Write a full medical record of the patient nguyễn đức long . . I have uploaded a pdf doc which is the patient case record. Now I want to write the case record in the format that I typed below :ORTHOPAEDIC CASE RECORD TEMPLATE I.ADMINISTRATIVE INFORMATION (0.25 pts) II. CLINICAL CONTENT: 1. Reason for admission (0.25 pts): The primary reason for the patient's admission 2. History of present illness (0.5 pts): Present all three key elements: mechanism of injury; symptoms following the injury; and first aid/initial management before hospital admission. 3. Past medical history (0.25 pts) - Comorbidities - Habits/risk factors related to the primary condition or to the patient's treatment course - Residual impairments of the musculoskeletal system 4. Condition on admission (0.25 pts) - Level of consciousness - Vital signs - Key physical findings documented on admission (DEPENDING ON WHETHER THE PATIENT HAS ALREADY RECEIVED DEFINITIVE TREATMENT, THE STUDENT SHOULD SELECT THE APPROPRIATE CASE-RECORD FORMAT) PREOPERATIVE 5. Ward course (0.25 pts): Summarize changes in symptoms and the management provided 6. Current condition (0.25 pts): Current symptoms 7. Clinical examination (2 pts) a. General examination b. Systemic examination 8. Case summary (1 pt): Summarize physical findings and symptoms into symptom/sign groups or clinical syndromes Examples: - Definite signs of fracture: - Signs of compartment syndrome: - Radial nerve palsy syndrome:... 9. Diagnosis (0.5 pts): State the primary injury, associated complications (if any) injuries, and/or 10. Diagnostic reasoning (1 pt): Explain the basis for the diagnoses listed above 11. Recommended investigations (0.5 pts): Select appropriate investigations according to the site of injury Examples: AP pelvic X-ray: AP and lateral femur X-rays; three-view calcaneal X-rays: etc. Interpret the results of all available investigations. 12. Definitive diagnosis (1 pt): State the primary injury and classification, together with associated injuries and/or complications (if any) 13. Treatment: a. Treatment plan (0.25 pts): Propose an overall treatment plan. Examples: analgesia, antibiotics, surgery, etc. ***Note: For the Basic Surgery course, the assessment may end here. Points assigned to the sections below will instead be redistributed to clinical examination (+1 pt), diagnosis (+0.5 pts), and treatment plan (+0.25 pts). b. Specific treatment (0.5 pts): Based on the treatment plan, provide the specific treatment regimen. Example: - Paracetamol 0.5 g, 1 tablet orally three times daily (every 8 hours). Open reduction and internal fixation with a locking plate and screws. * Explain the rationale for selecting the above treatment method (0.25 pts) 14. Prognosis (0.5 pts) Short-term: Based on the patient's clinical findings and investigations, predict potential problems during hospitalization,(preoperative, intraoperative, and postoperative). Example: The patient has diabetes mellitus and therefore has a higher risk of postoperative infection. A complex fracture may prolong surgery, increase blood loss, and raise the risk of infection. Long-term: Functional recovery and potential late complications or sequelae related to the injury. Example: Early knee osteoarthritis may develop because a complex articular injury is difficult to reduce anatomically. 15. Preventive measures (0.5 pts): Propose measures based on the prognosis to prevent complications. Example: Optimize glycemic control to reduce the risk of surgical-site infection. Plan the operation, prepare all required instruments, select an experienced surgeon, and arrange blood products in advance to mitigate prolonged operative time and blood loss in complex fractures. POSTOPERATIVE 5. Clinical diagnosis (0.25 pts) 6. Investigations and results (0.25 pts): Interpret the X-ray findings; describe the fracture location and pattern and any displacement; then provide a conclusion, including fracture classification. 