出院记录V20130719
Month 12 日Day
科别Department: 骨科 Orthopedics 床号Bed#: 162101 健康档案号MR#
入院时间Date of Admission:
2013年Year11月Month13日12时Hour20分Minute
出院时间Date of Discharge:2013年Year11月Month 21日Day15时Hour 00分Minute
住院天数Length of Stay:8天Days
○入院诊断Admitting Diagnosis:
1、 右胫骨平台骨折
Fracture of the plateau of right tibia
2、右小腿软组织挫伤并感染
Contusion and infection of the soft tissue of the right lower leg
2、 右腓神经损伤
The right peroneal nerve injury
入院情况Condition on Admission:
患者因右小腿外伤后肿痛,活动受限5天入院。入院后专科体查:BP133/82mmHg,检查合作,右小腿、足踝部周围皮肤明显红肿,局部压痛,未见皮肤溃烂,右足背动脉搏动可扪及,右踝屈伸活动受限,右足拇趾屈趾尚可,背伸活动障碍,右足2、3趾趾背触痛觉减退,血运尚可,双足背、足底、小腿外侧触痛觉正常。辅助检查:外院膝关节、胫腓骨X线示:右胫骨平台外侧皮质欠规则,髌上囊密度增高。
The patient was admitted because of pain, swelling and limitation of activity for 5 days after fall. On admission, his blood pressure is 133/82mmHg, well oriented, redness, swelling and tenderness around the right ankle and lower leg, no ulceration on the skin. The pedal pulsation is intact.the flexion of the right ankle and the extension of the right big toe is limited. The touch sensation of the right 2 and 3 toe is less sensitive and their circulation is fine. The touch sensation of the dorsal aspect of the feet, plantar aspect and the lateral aspect of the right lower leg is normal.
X ray of the right ankle, tibia and fibia (OSH): Irregularity of the lateral cortex of the plateau of the right tibia, the increased density of the suprapatellar bursae.
诊疗经过Hospital Course:
病人入院后予以卧床休息,骨科护理常规,一级护理,普通饮食,患肢抬高。完善入院常规检查及血培养、厌氧菌培养、胫腓骨MR,“头孢孟多酯钠 2G 静脉滴注 Q8H”抗感染, “迈之灵片 0.3G/次 口服 每日2次”“甘露醇 250ml 静滴 每日1次”消肿等对症支持处理。2013-11-14实验室检查血常规示:WBC 13.94×10~9/L ↑淋巴细胞百分比 15.1%↓ 中性粒细胞绝对值 10.45×10~9/L ↑中性粒细胞百分比 74.9↑ 胸部X线未见异常,ECG:窦性心动过速。2013-11-15尿常规正常,膝关节MRndrd ○ ○ ○
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Month 12 日Day
科别Department: 骨科 Orthopedics 床号Bed#: 162101 健康档案号MR#
示:1、右胫骨外侧平台骨折。2、右膝内、外侧半月板后角撕裂。3、右膝前交叉韧带改变,考虑撕裂,请结合临床。4、右膝关节腔及右膝髌上囊积液。5、右膝邻近软组织挫伤。胫腓骨MR示:右小腿软组织(胫骨前肌及邻近间隙、软组织)改变,考虑挫伤,请结合临床。2013-11-16血培养及厌氧菌培养均未见细菌生长。遂停用抗感染治疗。经一段时间止痛消肿、营养神经、护肝治疗后,2013-11-19病人复查血常规示:WBC、NEUT%、NEUT均正常。肝功能示谷草、谷丙转氨酶均下降,血清蛋白较前○提高。CRP较前下降。结果提示患者全身炎性反应降低,肝功能好转。患者因右足踝功能康复需较长时间,要求回本国医院继
续治疗,考虑其目前病情已好转并稳定,同意其出院。
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The patient is advised for bed rest. His right lower leg is raised. 11/14/2013: CBC: WBC 13.94×10~9/L↑,L 15.1%↓,Neutrocyte count 10.45×10~9/L↑,N 74.9↑.Liver enzyme AST 91 Units↑, ALT 87 Units↑. CXR: Unremarkable.EKG:Sinus tachycardia.11/15,2013:U/A:Unremarkable.The blood culture (aerobic and anaerobic culture) is negative. MRI of the ankle 1.the fracture of the plateau of the rght tibia 2.the tear of posterior horn of lateral and medial meniscus of the right knee. 3.the change of the anterior cruciate ligament of the right knee suggested its tear. 4. effusion in capsule of the right knee and suprapatellar bursae. 