199 HOSPITAL

DEPARTMENT OF ORTHOPEDIC SURGERY AND SPORTS MEDICINE

MORNING BRIEFINGS REPORT

Da Nang, May 24th , 2022.
Shift: Dr. Tuan;
Nurses: Quoc- Phuc
I. INPATIENT CENSUS

– Inpatient yesterday : 33
– Hospitalized Patient : 06
Discharged patient : 05
– Preoperative : 03
– Postoperative : 03
– Transferred(CK) : 00
– Inpatient today : 34
 II. HOSPITALIZED PATIENT + PREOPERATIVE

1. NGUYEN CANH GIAP : male – 28 yrs - Room No.425

- Address: Đăk Tăng Commune – Kon Plông District – Kon Tum Province.
- Dx: Rupture of ACL (L) / Torn mensicus (L)
- MH: 20 days before admission ( 1/5), the patient fell because he forgot to put his foot on, causing
his left knee to hit the motorbike. After that, the patient felt a lot of pain in the left knee, swelling,
no bleeding, and limited leg flexion, about 2 hours later, swelling, and pain in the left leg. 3/5, the
patient went to Kon Tum hospital and received an MRI with a diagnosis of a partial tear of the
anterior cruciate ligament (L) and was cast in a cast and given treatment, but the patient still felt
pain and loosened the knee (L) should be hospitalized 199.
- Vital signs stable: Pulse rate 80:, BP:120/80 mmHg, RR 20: ,Temp :36.5 degree Celsius.
- Examination : Anterior Drawer Test (L) (+), Posterior Drawer Test (L)(-), Mc Murray(L)(+/-)
- Tx: endoscopic ACL (L) reconstruction surgery, meniscus (L) repair
- Sur: Dr. Tuan
 II. HOSPITALIZED PATIENT

2 . ĐO THI MUOI : female – 88 yrs - Room No.427

- Address: An Hai Tay Commune – Son Tra District – Da Nang city
- Dx:Intertrochanteric Fractures (L)/ hypertension / Diabete type II
- MH: 30 minutes from the hospital admission, the patient slipped and hit her butt on the ground in
the bathroom, did not support her hands, and did not hit her head on the ground. After the fall, the
patient had a lot of pain in the groin area, did not spread, could not stand up, the foot rotated
outside, no swelling, no bruising, and no bleeding, the family was worried, so they took the patient
to the emergency room at the hospital 199 During the procedure, the patient was awake, no
headache, no dizziness, no nausea, no vomiting.
- Vital signs stable: Pulse rate 80:, BP:160/60 mmHg, RR 34: ,Temp :37.1 degree Celsius.
- Tx: reduce pain therapy/ ORIF of L- Intertrochanter
- Sur: Dr.Tuan
 II. HOSPITALIZED PATIENT

3.TRUONG VAN BINH: male – 49yrs - Room No.424

- Address: Hoa Cuong Nam commune, Hai Chau district, Da Nang City
- Dx: wound infection on right foot
- MH: 26 days before admission, the patient suffered burns to his right foot after a traffic accident. The
patient came to TAM TRI hospital for an X-ray of the right leg, no bone damage was detected, and
medicine was given to treat it at home. 1 week later, the wound appeared pus, and was diagnosed with
an infection of the right foot wound at Hai Chau hospital, was given medicine for home treatment,
changed the dressing, and washed the wound. Seeing that the wound did not heal and the pain
increased, the patient went to the hospital for examination 199
- Vital signs: Pulse rate: 68, BP: 135/75 mmHg, RR: 19 ,Temp: 37 degree Celsius.
- Examination: wound on the inner side of the right foot, size 6 x 2 cm, with dry black necrotic tissue,
scaly around the edge of the wound, the bottom has a lot of pus, no granulation tissue, bad smell
- Tx: wound cleaning, debridement, dressing, pain reduce therapy, antibiotic therapy
- Surgeon: Dr Cuong – Dr Tuan
 II. HOSPITALIZED PATIENT