7. Definitive diagnosis (0.25 pts): State the primary injury, associated injuries, and/or complications (if any) Surgery was indicated for the patient: 8. Operative report (if surgery was performed) (0.25 pts): Preoperative and postoperative diagnoses Operative duration Estimated blood loss (if any)record or by asking the surgeon) Operative procedure (from the medical Other intraoperative events (blood transfusion, adverse events/complications, etc.) 9.Postoperative/post-cast course (0.25 pts): Describe symptoms only. 10. Clinical examination (1.5 pts): a. General examination b. Systemic examination Postoperative/post-cast follow-up X-rays 11. Case summary (1 pt): 12. Conclusion (0.5 pts): Provide a complete statement of the diagnosis, treatment method, and current outcome Example: Postoperative day 3 after locked intramedullary nailing for a closed fracture of the middle third of the right femoral shaft; clinical course is stable. 13. Further treatment a. Treatment plan (0.25 pts): Propose the ongoing treatment plan Examples: analgesia, antibiotics, surgery, etc. ***Note: For the Basic Surgery course, the sections below may be omitted except for Comments. Points assigned to the omitted sections will instead be redistributed to clinical examination (+1 pt), diagnosis (+0.5 pts), and treatment plan (+0.25 pts). b. Specific treatment (0.5 pts): Based on the treatment plan, provide the specific treatment regimen. 14. Prognosis (0.5 pts) Short-term: Potential problems during hospitalization and the patient's expected ability to perform daily activities and ambulate. Long-term: Bone healing, rehabilitation, and potential late complications or sequclac. 15. Preventive measures (0.5 pts): Propose measures based on the prognosis to prevent complications 16. Comments (0.5 pts): Assess whether theoretical knowledge is consistent with the patient's actual course, from the time of injury to the time of examination.Example: The mechanism of injury is consistent with the fracture pattern. Initial management was inappropriate because the injured limb should have been immobilized at the scene. Surgical management may not have been indicated; for simple, nondisplaced fracture, conservative treatment would theoretically provide greater benefit. Write everything properly and clear and right information
cd /home/daytona/workspace/attachments/6af81a06-480e-454a-ae69-71f9b7281195/ && python3 -c " import pdfplumber with pdfplumber.open('Adobe Scan Jul 14, 2026_1.pdf') as pdf: print(f'Total pages: {len(pdf.pages)}') for i, page in enumerate(pdf.pages): print(f'--- PAGE {i+1} ---') text = page.extract_text() if text: print(text) else: print('[No text extracted]') "
cd /home/daytona/workspace/ && python3 -c " import fitz # PyMuPDF import os pdf_path = '/home/daytona/workspace/attachments/6af81a06-480e-454a-ae69-71f9b7281195/Adobe Scan Jul 14, 2026_1.pdf' output_dir = '/home/daytona/workspace/pdf_pages/' os.makedirs(output_dir, exist_ok=True) doc = fitz.open(pdf_path) print(f'Total pages: {len(doc)}') for i, page in enumerate(doc): pix = page.get_pixmap(dpi=150) img_path = f'{output_dir}page_{i+1:02d}.png' pix.save(img_path) print(f'Saved page {i+1} -> {img_path}') doc.close() print('Done') "
mkdir -p /home/daytona/workspace/pdf_pages && pdftoppm -r 150 -png '/home/daytona/workspace/attachments/6af81a06-480e-454a-ae69-71f9b7281195/Adobe Scan Jul 14, 2026_1.pdf' /home/daytona/workspace/pdf_pages/page && ls /home/daytona/workspace/pdf_pages/ | head -30
