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FULL MEDICAL RECORD - ENGLISH TRANSLATION
Source: Can Tho University of Medicine and Pharmacy Hospital
179 Nguyen Van Cu Street, Tan An Ward, Can Tho City
Tel: 02923 899 444 (Administrative) - 02923 898 201 (Laboratory)
Website: www.bvdhydeantho.com
I. ADMINISTRATIVE INFORMATION
| Field | Details |
|---|---|
| Patient ID (Ma BN) | 26072400 |
| Admission Number (So vao vien) | 116056 |
| BHYT Card Number | DN47901 12057344 |
| BHYT Valid Until | 31/12/2026 |
| Full Name | NGUYEN DUC LONG |
| Date of Birth | 16/09/1989 (Age: 37) |
| Sex | Male |
| Ethnicity | Not specified |
| Occupation | Unidentified |
| Address | Xa Quang Dong, Tinh Nghe An |
| District / Province | Tinh Nghe An |
| Workplace province | Tinh Nghe An |
| Insurance category | Health Insurance (BHYT) |
| Next of kin / Emergency contact | Hong Minh Tidy - Tel: 0339930898, Xa Quang Dong, Tinh Nghe An |
| Time of arrival | 15:49, 08 July 2026 |
| Department | Emergency and Intensive Care Unit (Khoa Cap Cuu - Hoi Suc Tich Cuc) |
| Attending Physician (initial) | Tran Quang Son |
II. REASON FOR ADMISSION
Left leg injury / Left ankle trauma
III. HISTORY OF PRESENT ILLNESS
Onset and mechanism:
The patient reported that on the same day of admission, while working at a construction site, he was caught in a rotating concrete mixer drum. Following the accident, he noticed deformity of the left ankle region, decreased range of motion, and an open wound on the left ankle (grade I), with mild bleeding. He was brought to the hospital for treatment.
Past medical history:
- Personal: Gastroesophageal reflux disease (GERD)
- Family: No known significant conditions (reported healthy)
IV. PHYSICAL EXAMINATION
General condition:
- Alert, cooperative, good contact
- Skin and mucous membranes: Pink
- Severe pain at left ankle region
- Left limb: Cool; right dorsal pedal pulse: palpable; left dorsal pedal pulse: not palpable
- Left ankle deformity noted
- Open wound on the medial aspect of the left ankle, approximately 1 cm, mild bleeding
- Toes with good capillary fill
- SpO2: 100%
- Reduced range of motion of left ankle
Vital Signs:
| Parameter | Value |
|---|---|
| Blood Pressure | 120/70 mmHg |
| Heart Rate | 78 beats/min |
| Respiratory Rate | 20 breaths/min |
| SpO2 | 100% |
| Temperature | Not recorded |
| Weight | 60 kg |
| Height | 165 cm |
| BMI | 22.04 |
Systems review:
- Respiratory: Clear air entry bilaterally, no crackles
- Abdomen: Soft, no localized tenderness
- Other systems: No abnormalities noted
V. LABORATORY RESULTS
Sample collected: 16:06, 08/07/2026
Collected by: Lam Thi Kim Hai
Sample type: Venous blood
Received: 16:19, 08/07/2026
Coagulation Studies (Stago Compact Max 3)
| Test | Result | Reference Range |
|---|---|---|
| PT (Prothrombin Time) | 13.5 seconds | - |
| PT% | 106% | 70 - 120% |
| INR | 0.96 | 0.8 - 1.2 |
| APTT (Activated Partial Thromboplastin Time) | 27.2 seconds | 24.8 - 34.4 seconds |
Complete Blood Count (CBC) - Page 4 data
(As extracted; values partially legible due to scan quality)
- WBC / RBC / Hemoglobin / Hematocrit / Platelets - within referenced normal range as indicated on the chart (no critical values flagged)
VI. IMAGING RESULTS
Chest X-Ray (Phieu Chieu/Chup X-Quang - Page 5)
Performed: 08/07/2026
Performed by: ThS.BS. Nguyen Hoang An
| Finding | Result |
|---|---|
| Lung fields | No abnormalities detected |
| Bone structures | No abnormalities detected |
| Diaphragm | No abnormalities detected |
| Pleural spaces | No abnormalities detected |
| Lung parenchyma | No abnormalities detected |
| Lung hilum | No abnormalities detected |
| Major vessels | No abnormalities detected |
| Heart size | Not enlarged |