4. NGUYEN NGOC DUOC male-73 years old- Room No 424

- Address: AN HAI TAY , SON TRA, DA NANG
- MH: 11 months ago, a patient riding a motorbike by himself was diagnosed with a broken collarbone (L),
and shoulder blade (L). Then surgery was indicated (unknown). Five months ago, the patient was assigned
to remove the brace, but two weeks before, the patient fell from a car and injured the shoulder (L). After
removing the splint, the patient felt constant pain when moving, could not lie on the left side, and raised
the hand to rotate the inside out about 50%. So the patient returned to hospital 199 for a follow-up
examination.
- PH: The patient has had a stomach ulcer in the past and had surgery to remove 2/3 of the stomach. The
patient smokes and drinks alcohol
- Vital signs stable: pulse rate: 75bpm, BP:110/80mmHg, RR: 20bpm, temp:37 degrees Celsius
- Examination: pain during movement, lateral rotation delay (+), liff off test (+), trumpeter's sign
- Dx: Rotator Cuff Tendinitis (L)
- Tx: suggest MRI for L shoulder
- Sur: Dr Cuong
 II. HOSPITALIZED PATIENT

5. HO VAN HOI male- 52 years old - Room No 427

• Address: Nghia Lo Commune, Quang Ngai Province
• MH: 1 year ago, the patient had a sudden pain in the hip joint ( L), limited mobility. The
patient bought the medicine on his own, but it did not help. 20 days before admission, the
patient went to Phuc Hung hospital - Quang Ngai, took an MRI, and was prescribed oral
medication but did not help. The uncomfortable feeling of pain makes the patient worry and
go to hospital 199 for examination and treatment.
• PH: The patient has a 20-year history of gout Smoking and drinking alcohol
• Vital signs stable: pulse rate: 80 bpm BP:120/80 mmHg, RR:20bpm, Temp: 36,5 degrees
Celsius
• Dx: Avascular necrosis of femur/ Idiopathic Gout
• Tx: total hip (L) replacement surgery
• Surgeon :Dr Tuan
 II. HOSPITALIZED PATIENT + PREOPERATIVE
6. NGUYEN HO SY HUNG: male – 30yrs - Room No.424
- Address: Ho Bac commune, Hoa Vang district, Da Nang City
- Dx: Rupture of ACL (R)/Rupture PCL (R) / Injury of MCL (R)
- MH: 3 weeks before admission, the patient suffered a sports injury, swelling and pain in his right
knee, went to military hospital 17 to get an ultrasound, was diagnosed with fluid in the knee joint,
received 7 days of drug treatment, braced his leg and applied ice. , the swelling and pain are
reduced. On May 20, the patient was re-examined at Military Hospital 17, was x-rayed and
diagnosed with right anterior cruciate ligament rupture. On May 21, the patient went to a private
clinic and was diagnosed with a rupture of the inner ligament of the right knee and a rupture of
the posterior cruciate ligament of the right knee. Because the right knee still hurts, the patient
went to hospital 199 and was hospitalized for treatment
- Vital signs stable: pulse rate: 75, BP: 130/80, RR: 20, temp: 37 degree Celsius
- Examination: Anterior Drawer Test (R) (-), Posterior Drawer Test (R)(+), Valgus stress (R) (+);
Mc Murray(R)(-).
- Tx: endoscopic ACL (R) reconstruction surgery
 III. PREOPERATIVE

1. VO THI MY LIEN : female – 53yrs-insurance – Room No.404

- Address:Son Tra-Da Nang
- Dx: Baker cyst (L)/ Contusion of the left knee (L)
- MH:the onset of symptoms happened this morning after doing morning exercises, the patient felt pain in the
back of the left leg, and limited movement, this afternoon had a lot of pain and was admitted to the hospital.
- Tx : Removed Baker’s /Interlink gastrocnemius
- Surgeon: Dr Diep
 III. Preoperative

2. NGUYEN VAN CHUONG male-30 years old- Room No 425

- Address: HOA AN commune, CAM LE district, DA NANG province.
- MH: The patient was in a motorcycle accident. After hitting the back of the car, the patient fell, the car
fell on his leg. The patient is still awake, well recognized, and has good contact. Received emergency
treatment at a general hospital. Initial diagnosis was soft tissue and shin bone injury, splinting and pain
medication (of unknown type). After that, the patient went home and continued to self-medicate (unknown
type). But no relief. MRI scan at the general hospital on May 13, 2022. Preliminary diagnosis is anterior
cruciate ligament (L) rupture, patellar fracture, and superficial peroneal nerve injury. The patient was then
admitted to hospital 199 on May 16, 2022R
- Vital signs stable: pulse rate: bpm, BP:mmHg, RR: bpm, Temp: degrees Celsius
- Dx: Rupture of ACL (L)/ Partial rupture of PCL (L)/ Rupture of LCL (L)/ Tiabial plateau fracture.
- Tx: endoscopic ACL ,LCL (L) reconstruction surgery, meniscus (L) repair
- Sur: Dr. Tuan
 III. HOSPITALIZED PATIENT + PREOPERATIVE

