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.
Admission Details
- Chief Complaint: [describe presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Diagnosis:
[Diagnosis details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Treatment Provided
- Interventions:
[Interventions provided] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Medications Administered:
[Medications administered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Results of Investigations
- Pathology: [Key results from blood tests, urine tests, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- Imaging: [Findings from X-rays, CT scans, MRIs, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Patient's Condition at Discharge
- [General condition at the time of discharge] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Vital Signs: [Latest recorded vital signs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Discharge Instructions
- Medications: [Prescriptions given at discharge, with dosages and instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Activity Level: [Recommended level of activity (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Any advised dietary changes or restrictions (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Instructions for wound care, if applicable (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Signs & symptoms to watch for that would necessitate a return to the hospital or further medical attention (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- Follow-Up: [Details of any scheduled follow-up appointments (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
(For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)