Orthopedics Case Studies

DISCHARGE SUMMARY

ADMITTING DIAGNOSIS

Admitting diagnosis was a nonunion of a fracture of the right radius, status post gunshot wound to the right forearm.

Operative procedures performed included a bone graft to the right radius from the iliac crest.

Briefly reviewing the patient’s admitting history, physical, and hospital course, he was admitted to the hospital for a bone grafting of the right radius from the right iliac crest.  Patient was status post gunshot wound to the right forearm with a segmental bone loss.  Patient was taken to the operating room, underwent the operative procedure without any difficulty.  Postoperatively he had an uneventful postoperative course and was subsequently discharged home to be followed up as an outpatient in my office.

DISCHARGE DIAGNOSIS

Discharge diagnosis included nonunion of fracture of the right radius, status post gunshot wound to the right forearm.

FOOTNOTE

Lines 7, 8.  “Admitting diagnoses was” was edited to “admitting diagnosis was” for proper subject-verb agreement.

Line 26.  The final sentence regarding the operative procedures performed (previously dictated in line 11) was deleted.