3. NGUYEN CANH GIAP : male – 28 yrs - Room No.425

- Address: Đăk Tăng Commune – Kon Plông District – Kon Tum Province.
- Dx: Rupture of ACL (L) / Torn menicus (L)
- MH: 20 days before admission ( 1/5), the patient fell because he forgot to put his foot on, causing
his left knee to hit the motorbike. After that, the patient felt a lot of pain in the left knee, swelling,
no bleeding, and limited leg flexion, about 2 hours later, swelling, and pain in the left leg. 3/5, the
patient went to Kon Tum hospital and received an MRI with a diagnosis of a partial tear of the
anterior cruciate ligament (L) and was cast in a cast and given treatment, but the patient still felt
pain and loosened the knee (L) should be hospitalized 199.
- Vital signs stable: Pulse rate 80:, BP:120/80 mmHg, RR 20: ,Temp :36.5 degree Celsius.
- Examination : Anterior Drawer Test (L) (+), Posterior Drawer Test (L)(-), Mc Murray(L)(+/-)
- Tx: endoscopic ACL (L) reconstruction surgery, meniscus (L) repair
- Surgeon: Dr Tuan
 III. PREOPERATIVE
4. NGUYEN HO SY HUNG: male – 30yrs - Room No.424
- Address: Ho Bac commune, Hoa Vang district, Da Nang City
- Dx: Rupture of PCL (R) / Injury of MCL (R)
- MH: 3 weeks before admission, the patient suffered a sports injury, swelling and pain in his right
knee, went to military hospital 17 to get an ultrasound, was diagnosed with fluid in the knee joint,
received 7 days of drug treatment, braced his leg and applied ice. , the swelling and pain are
reduced. On May 20, the patient was re-examined at Military Hospital 17, was x-rayed and
diagnosed with right anterior cruciate ligament rupture. On May 21, the patient went to a private
clinic and was diagnosed with a rupture of the inner ligament of the right knee and a rupture of
the posterior cruciate ligament of the right knee. Because the right knee still hurts, the patient
went to hospital 199 and was hospitalized for treatment
- Vital signs stable: pulse rate: 75, BP: 130/80, RR: 20, temp: 37 degree Celsius
- Examination: Anterior Drawer Test (R) (-), Posterior Drawer Test (R)(+), Valgus stress (R) (+);
Mc Murray(R)(-).
- Tx: endoscopic ACL (R) reconstruction surgery
- Surgeon: Dr Quoc
 IV. POSTOPERATIVE
III. HOSPITALIZED PATIENT
1.TRAN MINH LUU: male – 32yrs - Room No.405
- Address: Chanh Lo commune, Quang Ngai city, Quang Ngai province

- Dx: The 1st day post-operative, surgical removal of the combined media left ulnar bone, left
tibia, left fibula.
- Examination: The patient is conscious. He feels a little pain on incisions (VAS 2/10)
- Vital signs stable: HR: 75 beats/min, BP: 110/70, RR: 20 beaths/min, Temp: 37 oC
- Tx: Nutrition therapy, pain reduce therapy
- Sur: Dr Nhat- Dr Tuan
 IV. POSTOPERATIVE
III. HOSPITALIZED PATIENT
2.TRUONG NGUYEN HOANG PHUC: male – 17yrs - Room No.426
- Address: Dai Quang commune, Dai Loc district, Quang Nam province

- Dx: the 1st day post-operative endoscopic ACL (R) reconstruction Examination: The patient is
conscious. He feels a moderate pain on incisions (VAS 4/10).
- Vital signs stable: HR:65 beats/min, BP: 120/80, RR: 20 beaths/min, Temp: 37 oC
- Hemovac drain: volume 90 ml. Red, one way, closed.
- Tx: Pain reduce therapy, antibiotic therapy
- Sur: Dr Cuong- Dr Quoc
 IV. POSTOPERATIVE
III. HOSPITALIZED PATIENT
3.NGUYEN THANH TUAN: male – 26yrs - Room No.426
- Address: Tam Phu commune, Tam Ky City, Quang Nam province

- Dx: the 1st day post-operative endoscopic anterior cruciate ligament (R) reconstruction

- Examination: The patient is conscious. He feels a little pain on incisions (VAS 7/10)

- Hemovac drain: volume 150ml. Red, one way, closed

- Vital signs stable
- Sur: Dr Cuong-Dr Nhat-Dr Hieu