Case summary of this patient. Asked in viva questions
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cd /tmp/workspace/attachments/00fa4b3f-a119-475b-a2cf-2cc05c419da8/ && python3 -c " import pdfplumber with pdfplumber.open('Adobe Scan Jul 14, 2026 (1)_1.pdf') as pdf: print(f'Total pages: {len(pdf.pages)}') for i, page in enumerate(pdf.pages): text = page.extract_text() print(f'--- PAGE {i+1} ---') print(text) print() "
The PDF is a scanned document (image-based), so pdfplumber returns no text. I need to use vision analysis on the pages. Let me extract images from each page and analyse them.
Running Command
python3 -c " from pypdf import PdfReader import base64, json reader = PdfReader('/tmp/workspace/attachments/00fa4b3f-a119-475b-a2cf-2cc05c419da8/Adobe Scan Jul 14, 2026 (1)_1.pdf') print(f'Pages: {len(reader.pages)}') # Check for images on first few pages for i in range(min(3, len(reader.pages))): page = reader.pages[i] print(f'Page {i+1} resources: {list(page.get(\"/Resources\", {}).keys()) if page.get(\"/Resources\") else \"none\"}') images = list(page.images) print(f'Page {i+1} images: {len(images)}') if images: img = images[0] print(f' First image: name={img.name}, size={len(img.data)} bytes') "
Running Command
python3 -c " from pypdf import PdfReader import os reader = PdfReader('/tmp/workspace/attachments/00fa4b3f-a119-475b-a2cf-2cc05c419da8/Adobe Scan Jul 14, 2026 (1)_1.pdf') os.makedirs('/tmp/workspace/case_images', exist_ok=True) for i in range(len(reader.pages)): page = reader.pages[i] images = list(page.images) if images: img = images[0] ext = img.name.split('.')[-1] if '.' in img.name else 'jpg' out_path = f'/tmp/workspace/case_images/page_{i+1:02d}.{ext}' with open(out_path, 'wb') as f: f.write(img.data) print(f'Saved page {i+1} -> {out_path} ({len(img.data)} bytes)') "
Now I need to serve these images for analysis. Let me use a Python HTTP server approach, or better - use base64 data URIs with analyse_media. Actually, I need to use file:// URLs or serve them. Let me use analyse_media with a local file server.
Running Command
python3 -c " import subprocess, os, time # Start a simple HTTP server proc = subprocess.Popen(['python3', '-m', 'http.server', '8765', '--directory', '/tmp/workspace/case_images'], stdout=subprocess.DEVNULL, stderr=subprocess.DEVNULL) time.sleep(1) print(f'Server PID: {proc.pid}') print('Server started at http://localhost:8765') # Test it import urllib.request try: resp = urllib.request.urlopen('http://localhost:8765/page_01.jpg', timeout=3) print(f'Test request: {resp.status}') except Exception as e: print(f'Error: {e}') "
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The local server isn't reachable by the analyse_media tool. I've exhausted all analyse_media calls. Let me use fetch_image instead (which works with local files via a different mechanism) or use read_file to read the images as visual content directly.
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Images are too large. Let me resize them to smaller sizes and try fetch_image which renders images visually.
Running Command
python3 -c " from PIL import Image import os os.makedirs('/tmp/workspace/case_images_small', exist_ok=True) for i in range(1, 24): src = f'/tmp/workspace/case_images/page_{i:02d}.jpg' dst = f'/tmp/workspace/case_images_small/page_{i:02d}.jpg' img = Image.open(src) # Resize to max width 1200px maintaining aspect ratio w, h = img.size if w > 1200: ratio = 1200/w img = img.resize((1200, int(h*ratio)), Image.LANCZOS) img.save(dst, 'JPEG', quality=75) size = os.path.getsize(dst) print(f'Page {i}: {w}x{h} -> {img.size}, {size} bytes') "
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I can read the images visually now. Let me read the remaining pages.
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I now have all 23 pages. I have a comprehensive view of the entire case. Let me now compile the full case summary with viva questions.
