Detailed Treatment Process
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November 24, four years ago, at 10:27 Chief complaint: Right clavicle fracture, one month after surgery History of present illness: Right clavicle fracture, one month after surgery Past history: Drug allergy history: None Physical examination: Right clavicle fracture, postoperative status Diagnosis: Clavicle fracture Management: Auxiliary examination items: None In-house auxiliary examination items: Right clavicle anteroposterior view Important notes and recommendations: Perform shoulder joint functional exercises. Follow-up in one month. Continue outpatient monitoring.
March 21, at 13:31 Department: Orthopedics outpatient clinic Chief complaint: Right shoulder sprain with pain for one day. History of present illness: The patient had a right clavicle fracture 3.5 years ago that was treated surgically at another hospital. Yesterday, the patient twisted the right shoulder accidentally, resulting in pain afterward. Past history: None Allergy history: None Physical examination: Old surgical scar over the right clavicle area, well healed. Mild soft tissue swelling around the right shoulder with localized tenderness. Limited range of motion in the right shoulder joint. Auxiliary examination: X-ray: See report. Outpatient preliminary diagnosis: Shoulder injury Treatment plan: Examination: DR (DR_right shoulder anteroposterior view) Management: 1. Cervical-wrist sling suspension. Recommend CT for further evaluation to rule out fracture. Further treatment as needed. 2. Follow-up at the orthopedics outpatient clinic. Return promptly if condition changes.
Postoperative right clavicle fracture Diagnosis: Clavicle fracture Management: Auxiliary examinations: None In-house auxiliary examinations: Right clavicle anteroposterior view Important notes and recommendations: Shoulder joint functional exercises. Follow-up in one month. Return as needed.
March 21 at 13:31 Department: Orthopedic outpatient clinic Chief complaint: Right shoulder sprain with pain for 1 day. History of present illness: The patient had a right clavicle fracture 3.5 years ago and underwent surgery at another hospital. Yesterday the patient sprained the right shoulder accidentally, after which right shoulder pain developed. Past history: None Allergy history: None Physical examination: Old surgical scar over the right clavicle area, well healed. Mild soft tissue swelling around the right shoulder with localized tenderness. Limited range of motion in the right shoulder joint. Auxiliary examinations: X-ray: see report. Preliminary outpatient diagnosis: Shoulder injury Treatment plan: Examination: DR (DR_right shoulder anteroposterior view) Management: 1. Cervical collar and sling. Recommend CT for further evaluation to rule out fracture. Further treatment as needed. 2. Follow-up in orthopedic outpatient clinic. Return promptly if condition changes.
Outpatient record March 22 at 08:14 Trauma Orthopedics outpatient diagnosis: Clavicle fracture Dispensed medication. Current condition stable. Continue original treatment plan. Drug allergy history: None Prescription: None Important notes and recommendations: Follow-up. The patient now has clavicle nonunion with plate breakage and requires readmission for surgical treatment.
Discharge summary Department: Trauma Orthopedics Ward Discharge summary Admission date: March 23 Discharge date: March 25 Length of stay: 2 days Admission diagnosis: 1. Right clavicle fracture nonunion; 2. Removal of internal fixation device Discharge diagnosis: 1. Right clavicle fracture nonunion; 2. Removal of internal fixation device Admission status: Main symptoms and signs: Female, 56 years old, admitted on March 23 with a clinic diagnosis of “right clavicle fracture nonunion and internal fixation breakage” due to “right clavicle fracture nonunion for 3 years and plate breakage for 1 week.” Admission physical examination: Ambulatory. No obvious abnormalities on examination of the spine, left upper limb, or both lower limbs. Right shoulder prominence, clavicular swelling and tenderness. Obvious deformity of the mid-clavicle with palpable crepitus. Limited right shoulder motion. Normal sensation and muscle strength in the right upper limb and forearm. Main examination results during hospitalization: March 22 plain film showed postoperative right clavicle fracture with internal fixation, nonunion of the fracture ends, and plate breakage. Treatment course: Treatment: After admission, routine laboratory tests, chest X-ray, electrocardiogram, and other auxiliary examinations were completed. After contraindications to surgery were ruled out, on March 24 under brachial plexus block anesthesia the patient underwent removal of right clavicle fracture internal fixation, open reduction and internal fixation of right clavicle fracture, and right iliac bone graft harvesting. The procedure went smoothly. Postoperatively the patient was stable and received treatment to promote bone healing and protect the gastric mucosa. Recovery has been good. Pathology results: None. Discharge status: The patient’s condition is now stable, and discharge was approved by the outpatient physician. Discharge destination: Home Discharge instructions: Discharge medications: Salmon calcitonin nasal spray (2 bottles) 2 times/day Glucosamine (1 box) oral *2*20 mg/day Cefaclor sustained-release tablets (2 boxes) Medication guidance: Follow the instructions in the package insert.