| Lung fields | No abnormalities detected |
Conclusion: NO ABNORMALITIES DETECTED ON CHEST X-RAY
Left Ankle X-Ray - AP and Lateral Views (Page 6 & 7)
Performed: 08/07/2026
Performed by: ThS.BS. Nguyen Hoang An
Requested by: Truong Ngoc Thach
Indication: Left ankle X-ray (AP and lateral, 2 views), for suspected:
- Joint injury / soft tissue injury around the ankle and foot (unspecified)
- Dislocation and/or subluxation, not elsewhere classified, ankle and/or foot (ICD-10: M24.37)
- Gastroesophageal reflux disease (ICD-10: K21)
Findings:
- Bone structure: No abnormalities detected
- Joint: No abnormalities detected
- Other: Soft tissue swelling noted
Conclusion: SOFT TISSUE SWELLING OF THE LEFT ANKLE
VII. DIAGNOSES
ICD-10 Coded Diagnoses:
| Code | Diagnosis |
|---|---|
| T14.3 | Dislocation of joint, ligament rupture, and periarticular injury, region of body unspecified (traumatic) |
| M24.37 | Dislocation and/or subluxation (not elsewhere classified) of ankle and/or foot; possible capsular/ligamentous injury, left ankle and/or foot |
| K21 | Gastroesophageal Reflux Disease (GERD) |
Clinical working diagnosis (Admission):
- Left ankle dislocation - open wound of left ankle, suspected joint penetration
- Left ankle trauma
- Gastroesophageal reflux disease
VIII. SURGICAL PROCEDURE
Date / Time: 08/07/2026, 15:50
Department: Orthopedics and Trauma Surgery (Khoa Ngoai Chan Thuong Chinh Hinh)
Surgery Type: Type 2 (with anesthesia / regional block)
Anesthesia Method: Spinal anesthesia (gay te tuy song)
Surgeon: Tran Quang Son
Anesthesiologist: Vo Nguyen Hong Phuc
Operative Technique:
- Patient positioned supine.
- Left thigh tourniquet applied at 250 mmHg.
- Wound extended and explored.
- Intraoperative findings: damage to the cartilage of the joint surface; injury to the deltoid ligament, medial collateral structures, and medial ankle tendons/vessels of the left ankle; confirmed joint penetration (open joint injury).
- Joint cavity thoroughly irrigated with large volumes of normal saline.
- Reduction performed.
- Fasciotomy performed - left ankle compartment syndrome release / decompression of left foot.
- Deltoid ligament and joint capsule repaired and sutured.
- Skin closed in layers.
- Wound dressed; external splint applied.
IX. TREATMENT FOLLOW-UP AND PROGRESS NOTES
Admission Day - 08/07/2026 (15:49)
Clinical status:
- Patient alert, good cooperation
- Vital signs stable: BP 120/70 mmHg, HR 78 bpm, SpO2 98% (room air), afebrile
- Severe pain at left ankle region
- Left limb cool; left dorsal pedal pulse absent; right dorsal pedal pulse palpable
- Left ankle deformity; open wound ~1 cm on medial aspect, mild bleeding
- Good toe capillary fill; SpO2 100%
- Reduced ankle range of motion
Orders issued (08/07/2026, 15:50):
- Stat blood tests (CBC - type 01A)
- Urgent X-ray: Left ankle AP and lateral (2 views, digitized)
- Imaging: Left dorsal pedal pulse absent - urgent Doppler/vascular evaluation noted
Post-operative Day 1 - 08/07/2026 (22:12)
Orthopedics and Trauma (Ngoai CTCH) Admitting Note:
- Patient alert, good contact
- Vital signs stable
- Wound: closed surgical wound
- Post-operative wound and splint: maintained, intact
- Diagnosis confirmed: Deltoid ligament rupture, ankle dislocation, left ankle compartment syndrome decompressed
Orders:
- Continue prescribed medications
- Wound care: closed wound dressing
- Nursing care: Level 2
Signed by: TS.BS. Tran Quang Son
09/07/2026 - 05:00 (Medication Review / Drug Round)
Medications Prescribed:
| Drug | Dose / Route / Frequency |
|---|---|
| TENAMYD-CEFTAZIDIME 1000 mg | 2 vials IM/IV - TID (08:00, 16:00, 23:00); 6 vials/day |
| Sterile Water for Injection 5 mL | 4 ampoules per dose, TID (with ceftazidime) |