CASE SUMMARY - NGUYEN DUC LONG
Patient Demographics
| Name | Nguyen Duc Long |
| DOB / Age | 16/09/1989 - 37 years old |
| Sex | Male |
| Ethnicity | Kinh |
| Address | Xa Quang Dong, Tinh Nghe An |
| Hospital ID | 116056 (PID 26072400) |
| BHYT (Health Insurance) | DN4790112057344, valid to 31/12/2026 |
| Emergency contact | Hoang Minh Tien, 0339930898 |
| Admitted | 15:47 on 08/07/2026 |
| Facility | Can Tho University of Medicine and Pharmacy Hospital - Emergency & ICU Department |
| Attending | Ths. BS. Truong Ngoc Thach (admission), TS. BS. Tran Quang Son (primary surgeon) |
Chief Complaint
Left ankle/foot injury - the patient was struck by a falling roll of zinc sheeting while working on a construction site. He noticed deformity of the left ankle region, reduced movement, and a surface wound on the left foot with minor bleeding. Transferred to hospital.
History of Present Illness
On the day of admission (08/07/2026), the patient was working at a construction site when a roll of zinc sheeting fell and hit his left leg. After the accident he noted:
- Deformity of the left ankle
- Reduced mobility
- Surface wound on the medial aspect of the left ankle (~1 cm), with minor bleeding
No loss of consciousness. No chest pain. No abdominal pain.
Past Medical History: Gastroesophageal reflux disease (GERD)
Family History: Unremarkable
Examination on Admission
Vital Signs:
| Parameter | Value |
|---|---|
| Pulse | 78 bpm |
| Temperature | 37°C |
| Blood Pressure | 120/70 mmHg |
| Respiratory Rate | 20 breaths/min |
| Weight | 60 kg |
| Height | 165 cm |
| BMI | 22.04 |
| SpO2 | 98% (room air) |
General: Alert, cooperative, mucous membranes pink, no fever.
Local (Left Ankle/Foot):
- Significant pain over the left ankle
- Deformity of the left ankle, with an open wound on the medial aspect of the ankle (~1 cm), minor bleeding
- Left dorsal pedal pulse NOT palpable; right dorsal pedal pulse palpable
- Left ankle axis-foot alignment deviated
- Left toe tips warm/pink, SpO2 100%
- Reduced movement of the left ankle
Systemic:
- Heart: Regular, no murmurs
- Lungs: Clear, no adventitious sounds
- Abdomen: Soft, non-tender
Investigations
Blood Count (CBC - 08/07/2026 16:06)
| Test | Result | Reference | Flag |
|---|---|---|---|
| WBC | 10.43 x10⁹/L | 4.0-9.0 | H |
| NEU% | 55.7% | 42-85 | normal |
| LYM% | 36.8% | 11-49 | normal |
| RBC | 5.27 x10¹²/L | 3.8-5.3 | normal |
| HGB | 15.7 g/dL | 12-17.2 | normal |
| HCT | 47.5% | 37-47 | H |
| MCV | 90.2 fL | 80-100 | normal |
| PLT | 258 x10⁹/L | 150-400 | normal |
| MPV | 9.4 fL | 5-9 | H |
Coagulation (08/07/2026)
| Test | Result | Reference |
|---|---|---|
| PT | 13.1 sec | Control 13.5 sec |
| PT% | 106% | 70-120 |
| INR | 0.96 | 0.8-1.2 |
| APTT | 27.2 sec | 24.8-34.4 |
Biochemistry (08/07/2026)
| Test | Result | Reference | Flag |
|---|---|---|---|
| Na+ | 143.8 mmol/L | 134-145 | normal |
| K+ | 3.97 mmol/L | 3.4-4.8 | normal |
| Cl- | 108.0 mmol/L | 98-107 | H |
| AST (GOT) | 27 U/L | 5-34 | normal |
| ALT (GPT) | 23 U/L | <55 | normal |
| Urea | 5.6 mmol/L | 2.5-6.7 | normal |
| Creatinine | 97.0 umol/L | 62-106 | normal |
| eGFR | 80.73 mL/min/1.73m² | normal | |
| Blood Glucose | 4.76 mmol/L | 3.8-6.1 | normal |
Imaging
Chest X-ray (08/07/2026): No abnormality detected - normal cardiac size, no pleural effusion, no pulmonary lesion, no bony abnormality.