5. the contusion of the adjacent soft tissue of the right knee. MRI of the tibia and fibia: change of the soft tissue (tibialis anterior muscle and its adjacent space, soft tissue) suggested contusion. He received 2 grams of infusion of Cefamandole sodium, three times a day for bacterial infection and 250ml Manitol one time a day for swelling. He took 0.3 gram of Aescuvenforte, two times a day by mouth. 11/16/2013: CBC: Within normal limit. Liver enzyme and C-RP returned to a lower level.the prealbumin level increased. The systematic inflammatory reaction resolved gradually. The patient requested to return to his home country since it will take time for the recovery. 出院情况Condition at Discharge: 右小腿胫前皮肤红肿明显消退,右足背动脉搏动可扪及,右踝屈伸活动受限,右足拇趾屈趾尚可,背伸活动
障碍,右足2、3趾趾背触痛觉减退,血运尚可,双足背、足底、小腿外侧触痛觉正常。右膝抽屉试验(+ -),侧方应力试验(-),麦氏试验(+ -),浮髌试验(+ -)。
The redness, swelling of the pretibial aspect of the right lower leg resolved significantly. the pedal pulsation of the right foot is intact.the flexion of the right ankle is limited.The flexion of the right toe is ok, but its extension is limited.the touch sensation of the right 2 and 3 toe is less sensitive and their circulation is good. The touch sensation of the dorsal aspect of the feet,plantar aspect of the right foot and the lateral aspect of the right lower leg is normal.The anterior drawer test(+ -),McMurry-Fouche test(+ -),patella tap test(+ -).
出院诊断Discharge Diagnosis:
1. 右胫骨外侧平台骨折
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Month 12 日Day
科别Department: 骨科 Orthopedics 床号Bed#: 162101 健康档案号MR#
Fracture of the right lateral tibial plateau
2.右小腿前室间隔骨筋膜室综合症(亚急性期)
Subacute anterior compartment syndrome of the right lower leg
3、右腓深神经损伤
Injury of right deep peroneal nerve
○4、右膝内、外侧半月板后角撕裂
Tear of the posterior horn of lateral and medial meniscus of the right knee
5、右膝前交叉韧带撕裂
Tear of the anterior cruciate ligament of the right knee
出院医嘱Physician’s Order at Discharge:
1、转运过程中尽可能避免患肢长时间下垂,患膝3月内避免负重运动。
Avoid long time dependent positioning of the right lower leg during transportation. No weight bearing on the right knee within 3 months
3、 出院后继续口服药物消肿止痛治疗
(迈之灵片 0.3G/次 口服 每日2次餐后;甲钴胺片 500ug /次 口服 每日3次;塞来昔布 200mg/次 口服 每日2次餐后)
Continue to take anti-inflammatory and neurotropic medicines. ○ ○
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Aescuvenforte 0.3 gram by mouth, two times a day.
Vitamin B12 500 microgram by mouth,three times a day
Celecoxib 200 mg by mouth, two times a day after meal
随访指导Follow-up:
如有不适,骨科门诊随诊。
Follow-up with local doctor.
健康教育Health Education:
优质蛋白、低脂饮食,避免进食辛辣食物。禁止烟酒。
Low lipid diet. No smoking or drinking alcohol.Aviod spicy food.
交通需求Transportation:
平车
Gurney and Crutches
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Month 12 日Day
科别Department: 骨科 Orthopedics 床号Bed#: 162101 健康档案号MR#
医师签名Physician’s signature/工号Badge#:
时间Time:2013年Year11月Month21日Day15时Hour 00分Minute
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