python3 -c " import pytesseract from PIL import Image import os pages_dir = '/home/daytona/workspace/pdf_pages/' all_text = '' for i in range(1, 24): fn = f'page-{i:02d}.png' path = os.path.join(pages_dir, fn) img = Image.open(path) text = pytesseract.image_to_string(img, lang='vie+eng') all_text += f'\n\n=== PAGE {i} ===\n' + text print(f'Page {i} done, chars: {len(text)}') with open('/home/daytona/workspace/pdf_ocr_full.txt', 'w', encoding='utf-8') as f: f.write(all_text) print('OCR complete') " 2>&1 | tail -30
ORTHOPAEDIC CASE RECORD
I. ADMINISTRATIVE INFORMATION
| Field | Details |
|---|---|
| Full Name | NGUYEN DUC LONG |
| Sex | Male |
| Date of Birth | 16/09/1989 (37 years old) |
| Ethnicity | Kinh |
| Occupation | Unspecified (construction worker at time of injury) |
| Address | Xa Quang Dong, Tinh Nghe An |
| Health Insurance No. | DN47901 12057344 (valid to 31/12/2026) |
| Emergency Contact | Hoang Minh Tien - Tel: 0339930898 - Xa Quang Dong, Tinh Nghe An |
| Hospital | Can Tho University of Medicine and Pharmacy Hospital |
| Department (Admission) | Emergency and Intensive Care Unit |
| Department (Current) | Orthopaedic and Traumatology Ward |
| Admission Date/Time | 15:49 on 08/07/2026 |
| Inpatient Record No. | 116056 |
| Physician (ED) | Dr. Tran Quang Son |
II. CLINICAL CONTENT
1. Reason for Admission
2. History of Present Illness
- Visible deformity of the left ankle region
- Reduced movement of the left ankle
- An open wound on the medial aspect of the left ankle, approximately 1 cm in length, with minimal bleeding
- Pain at the left ankle
3. Past Medical History
- Comorbidities: Gastroesophageal reflux disease (GERD) - ICD K21
- Habits/Risk Factors: None documented (no tobacco, alcohol, or drug use recorded)
- Family History: Unremarkable (khai khoe)
- Residual Musculoskeletal Impairments: None previously documented
4. Condition on Admission
- Level of Consciousness: Alert and fully oriented; cooperative (benh tinh, tiep xuc tot)
- Vital Signs:
- Heart rate: 78 beats/min
- Respiratory rate: 20 breaths/min
- SpO2: 100% (left toe pulse oximetry)
- Blood pressure: not separately recorded on admission sheet (postoperatively 100/70 mmHg)
- Weight: 60 kg; Height: 165 cm; BMI: 22.04
- Key Physical Findings on Admission:
- Skin and mucous membranes: pink and well-perfused
- Left ankle deformity present
- Open wound on medial aspect of the left ankle, approximately 1 cm, with minimal bleeding
- Left dorsalis pedis pulse: not palpable (mach mu chan trai khong bat duoc)
- Right dorsalis pedis pulse: present and strong
- Left toes: warm with SpO2 100%, active movement of left toes present but reduced
- Cardiopulmonary: regular heart sounds, clear lung fields bilaterally, abdomen soft and non-tender
5. Clinical Diagnosis (Pre-operative)
6. Investigations and Results
| Test | Result | Reference Range | Interpretation |
|---|---|---|---|
| WBC | 10.43 x 10⁹/L | 4.0 - 9.0 | Elevated (reactive) |
| Neutrophils (%) | 36.8% | 47 - 77% | - |
| Lymphocytes (%) | 35.7% | 42 - 85% | - |
| Platelet count | 475 x 10⁹/L | 150 - 400 | Elevated (reactive thrombocytosis) |
| Hematocrit | 38.53% | 38 - 53% | Normal |
| MCH | 29.7 pg | 27 - 32 | Normal |
| MCHC | 33.0 g/dL | 32 - 36 | Normal |
| RDW | 12.9% | 10 - 14.5 | Normal |
| PT | 106% / INR 0.96 | 80-120% / 0.8-1.2 | Normal |
| APTT | 27.2 s | 24.8 - 34.4 s | Normal |
- No fracture identified (chua ghi nhan ton thuong xuong)
- Findings consistent with ankle dislocation without bony injury
7. Definitive Diagnosis
- Open (compound) dislocation of the left ankle joint (Trat ho khop co chan trai) - ICD T14.3
- Open wound penetrating the left ankle joint (vet thuong thau khop co chan trai) - ICD S91
- Rupture of the left ankle delta ligament (dut day chang delta)
- Articular cartilage contusion (ton thuong sun xuong san)
- Gastroesophageal reflux disease - ICD K21
8. Operative Report
- Patient placed supine. Left thigh tourniquet applied at 250 mmHg.