Left Leg X-ray (AP + Lateral, 08/07/2026): Cast artifact obscures assessment. Soft tissue: difficult to evaluate. Bone structure: no fracture seen. Joint space: normal. Conclusion: Plaster cast artifact on left leg.
Left Ankle X-ray - AP/Lateral (08/07/2026): Bone structure: no fracture. Joint space: Wide tibiotalar (mortise) joint space on left side. Soft tissue: difficult to assess. Cast artifact noted. Conclusion: WIDENED LEFT TIBIOTALAR JOINT SPACE (indicating ligamentous disruption / open ankle dislocation).
Diagnosis
Primary Diagnosis (confirmed after multidisciplinary consultation):
Open ankle dislocation of the left ankle due to occupational/work injury
- Vietnamese: Trật hở khớp cổ chân trái do tai nạn lao động
ICD-10 Codes:
- T14.3 - Dislocation, sprain and strain, ligament tear in unspecified body region
- M24.37 - Dislocation/subluxation of joint - ankle and/or foot
- S90.9 - Superficial injury of ankle and/or foot (unspecified)
- S91 - Open wound of ankle and foot
- K21 - Gastro-oesophageal reflux disease (co-morbidity)
Multidisciplinary Board (Hoi Chan) Decision (18:00, 08/07/2026):
- Diagnosis confirmed: Open left ankle dislocation (traumatic, work injury)
- Treatment plan: Surgical exploration, debridement + open reduction + joint drainage
- Anaesthesia: Spinal (tê tủy sống) / General endotracheal (mê nội khí quản)
- Surgeon: BS. Son
- Severity: Severe (Tiên lượng: Nặng)
Treatment
Emergency Phase (08/07/2026):
- Closed reduction + backslab plaster (Nắn, bó bột - 16:10, 08/07/2026)
- Under local anaesthesia (Lidocaine)
- Traction applied, ankle reduced, wound cleaned, splint applied
- Post-reduction X-ray confirmed
- Analgesic: Tramadol 50mg/mL IV
- Antibiotic: Ceftazidime 1g x2 vials IV
Operative Treatment (18:50, 08/07/2026):
Open Reduction + Debridement + Joint Drainage + Left Ankle Internal Fixation
- Anaesthesia: Spinal anaesthesia (tê tủy sống) by Dr. Vo Nguyen Hong Phuc
- Surgeon: Dr. Tran Quang Son
- Patient supine, left thigh tourniquet 250 mmHg
- Wound extended, joint opened: confirmed deltoid ligament torn, fibular (peroneal) tendon cut, lateral malleolus cartilage injury; vessels intact
- Left ankle grossly unstable
- Thorough irrigation, debridement of crushed tissue
- Delta ligament repaired; joint capsule repaired; wound closed in layers
- Left leg posterior splint applied
- Post-op: Patient stable, spinal anaesthesia resolved, both legs sensation returned, transferred to Orthopaedic Ward
Post-operative Medications (from 08/07 onwards):
| Drug | Dose | Route | Indication |
|---|---|---|---|
| Tramadol 50mg | 1 amp IV | IV | Acute pain |
| Lidocaine 200mg | 1 amp | Local | Anaesthesia for reduction |
| Ceftazidime 1g | 2 vials x 3 times/day (6g/day) | IV | Antibiotic (open wound) |
| Levofloxacin 500mg/100mL | 1 bottle/day | IV infusion | Broad-spectrum antibiotic coverage |
| Paracetamol 10mg/mL | 1 bag x 3/day | IV infusion | Analgesia |
| Meloxicam 10mg | 1 amp | IM | Anti-inflammatory / analgesia |
| Esomeprazole 40mg | 1 tab/day | Oral | GI protection (for GERD + NSAID use) |
| Celecoxib 200mg | 1 tab/day | Oral | Anti-inflammatory |
| Amoxicillin-Clavulanate 1g | 2 tabs/day | Oral | Step-down antibiotic (from day 5) |
| Paracetamol (Hapacol) 500mg | 3 tabs/day | Oral | Step-down analgesia |
Wound Care:
- Daily dressing change, stitch removal as needed (wound length ≤15 cm)
- Post-op monitoring: Circulation, sensation, movement of toes
Hospital Course (Day by Day)
| Date | Key Events |
|---|---|
| 08/07/2026 | Admission via ED; initial reduction + splint; surgery (18:50) - open reduction + debridement + ligament repair |
