ADMISSION DIAGNOSIS: Penetrating left thigh injury.
DISCHARGE DIAGNOSES:
1. Status post foreign body removal of left thigh.
2. Fasciotomy of left thigh.
3. Status post repair of left sciatic nerve.
PROCEDURES:
1. Removal of foreign body, left thigh.
2. Fasciotomy, left thigh.
3. Evacuation of hematoma.
4. Repair of sciatic nerve.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who was transferred from an outside hospital after a blast wound to his left thigh. An x-ray showed a foreign body in the posterior left thigh. He complained of pain in this area as well as some numbness down to the foot, which propagated upward. No other complaints.
PAST MEDICAL HISTORY: Significant for murmur since birth.
PAST SURGICAL HISTORY: None.
CURRENT MEDICATIONS: Zyrtec, amoxicillin, and Flonase.
ALLERGIES: None.
FAMILY HISTORY: Significant for father with blood clots.
SOCIAL HISTORY: The patient denies smoking and drug use. He does use occasional alcohol.
PHYSICAL EXAMINATION: Vital Signs: The patient’s vital signs were stable. General: The patient is alert and oriented x3. He is cooperative and pleasant. HEENT: Head is atraumatic and normocephalic. Ears: Pneumotympanum. Eyes: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Nose: No rhinorrhea. Mouth reveals mucous membranes to be pink and moist throughout. Trachea is midline. No tracheal deviation. Lungs: Clear to auscultation bilaterally. Heart: Regular rate and rhythm. S1 and S2. There is a grade 3/6 systolic murmur noted. Abdomen: Soft, flat, and nontender. Bowel sounds are positive in all four quadrants. Extremities: Pulses are +2. No ankle edema. He has no swelling to the left thigh. He did have a jagged entrance wound in the left lateral thigh. He has normal strength in the left foot but decreased sensation.
HOSPITAL COURSE: The patient was taken to surgery next day for evacuation of foreign body throughout the sciatic nerve. The patient’s pain was well controlled. Due to this, his diet was advanced, and he did continue to work with physical therapy. He did progress well. He received daily dressing changes, which were uneventful. The patient was discharged home in stable condition. He will follow up with Dr. John Doe in approximately two weeks and with Dr. Jane Doe in one week. He will continue on a regular diet and was instructed to continue using a walker and not to bear full weight on his left foot. He and his wife were taught how to perform dressing changes for the left thigh. He was instructed to perform daily dressing changes, to wash surgery wound with soap and water, pad it dry, and then cover with dry dressings. He was sent home on Keflex and Darvocet. He was instructed to look for any redness, swelling, drainage or fever greater than 101 degrees. He was advised to give the doctors a call and/or present to the emergency department immediately without hesitation. He did verbalize understanding of all instructions given.
CONDITION ON DISCHARGE: Stable.
