DISCHARGE SUMMARY

The patient is a 62-year-old female who fell while walking her dog. She was walking on the sidewalk in her neighborhood and accidently slipped and fell. 

She sustained a comminuted fracture of the shaft of her right tibia confirmed by x-ray done in the emergency room. She also hit her head on a fire hydrant and suffered a slight concussion but no loss of consciousness. 

She also had a laceration down to the fascia on her right hand, which needed repair with sutures in the ED.

The patient was admitted and taken to surgery, where an open reduction with internal fixation of the shaft of the right tibia was accomplished with good alignment of fracture fragments. 

Her chronic conditions of diabetes, CHF, and hypertension were managed with home medications.

Postop course was uneventful, and the patient was discharged home with daily physical therapy.

Procedures:

1. ORIF of Right Tibia Shaft
2. Open Repair of subcutaneous tissue and fascia of right hand