STATUS REPORT

DEPARTMENT OF ORTHOPAEDICS

UHID ENCOUNTER NO

Ms. ANUSUYAMMA M
64 Years / Female
HANUMAREDDY COLONY 5256651 902504198047
GOLLAHALLI KARNATAKA -
DATE OF ADMISSION
560100 IP NR.
19 APR 2025
1904251812044

WARD/ROOM UNIT DATE OF DISCHARGE

ORTHO COMMON WARD (A) - FEMALE - ORTH3 22 APR 2025
A BLOCK 5th FLOOR / 5012-A

CONSULTANTS : Ortho Unit III : Dr. Madan Mohan.M (HOD) , Dr. Rajkumar S. Amaravati , Dr.
Sandesh G.M , Dr. Anoop.P : Emergency Contact: 080 22065800 (Ward) ,
080-22065040 (OPD) .

PRINCIPAL DIAGNOSIS : RIGHT SHAFT OF FEMUR FRACTURE MID 1/3 RD

PROCEDURE(S) : CLOSED REDUCTION AND INTERNAL FIXATION OF THE RIGHT FEMUR

FRACTURE WITH IMILN (MIREL - TITANIUM) DONE AS AN ELECTIVE
PROCEDURE UNDER GENERAL ANAESTHESIA ON 22/04/25

HISTORY : Presenting complaints:

Complaints of right thigh pain since 2 days

History of presenting illness:

64 year old, no known co-morbidities, came with alleged history of slip and
fall at home 2 days back sustained closed injury to right thigh associated
with sudden onset of pain and inability to bear weight on affected limb,
gradually progressive, aggravated on movment, relived with rest.
No history of LOC/head injury
No history of radiculopathy
No history of any other joint involved.

Past history:
Nil

Family history:
Nil

Personal history:

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UHID : 5256651 ENCOUNTER NO : 902504198047 IP NR : 1904251812044

Bowel and bladder movements normal

Sleep and appetite normal.

PHYSICAL EXAMINATION : General physical examination:

Patient is conscious, oriented to time, place and person

Vitals:
HR- 88/min
Peripheral pulses- well felt
RR- 20/min
Temp-Afebrile
BP- 130/80 mm of Hg
SpO2-98% RA
Pallor present
No Icterus/Cyanosis/Clubbing/Edema/Lymphadenopathy

Systemic examination:
RS: Air entry bilaterally equal, NVBS present
CVS:S1,S2 heard, No murmurs
P/A:Soft, non tender, no organomegaly
CNS:NFND

Local examination:Left lower limb

Inspection:
Hip extended, knee extended, ankle in neutral position with apparent
shortening
No scars/sinuses seen
No open injuries

Palpation:
All inspectory findings are confirmed
Tenderness present mid thigh

ROM painfully restricted

Toe movements present
Distal pulses present
No DNVD

LABORATORY INVESTIGATIONS :
DATE INVESTIGATIONS RESULTS UNIT DATE INVESTIGATIONS RESULTS UNIT

20/04/2025 Haemoglobin % (HB) 10.9 g/dl 20/04/2025 Leukocyte Count - Total 7.41 [*10^3
(TC) /μl]

20/04/2025 Neutrophils 61.0 % 20/04/2025 Lymphocytes 29.0 %

20/04/2025 Eosinophils 2.2 % 20/04/2025 Monocytes 7.3 %

20/04/2025 Basophils 0.5 % 20/04/2025 Nucleated RBC 0.0 /100

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UHID : 5256651 ENCOUNTER NO : 902504198047 IP NR : 1904251812044

wbc

20/04/2025 Absolute Neutrophil Count 4.52 [*10^3 20/04/2025 Absolute Lymphocyte 2.15 [*10^3
(ANC) /μl] count (ALC) /μl]

20/04/2025 Absolute Eosinophil 0.16 [*10^3 20/04/2025 Absolute Monocyte Count 0.54 [*10^3
Count(AEC) /μl] (AMC) /μl]