| 09/07/2026 | Post-op stable; transferred to Orthopaedic & Neurosurgical ward (Khoa Ngoai Chan Thuong Chinh Hinh va Than Kinh); wound draining slightly; both feet moved |
| 10/07/2026 | Wound dressing; stable; bilateral pedal pulses present bilaterally |
| 11/07/2026 | Continued wound dressings; stable; care level downgraded |
| 12/07/2026 | Continued medications; wound care |
| 13/07/2026 | Mild wound pain; wound soaking bandage slightly; moving both feet; bilateral pulses present |
| 14/07/2026 | Continued medications (oral antibiotics - Amoxicillin-Clavulanate, oral analgesia, Levofloxacin IV); wound care |
Doctors Involved
- Ths. BS. Truong Ngoc Thach - Emergency physician (admission)
- TS. BS. Tran Quang Son - Primary surgeon (Orthopaedics / Trauma)
- TS. BS. Vo Nguyen Hong Phuc - Anaesthesiologist
- Vo Minh Phuong - Chair of MDT board
- TS. BS. Tran Nguyen Anh Duy - Orthopaedic ward physician (post-op)
- Ths. BS. Ho Dien - Orthopaedic ward physician (follow-up)
VIVA QUESTIONS (Likely to be Asked)
1. Diagnosis & Classification
Q: What is the diagnosis in this patient?
Open ankle dislocation of the left ankle secondary to work-related trauma. The deltoid ligament was torn, the peroneal tendon was cut, and there was cartilage injury of the fibula. The wound penetrated the joint, classifying it as an open (compound) dislocation.
Q: How do you classify ankle dislocations?
Ankle dislocations are classified by the direction of talar displacement relative to the tibia: posterior (most common), anterior, lateral, medial, and superior (divergent). They can also be classified as closed vs open (compound). This patient had an open dislocation with joint penetration.
Q: What ICD-10 codes apply?
T14.3 (dislocation/sprain, unspecified body region), M24.37 (dislocation of ankle/foot joint), S91 (open wound of ankle), K21 (GERD).
2. Mechanism of Injury
Q: Describe the mechanism of injury.
A roll of zinc sheeting fell onto the left leg while the patient was working at a construction site. The combination of axial loading and a torsional/shear force caused ankle dislocation, rupture of the deltoid ligament, peroneal tendon injury, and an open wound penetrating the ankle joint.
3. Clinical Assessment
Q: What are the key clinical signs of ankle dislocation?
Deformity of the ankle, severe pain and swelling, inability to bear weight, abnormal axis alignment between foot and leg, absent dorsal pedal pulse (vascular compromise), and in open dislocation, a wound with visible joint structures.
Q: Why was the left dorsal pedal pulse absent on arrival?
Acute ankle dislocation can compress or kink the anterior tibial/dorsalis pedis artery due to the abnormal positioning of the talus. After reduction, vascular flow typically returns - confirmed by warm pink toes and SpO2 100% on toes.
Q: What does SpO2 100% on left toes mean in this context?
It indicates adequate peripheral oxygen delivery despite the absent pedal pulse, suggesting collateral circulation or arterial spasm rather than complete arterial occlusion, reassuring that the distal foot is still viable.
4. Investigations
Q: Interpret the CBC findings.
WBC 10.43 (mildly elevated - reactive leukocytosis from trauma), HCT borderline high at 47.5%, other parameters normal. No evidence of significant bleeding or infection at this stage.
Q: Why was coagulation checked?
Pre-operative workup. All values (PT 13.1s, INR 0.96, APTT 27.2s) are within normal limits, confirming safe to proceed with surgery.
Q: What did the ankle X-ray show?
Widening of the left tibiotalar (mortise) joint space, consistent with ankle dislocation / ligamentous disruption. No fracture of the malleoli was identified on initial X-ray (though soft tissue is difficult to assess under cast).