- Sterile draping of the left lower limb.
- Wound on the medial aspect of the left ankle was extended/explored. Capsular laceration identified. Articular cartilage contusion noted. Dorsal veins intact. Delta ligament completely ruptured. Left ankle joint found grossly unstable.
- Copious irrigation with normal saline.
- Debridement of devitalized/crushed tissue.
- Repair of delta ligament (khau lai day chang delta).
- Repair of joint capsule (bao khop).
- Layered skin closure (khau da tung lop).
- Wound dressing applied.
- Short-leg cast applied with left ankle in neutral position (nep bot cang ban chan trai).
9. Postoperative Course
- Patient alert and cooperative following spinal anaesthesia
- Vital signs stable: HR 80/min, BP 100/70 mmHg, SpO2 98%
- Bilateral lower limb sensation returning (hai chan het te)
- Heart sounds regular, lungs clear, abdomen soft
- Transferred from ICU/recovery to Orthopaedic ward (Khoa Ngoai Chan Thuong Chinh Hinh)
- Patient stable, alert
- Wound dressing intact, no abnormal symptoms noted
- Cast in place, neurovascular status intact
- Medications continued
- Wound dressing changes performed daily
- Surgical wound shows serosanguinous drainage (vet mo co dich tham bang)
- Both lower limb movements maintained
- Both dorsalis pedis pulses palpable (mach mu chan, chay sau hai ben)
- Clinical diagnosis: Status post open reduction, debridement, delta ligament repair, and joint capsule repair + cast application for left ankle open dislocation
- Continued wound dressing and suture line monitoring
- Wound healing progressing (thay bang, cat chi vet mo < 15 cm)
- Medications adjusted per daily orders
10. Clinical Examination (Current - Postoperative Day 6, 14/07/2026)
a. General Examination
- Consciousness: Alert, fully oriented, cooperative
- Nutritional status: Good (BMI 22.04, weight 60 kg)
- Skin/mucous membranes: Pink, warm, well-perfused
- Lymph nodes: No significant lymphadenopathy
- Vital signs: Haemodynamically stable (HR ~78-80/min, BP ~100-110/70 mmHg, SpO2 ≥97%)
b. Systemic Examination
- Left ankle: Short-leg cast in situ, applied in neutral position
- Left toes: Warm, pink; active movement of all toes present
- Left dorsalis pedis pulse: palpable
- Left posterior tibial pulse: palpable
- Surgical wound medial ankle: Healing; daily dressing changes; no signs of deep infection observed
- Swelling: Mild residual periarticular swelling under cast
- No compartment syndrome signs noted (toes warm, SpO2 normal, movement maintained)
- Post-reduction X-ray confirms satisfactory reduction of the left ankle joint with restoration of normal joint anatomy
- No bony injury identified; no retained foreign body
- Cast position appropriate
11. Case Summary
- Left ankle deformity
- Open wound (~1 cm) on medial aspect of the left ankle with minimal bleeding
- Absent left dorsalis pedis pulse on admission (vascular compromise at presentation)
- Reduced active range of motion of the left ankle
- Intraoperatively confirmed: capsular tear, delta ligament rupture, articular cartilage contusion, grossly unstable ankle joint
- Open wound communicating with the joint capsule (confirmed at surgery)
- Capsular laceration identified intraoperatively
- Left dorsalis pedis pulse absent on admission
- Restored following closed reduction pre-operatively (pulse returned after traction)
- Complete rupture of the delta (medial collateral) ligament of the left ankle
12. Conclusion
13. Further Treatment
a. Treatment Plan
- Continue analgesia (oral and/or IV as needed)
- Continue broad-spectrum antibiotics (given open/contaminated joint injury)
- Continue proton pump inhibitor (for known GERD and NSAID use)
- Wound care: daily dressing changes; suture removal when appropriate
- Immobilization: maintain short-leg cast for 4-6 weeks
- Physiotherapy/rehabilitation once cast is removed
- Ongoing orthopaedic outpatient follow-up with repeat X-rays
