Discharge Case Studies

Decent Essays
This is a 54-year-old male with a 1/14/2016 date of injury. IW was working on a skip loaders hydraulic piston, when an operator accidently moved the piston causing a partial amputation of right middle finger. DIAGNOSIS: Complete traumatic MOP amputation of r mid finger, subs & c/o Devascularization of right middle finger 02/05/16 Progress Report noted that the patient is s/p work related injury on 01/14/16, where his right MF was devascularized. He underwent revascularization on the DOI and returned one week later. He was noted to have an infected MF with c/f wet gangrene. On 01/22/16, he underwent amputation of the MF. He returns today for a wound check. He stated that his daughter has been doing daily dressing changes, Request narcotic refill. 01/19/16 Discharge note indicated that the patient was taken to OR on 01/14/16 and he underwent the surgical procedures. The procedure was tolerated well and there weer no immediate complications. Postoperatively, he was admitted for further monitoring, and recovered following the expected trajectory. By the day of discharge, the patient was tolerating PO and pain was well controlled. And thus was deemed stable for discharge. Start Aspirin,…show more content…
He could not feel his finger. There is numbness. The symptoms are continuous in nature and currently present. He also reports paresthesias. There were no chemical or toxic compounds involved. The findings were consistent with the injury. There were no conditions that may impede or delay the recovery. The exam revealed circumscribed laceration around the PIP joint of the middle finger. ROM: the finger is pale and cool without restriction. Neurologically: no sensation in his right middle finger. Plan: OR for revascularization, possible operative fixation, possible revision amputation, possible nerve graft, and possible vein
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