Q: Why was a chest X-ray ordered?
Standard pre-operative workup - to rule out thoracic injury (given the mechanism, falling debris) and as baseline for anaesthesia clearance. Result: no abnormality.
5. Management
Q: What was the initial management?
Closed reduction under local anaesthesia (Lidocaine), backslab plaster immobilisation, wound cleaning and dressing, IV analgesia (Tramadol), IV antibiotic (Ceftazidime). Then multidisciplinary consultation followed by formal surgical exploration.
Q: What is the surgical approach for open ankle dislocation?
Emergency surgical debridement is mandatory in open dislocation to reduce infection risk. The wound is extended, joint irrigated thoroughly with saline, devitalised tissue removed, and reduction performed under direct vision. In this case, the deltoid ligament and joint capsule were repaired in layers, the peroneal tendon was addressed, and the joint was drained. A posterior splint was then applied.
Q: What anaesthesia was used and why?
Spinal anaesthesia (tê tủy sống). This provides excellent lower limb anaesthesia and motor block while avoiding the risks of general anaesthesia. The anaesthesiologist had general intubation as backup.
Q: Why was the tourniquet used?
Left thigh tourniquet at 250 mmHg to provide a bloodless surgical field, allowing proper visualisation of structures within the ankle joint.
Q: What post-operative complications should be monitored for?
(1) Vascular compromise - check pedal pulses, capillary refill, colour, SpO2 on toes; (2) Compartment syndrome - assess pain on passive stretch, swelling, tightness of cast; (3) Infection / septic arthritis (open wound, joint penetration); (4) Avascular necrosis of the talus (rare but serious); (5) Re-dislocation; (6) Post-traumatic arthritis; (7) Nerve injury (superficial peroneal, sural); (8) Deep vein thrombosis.
Q: Why was the cast checked for tightness post-application?
After cast application, the physician is instructed to check circulation, sensation, and movement of the toes to ensure the cast is not too tight and is not causing compartment syndrome.
6. Antibiotics
Q: Justify the antibiotic choice.
Open joint injuries carry a high infection risk, including septic arthritis which can rapidly destroy cartilage. Initial cover was IV Ceftazidime (3rd-generation cephalosporin, broad-spectrum, good gram-negative cover) + Levofloxacin (fluoroquinolone, broad-spectrum). As the patient improved, oral step-down to Amoxicillin-Clavulanate was appropriate. Esomeprazole was added to protect the gastric mucosa given GERD history and NSAID use.
7. Work Injury / Occupational Medicine Angle
Q: What is the significance of this being a work (occupational) injury?
The patient sustained the injury during employment, making this a "tai nan lao dong" (occupational injury). This has legal, insurance, and compensation implications in Vietnam. Documentation is required. The BHYT (health insurance) covers treatment; however, occupational injury may entitle the patient to additional compensation from the employer or workers' compensation fund.
8. Co-morbidity
Q: What co-morbidity does this patient have and how does it influence management?
GERD (K21). This influenced the prescribing of Esomeprazole 40mg daily throughout the admission, given that the patient was also receiving NSAIDs (Meloxicam, Celecoxib) and Paracetamol, all of which can worsen gastric symptoms. NSAIDs should be used cautiously in patients with GERD.
9. Prognosis
Q: What is the prognosis for open ankle dislocation?
Early open reduction, thorough debridement, and antibiotic coverage significantly reduce the risk of septic arthritis and osteomyelitis. If vascular supply is preserved (as here), risk of avascular necrosis is lower. Long-term risks include post-traumatic osteoarthritis, stiffness, and recurrent instability, requiring physiotherapy rehabilitation. This patient's prognosis is guarded-to-fair given the severity label ("Nặng") at initial consultation.
This case was managed at Can Tho University of Medicine and Pharmacy Hospital (Benh Vien Truong Dai Hoc Y Duoc Can Tho), Emergency & ICU Department, then transferred to the Orthopaedic & Neurosurgical Ward. Documents span 08/07/2026 to 14/07/2026.
Anatomy questions to ask for this patient.
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