Inpatient discharge summary

Admission Details - Chief Complaint: MOTOR VEHICLE ACCIDENT - Diagnosis: CONCUSSION FRACTURE OF FEMUR FRACTURE OF RT DISTAL RADIS FRACTURE OF MANDIBLE Treatment Provided - Interventions: ORAL SURGERY ORTHOPEDIC SURGERY PHYSICAL THERAPY - Medications Administered: IV fluids, Morphine for pain management, Antibiotics to prevent infection. Results of Investigations - Pathology: Elevated white blood cell count, indicating inflammation. - Imaging: X-rays confirmed fractures of the femur, right distal radius, and mandible. CT scan revealed a mild concussion. Patient's Condition at Discharge - Patient was stable at the time of discharge, with improved pain management and mobility. - Vital Signs: Temperature 37°C, Blood Pressure 120/80 mmHg, Heart Rate 80 bpm, Respiratory Rate 16 breaths/min, SpO2 98% on room air. Discharge Instructions - Medications: - Paracetamol 1000mg every 6 hours as needed for pain. - Ibuprofen 400mg every 8 hours as needed for pain and inflammation. - Amoxicillin 500mg three times a day for 7 days. - Activity Level: Gradual increase in activity as tolerated, avoiding strenuous activities. - Dietary changes: Regular diet as tolerated. - Instructions for wound care: Clean surgical sites with soap and water daily, apply a clean dressing. - Signs & symptoms to watch for that would necessitate a return to the hospital or further medical attention: Worsening pain, fever, signs of infection (redness, swelling, pus), difficulty breathing, or any neurological changes. - Follow-Up: - Orthopedic follow-up appointment in 2 weeks. - Oral surgery follow-up appointment in 1 week. - General practitioner follow-up in 1 week.