b. Specific Treatment
- Paracetamol 1000 mg (10 mg/mL x 100 mL), IV infusion, three times daily (08:00, 16:00, 23:00)
- Celecoxib (Beroxib) 200 mg, 1 tablet orally once daily (08:00)
- Meloxicam (Brosiral) 10 mg/mL 1.5 mL, intramuscular injection, as required for breakthrough pain
- Ceftazidime (Tenamyd) 1 g, IV, every 8 hours (08:00, 16:00, 23:00) - covering gram-negative organisms including Pseudomonas
- Levofloxacin 500 mg/100 mL, IV infusion at 30 drops/min, once daily (08:00) - extended gram-negative and atypical coverage for open joint infection prophylaxis
- Esomeprazole 40 mg, 1 tablet orally once daily (08:00) - indicated for GERD comorbidity and NSAID gastroprotection
- Daily wound dressing changes with aseptic technique
- Suture removal planned (wound length < 15 cm protocol)
- Short-leg cast to remain in place; non-weight-bearing left lower limb
14. Prognosis
- Risk of surgical site infection or septic arthritis is elevated given the open/penetrating nature of the joint injury and the intraoperative finding of capsular tear - the dual antibiotic regimen mitigates but does not eliminate this risk
- Risk of wound dehiscence or delayed healing is low given the patient is otherwise healthy (no diabetes, no immunosuppression, normal BMI)
- Ankle instability post-repair may persist until full ligamentous healing (6-12 weeks); re-dislocation risk while in cast is low
- Neurovascular recovery: Left dorsalis pedis pulse was absent on admission but returned after reduction, suggesting transient vascular spasm rather than vessel transection - prognosis for full vascular recovery is good
- The patient is expected to be independently ambulatory with crutches (non-weight-bearing) by discharge
- With anatomical delta ligament repair and appropriate rehabilitation, restoration of ankle stability and function is expected in the majority of cases
- Risk of post-traumatic ankle osteoarthritis exists given articular cartilage contusion identified intraoperatively; this may manifest as pain and stiffness over 5-10 years
- Risk of chronic ankle instability if ligament repair stretches or fails during the healing period
- Full return to physical/construction work activities is expected at approximately 3-6 months post-injury, subject to rehabilitation progress
15. Preventive Measures
-
Infection prevention: Continue dual-antibiotic prophylaxis for the full prescribed course; perform strict aseptic wound dressing daily; monitor for signs of septic arthritis (increasing pain, warmth, fever, elevated CRP/ESR) - early washout and re-debridement if infection develops
-
Cast care and neurovascular monitoring: Daily assessment of left toe perfusion, sensation, and movement to detect early compartment syndrome or cast pressure sores; patient educated to report any increasing pain, numbness, or coldness in the left foot
-
Thromboprophylaxis: The patient is immobilized and has undergone lower limb surgery - consider low-molecular-weight heparin (LMWH) prophylaxis for DVT prevention during the immobilization period, particularly once transferred to a step-down setting
-
Rehabilitation planning: Early physiotherapy consultation for upper limb strengthening, non-weight-bearing mobilization, and ankle range-of-motion exercises to begin after cast removal to prevent stiffness and muscle atrophy
-
Post-traumatic arthritis prevention: Ensure anatomical reduction is maintained on follow-up X-rays; advise the patient on weight management and avoidance of high-impact activities during the healing phase to reduce cartilage loading
-
GERD management: Maintain proton pump inhibitor throughout NSAID course; avoid NSAIDs once pain is adequately controlled with paracetamol alone
-
Occupational safety: Advise the patient and employer regarding appropriate worksite safety measures and protective footwear to reduce the risk of repeat ankle injury upon return to construction work