| LEVOFLOXACIN (Cooper) 500 mg/100 mL IV Solution | 1 bottle IV infusion at 30 gtt/min, once daily (08:00) |
| PARACETAMOL 10 mg/mL IV | 1 bag IV infusion at C gtt/min - TID (08:00, 16:00, 23:00) |
| ESOMEPRAZOLE 40 mg (oral) | 1 tablet orally, once daily (08:00) |
| BEROXIB (Celecoxib) 200 mg (oral) | 1 tablet orally, once daily (08:00) |
Nursing care level: Level 2
10/07/2026
Clinical status:
- Patient alert, good contact, vital signs stable
- Bilateral wounds dressed, wound edges approximated, sutures intact
- Both ankles bandaged; wound length < 15 cm, post-fasciotomy wounds healing
- Joint capsule and deltoid ligament repair intact
- Follow-up protocol: BTO1
Orders:
- Wound care: Change dressing bilateral ankles; suture removal pending healing
- Continue all previously prescribed medications
- Nursing care: Level 3
Signed by: TS.BS. Tran Nguyen Anh Duy
11/07/2026 - 05:00 (Medication Review)
Medications Continued (Day 3 post-op):
| Drug | Dose / Route / Frequency |
|---|---|
| TENAMYD-CEFTAZIDIME 1000 mg | 2 vials IV - TID (08:00, 16:00, 23:00) |
| Sterile Water for Injection 5 mL | 4 ampoules per dose, TID |
| LEVOFLOXACIN 500 mg/100 mL IV | 1 bottle IV drip daily at 30 gtt/min (08:00) |
| PARACETAMOL 10 mg/mL IV | 1 bag IV - TID (08:00, 16:00, 23:00) |
| ESOMEPRAZOLE 40 mg | 1 tablet orally, once daily |
Nursing care level: Level 2
Signed by: TS.BS. Tran Nguyen Anh Duy
Final Treating Physician
TS.BS. Ho Dien (noted on final page)
X. SUMMARY OF KEY MEDICAL PERSONNEL
| Role | Name |
|---|---|
| Initial/Admitting Physician (Emergency) | Tran Quang Son |
| Surgeon (Primary) | TS.BS. Tran Quang Son |
| Anesthesiologist | Vo Nguyen Hong Phuc |
| Radiologist | ThS.BS. Nguyen Hoang An |
| Ward Physician (Post-op follow-up) | TS.BS. Tran Nguyen Anh Duy |
| Final attending physician | TS.BS. Ho Dien |
| Laboratory Technician | CNXN Le Van Phat |
| Phlebotomist | Lam Thi Kim Hai |
XI. SUMMARY
Patient: Nguyen Duc Long, Male, DOB 16/09/1989 (37 years old)
Admission: 08/07/2026, 15:49
Hospital: Can Tho University of Medicine and Pharmacy Hospital
Clinical summary:
A 37-year-old male construction worker was admitted following a workplace accident in which his left leg was caught in a rotating concrete mixer drum. He presented with left ankle deformity, an open wound on the medial ankle (~1 cm), absent left dorsal pedal pulse, reduced range of motion, and mild bleeding.
Key findings: Left ankle dislocation with open joint injury, deltoid ligament rupture, left ankle compartment syndrome, absent left dorsal pedal pulse on presentation. X-ray showed soft tissue swelling without bony fracture. Chest X-ray was normal. Coagulation studies were within normal limits.
Treatment: Emergency surgery on 08/07/2026 under spinal anesthesia - wound extension and exploration, joint irrigation, reduction of dislocation, repair of deltoid ligament and joint capsule, fasciotomy (compartment syndrome decompression) of the left ankle/foot, and wound closure. Post-operatively managed with dual antibiotic therapy (Ceftazidime + Levofloxacin), IV Paracetamol for analgesia, Celecoxib, and Esomeprazole (for known GERD).
Comorbidity: Gastroesophageal reflux disease (GERD, ICD-10 K21)
Note: This English translation is based on OCR extraction from a scanned Vietnamese medical record. Some values (particularly CBC results and certain handwritten entries) were partially illegible due to scan quality. Where uncertain, the most clinically consistent interpretation has been provided. This document should be verified against the original Vietnamese record for any medico-legal or clinical decision-making purposes.
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