Detailed Treatment Process
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The following is the discharge summary for the first patient. Below is the discharge summary for the first patient Discharge Summary Department: Orthopedics Gender: Male Age: 77 years Admission Date: November 9 Discharge Date: December 26 Outpatient Diagnosis: Postoperative infection following left femoral intertrochanteric fracture fixation; hypertension; chronic renal insufficiency Admission Diagnosis: Postoperative infection following left femoral intertrochanteric fracture fixation; hypertension; chronic renal insufficiency Discharge Diagnosis: Status post left femoral intertrochanteric fracture fixation; hypertension; chronic renal insufficiency Main symptoms and signs on admission Four months after internal fixation for left femoral intertrochanteric fracture, with local redness and swelling for 1 week Physical examination: Old surgical incision visible on left hip, with local redness and swelling, tenderness +, longitudinal percussion pain -, normal sensation and movement in left lower limb, left dorsalis pedis artery palpable Main laboratory results on admission: Complete blood count: hemoglobin 94 g/L, red blood cells 3.64 × 10¹²/L, white blood cells 11.1 × 10⁹/L, neutrophils 78.9%; urea nitrogen 7.9 mmol/L, creatinine 147 μmol/L. Discharge laboratory results: Complete blood count: hemoglobin 97 g/L, red blood cells 3.72 × 10¹²/L, white blood cells 7.3 × 10⁹/L, neutrophils 75.1%. Special tests and important consultations November 16 wound bacterial culture: no bacterial growth after 2 days; acid-fast bacilli smear: negative. Course and treatment outcome After admission, the patient completed relevant auxiliary examinations. On November 14, under lumbar anesthesia, debridement and open drainage were performed for the postoperative left femoral intertrochanteric fracture site. The procedure went smoothly. Intraoperatively, liquefaction of subcutaneous fat was noted at the left thigh wound. Incision and drainage were carried out, the abscess wall was excised, and the wound was repeatedly irrigated with hydrogen peroxide, diluted povidone-iodine, and normal saline. The wound was then packed with diluted povidone-iodine gauze for drainage. Postoperatively, cefuroxime sodium was administered for infection control. Wound bacterial culture and acid-fast bacilli smear were both negative. On November 24, under local anesthesia, wound closure of the left thigh was performed successfully. Cefuroxime sodium was continued for anti-infective treatment, along with acetaminophen oxycodone for pain relief and symptomatic management. The patient is now in generally good condition with healed wounds. After consultation with the attending physician, the patient was advised to rest, improve nutrition, attend regular follow-up visits, and return to the outpatient clinic if any discomfort arises. Complications: None At discharge, general condition was good, temperature 37℃, heart and lungs unremarkable. The wound at the affected site had healed without redness or exudation. Distal limb sensation and movement were intact, and peripheral circulation was good. Post-discharge medications and recommendations: Regular orthopedic follow-up (at 1 month and 3 months after discharge) Treatment outcome: Improved
After discharge, this patient continued to experience fever, leading to repeated hospitalizations. Fever would subside with antibiotics but recur afterward. This cycle repeated multiple times until, five months later, the fever resolved following removal of the intramedullary nail. Below is the discharge summary for the second patient Department: Orthopedics Admission Date: May 14 Discharge Date: May 24 Admission status (including main symptoms and signs) 1. The patient is an 80-year-old female. 2. Admitted due to “left hip pain and limited mobility for 1 day after a fall.” 3. Physical examination: Left lower limb in external rotation deformity, shortened by 2 cm compared with the contralateral side, left hip tenderness (+), limited flexion, extension, and rotation, longitudinal percussion pain (+), 4-sign (+), intact superficial and deep sensation in left lower limb, good pulsation of left dorsalis pedis artery. 4. Auxiliary examination: X-ray showed left femoral intertrochanteric fracture. Admission Diagnosis: Left femoral intertrochanteric fracture Laboratory results (including main findings on admission and at discharge with dates) May 15 hepatitis C markers, RPR, and HIV: normal May 14 coagulation profile (anticoagulation) plasma fibrinogen (FBG): 4.251 g/L May 14 blood cell analysis (five-classification): white blood cells 8.60 × 10⁹/L, neutrophil percentage 79.20%, red blood cells 2.74 × 10¹²/L, hemoglobin 84 g/L, hematocrit 27.4%, platelets 139 × 10⁹/L May 14 blood typing (ABO+RH) (gel): ABO blood type B, Rh positive. May 15 biochemical panel: urea 10.3 mmol/L, creatinine 178 μmol/L May 15 hepatitis B quantification: hepatitis B core antibody (Anti-HBc) 7.19 (+) S/CO Treatment course: After admission, relevant examinations were completed. On May 15, under general anesthesia, closed reduction and internal fixation of the left femoral intertrochanteric fracture were performed. The patient recovered well postoperatively. Discharge Diagnosis: Left femoral intertrochanteric fracture Discharge status (including main symptoms and signs) Alert and oriented, general condition fair. Physical examination: normal temperature, heart and lungs unremarkable, incision dressing dry and clean with no obvious exudation, good wound healing. Limb movement and sensation intact, dorsalis pedis artery palpable, good peripheral circulation. Discharge orders: (omitted)
Below is the complete blood count report from the second patient’s second hospitalization Report Date: June 25 Gender: Female Age: 80 years Clinical Diagnosis: Pulmonary infection Test Items and Results (Reference Range) Hemoglobin 84.00 g/L (113–151 g/L) Red blood cells 2.31 × 10¹²/L (3.68–5.13 × 10¹²/L) Platelets 70.00 × 10⁹/L (101–320 × 10⁹/L) White blood cells 3.27 × 10⁹/L (3.69–9.16 × 10⁹/L) Neutrophils 48.90% (50–70%) Lymphocytes 45.0% (20–40%) Monocytes 5.2% (3–10%) Eosinophils 0.6% (0.5–5%) Basophils 0.3% (0–1%) Neutrophils (absolute) 1.6 × 10⁹/L (2–7 × 10⁹/L) Lymphocytes (absolute) 1.47 × 10⁹/L (0.8–4.00 × 10⁹/L) Monocytes (absolute) 0.17 × 10⁹/L (0.12–1.00 × 10⁹/L) Eosinophils (absolute) 0.02 × 10⁹/L (0.02–0.50 × 10⁹/L) Basophils (absolute) 0.01 × 10⁹/L (0–1 × 10⁹/L) Hematocrit 25.3% Mean corpuscular volume 109.5 fL Mean corpuscular hemoglobin 36.4 pg Mean corpuscular hemoglobin concentration 332 g/L Red cell distribution width 20.90% Plateletcrit 0.07% Platelet distribution width 14.1 Mean platelet volume 11.7 fL C-reactive protein 17.5 mg/L
The second patient was readmitted due to fever that developed after discharge from the first hospitalization.