY WITH MENISCAL BALANCING WITH IMPLANT REMOVAL
TREATMENT DONE UNDER SPINAL ANAESTHESIA ON 20/12/2024.
CHIEF COMPLAINTS AND HISTORY OF PRESENTING ILLNESS:
C/ o pain and locking of knee on and off over right knee since 8months
A/H/O self fall in his residence -8months ago
Patient was apparently alright then he had self fall after which he complains pain over right knee. Pain was sudden
in onset , continuous in nature ,aggravates on movement at knee ,non radiating,relieving on rest and medication.
No H/O LOC/vomiting /seizures present /ENT Bleed
No H/o breathlessness/ abdominal pain
No H/o blunt trauma to chest/abdomen/external genitalia
Past history:
K/c/o T2DM and on Tab Metformin 500mg 1-0-0 ,HTN on Tab Telmikind -H 1-0-0
Not a K/c/o,BRONCHIAL ASTHMA,Epiepsy,TB
Family history
H/o DM and HTN for father
Personal history :
Diet :mixed
Appetite :normal
Sleep : adequate
Bowel and Bladder : normal and regular
CLINICAL EXAMINATION:
Patient is a young male , who is moderately built and nourished, conscious and oriented to time, place and person.
Vitals:
PR-82bpm
RR-16cpm
Temp-Afebrile
BP- 130/90 mmhg
SpO2- 99%@RA
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
Gait - normal
Attitude- Patient is examined in supine position
Patient B/L shoulder lies at same level
Patients head, neck,trunk and spine lies central
B/L ASIS and PSIS same level
Spine center
Right lower limb
Local Examination
Right lowerlimb :
Inspection:
No external wound
No Swelling present
Bony deformities present
Active toe vmovements present
No skin changes
No sinuses/scars
Palpation:
All inspection findings are confirmed
Bony tenderness present
Sensations positive
Bony crepitus not present
Active toe movements present
Macmurray test present
Anterior drawer test (-)
Posterior drawer test (-)
Apleys tesy (-)
DPA / PTA :::
ROM: Hip : normal
Knee: painfull
Ankle : normal
Systemic examination:
CVS: S1 S2 heard, no murmurs
CNS: conscious, oriented
P/A: Soft, non-tender, Bowel sounds present
RS: Bilateral air entry +
Investigations:-
DATE: 16/12/2024
Hb 19.1gm/dl UREA 15.3 mg/dl
(Hemoglobin)
URIC ACID 7.4
. TC 10880cells/cumm CREATININE 0.7 mg/dl
. DC N-62,L-29,E-05,M-03,B-01 SODIUM 137
. PLT 1.49 lakhs/cumm POTASSIUM 3.2
. Pcv 57.0 CHLORIDE 99
. ESR 2 LFT Total bilirubin:1.6
Direct bilirubin:0.4
Indirect bilirubin:1.2
Total protein:7.1
S.Albumin:4.2
S.Globulin:2.9
A/G Ratio:1.3
SGOT:25
SGPT:25
Alkaline phosphatase:86
. BT 2min 15sec HIV Negative
. CT 5min 35 secs HbsAG Negative
. PT 14.3 HCV Negative
. INR 0.9 BLOOD GROUP ABpositive
. APTT 29 URINE ANALYSIS 6-8 pus cells,
bacteria present
. PPBS 289 RTPCR -
FBS 154 HbA1c 6.9
. TROPONIN I <0.1 UKB -
Total cholesterol 118 VLDL 51.5
Triglycerides 258 Cholesterol/HDL 4.1
HDL 29 LDL/HDL 2.1
LDL 61.3 TG/HDL 8.9
XRAY - NO RADIOLOGY ABNORMALITIES
Treatment given:- DIAGNOSTIC ARTHROSCOPY WITH MENISCAL BALANCING AND IMPLANT REMOVAL
ON 20/12/2024.
-INJ PAN 1-0-0 FOR 3 DAYS
-INJ AMIKACIN 500MG FOR 3 DAYS
-INJ GRAMOCEF S 1.5MG 1-0-1 FOR 3DAYS
-INJ EMESET IV SOS
-INJ PCT 1GM IV SOS
-INJ DYNAPAR AQ 1-0-1 FOR 3DAYS
-TAB CYBERDOL FORTE 3 DAYS
-REGULAR STERILE DRESSING WAS DONE ALTERNATIVE DAYS
CONDITION AT DISCHARGE: POD-03
Vitals -stable
Pain reduced
Long knee brace present
All SUTURES intact
Dressing intact
No soak age
Active toe movements
DPA /PRA Pulse parent
Sensations +
No DNVD
Course in the hospital
Patient presented to OPD with above mentioned complaints and was admitted to male orthopedic ward and was
diagnosed with BUCKET HANDLE TEAR OF LATERAL MENISCUS OF RIGHT SIDE WITH 2YR OLD UNITED OPERATED
DISTAL END FIBULA FRACTURE WITH INPLANT INSITU RIGHT SIDE . Medicine fitness for surgery was taken and
underwent DIAGNOSTIC ARTHROSCOPY WITH MENISCAL BALANCING AND IMPLANT REMOVAL DONE UNDER
SPINAL ANAESTHESIA ON 20/12/2024. Pain reduced , regular dressing was done and patient fit for discharge.
ADVICE ON DISCHARGE:
Wound care and regular dressing to be done
PARTIAL WEIGHT BEARING MOBILISATION FOR 2 WEEKS
Active mobilization of knee
QUADRICEPS STRENGTHENING EXERCISES
TAB GRAMOCEF CV 1-0-1 FOR 5days
TAB ESOFAG 40MG 1-0-0 FOR 5days
TAB.SUPRACAL 500MG 0-1-0 FOR 30DAYS
TAB.LIMCEE 500MG 1-0-1 FOR 15DAYS
TAB.ZERODOL SP 1-0-1 FOR 5DAYS
TAB TENDOPRO 0-1-0 FOR 15 DAYS
REGULAR DRESSING ON WEDNESDAY AND SATURDAY.
FOLLOW-UP:
Review after 1 weeks in ORTHO C OPD (Wednesday)
Further follow up in Orthopaedics OPD on Wednesday and Saturday
IF ANY OF THE FOLLOWING “WARNING SIGNS” LIKE EXCESSIVE PAIN, FEVER, DISCHARGE, AND
SWELLING OCCUR PLEASE CONTACT ON THE DETAILS GIVEN BELOW IMMEDIATELY.
IN CASE OF EMERGENCY/URGENCY PLEASE CALL 08234287075
WRITTEN BY: Dr. Sudarshan k s
VERIFIED BY: Dr. Harish K
SIGNATURE OF UNIT CHIEF