20/04/2025 Absolute Basophil Count 0.04 [*10^3 20/04/2025 Platelet Count 314 [*10^3
(ABC) /μl] /μl]

20/04/2025 Packed Cell Volume (PCV) 32.1 % 20/04/2025 Erythrocyte 31 mm/hr

Sedimentation Rate (ESR)

20/04/2025 Prothrombin Time, 11.4 second 20/04/2025 Prothrombin Time, 12 second

Patient* s Control* s

20/04/2025 INR 0.95 20/04/2025 Activated Partial 24.0 second

Thromboplastin (APTT), s
Patient*

20/04/2025 Activated Partial 30 second

Thromboplastin (APTT), s
Control*

21/04/2025 Serum Sodium 135 mEq/L 21/04/2025 Serum Potassium 4.72 mEq/L

21/04/2025 Serum Chloride 107 mEq/L 21/04/2025 Random Glucose 129 mg/dL

21/04/2025 Serum Urea 29 mg/dL 21/04/2025 Serum Creatinine 0.67 mg/dL

21/04/2025 Serum CRP 3.02 mg/dL 21/04/2025 ABO Blood Group A

21/04/2025 Rh Type POSITIVE 21/04/2025 Human Immunodeficiency Nonreactiv

Virus (HIV) Test e

21/04/2025 Hepatitis B Surface Nonreactiv 21/04/2025 Hepatitis C virus (HCV) Nonreactiv

Antigen ( HBsAg) e Antibodies e

COURSE IN HOSPITAL: : Patient was admitted with above complaints, Pre op. evaluation done,
patient underwent above mentioned procedure. Post operative period was
uneventful. Non weight bearing mobilisation started on Post operative day
2, Wound inspection done on 2nd Post operative day, found healthy.
Patient stable and fit for discharge.

ADVICE ON DISCHARGE : 1. TAB CEFTUM 500 MG BD FOR 5 DAYS.

2. TAB PARACETAMOL 650MG 1-1-1 FOR 10 DAYS.
3. TAB PANTODAC 40MG 1-0-0 FOR 10 DAYS.
4. TAB SHELCAL 500MG 1-0-0 FOR 30 DAYS.
5. D-360 SACHET 60000 I U ONCE A WEEK FOR 4 WEEKS.
6. TAB ECOSPIRIN 150 MG OD FOR 30 DAYS.
7. TAB VITAMIN C 500MG 1-0-0 FOR 30 DAYS.
ICE PACKS FOR 15 MINUTES - 4 TIMES A DAY

PHYSIO - AS ADVISED. NON WEIGHT BEARING WALKING AND FRACTURE

CARE AS ADVISED, CHEST PHYSIOTHERAPY.

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 UHID : 5256651 ENCOUNTER NO : 902504198047 IP NR : 1904251812044

TO REVIEW FOR DRESSING AND SUTURE REMOVAL ON 16/04/2025

SATURDAY AT 3PM.

In case of any emergency, : This is especially if you develop any of the following severe, persistent, new
please report 24/7 to our onset and unusual complaints listed below: "Severe unbearable pains
Emergency or to the nearest anywhere, bleeding anywhere, convulsions, unresponsiveness, loss of
doctor or hospital in your vision, inability to drink liquids, vomiting, diarrhea, breathlessness,
vicinity palpitations, jaundice, absence of urine, fever, rash, joint swellings,
behavioural changes including violence/self-harm/agitation, and
weakness/fatigue" In addition, any of these listed specific complaints for
your condition such as �����

________________________ ________________________
Prepared By : Checked By :

Name : ____________________________________ Name : ____________________________________

KMC NO.: _________________________________ KMC NO.: _________________________________

Date & Time: _______________________________ Date & Time: _______________________________

Summary Recieved by: _____________________ Signature: ________________________________

Receiver`s Contact / Mobile No.: ___________________ Reciever`s Name:____________________________

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