Narrative Summary Services

On mm/dd/yyyy, Jane Doe was evaluated by Dr. [PHYSICIAN A] and [PHYSICIAN ASSISTANT A] at [TREATING FACILITY] following a trauma transfer. She had previously been admitted to [PRIOR FACILITY] from mm/dd/yyyy to 15 after sustaining multiple injuries in a helmeted motorcycle sidecar collision during a wine tour. The motorcycle had veered off the road and struck an intersection pole at approximately 25 mph.

Jane Doe suffered a left femoral head fracture/dislocation and a comminuted right bimalleolar ankle fracture. At [PRIOR FACILITY], she underwent closed reduction of the left hip on mm/dd/yyyy by Dr. [SURGEON A], followed by ORIF with labral repair on mm/dd/yyyy by Dr. [SURGEON B]. She also received a washout, staple closure, and external fixator placement for the right ankle fracture on mm/dd/yyyy, followed by a 72-hour course of IV Gentamicin.

Upon transfer to [TREATING FACILITY], Dr. [PHYSICIAN A] was notified at 11:15 AM, and Jane Doe was seen at 9:49 PM. She reported ongoing pain in her surgical extremities but denied any focal motor or sensory deficits. She was accompanied by her companion, who provided additional history. Jane Doe’s examination revealed stable airway, bilateral breath sounds, intact circulation, and a GCS of 15. Her pelvis was stable, and extremity examination showed appropriate postoperative tenderness and expected range of motion limitations. The right lower extremity had an external fixator with intact surgical wounds. The left hip incision site was dressed and without drainage.

A trauma tertiary examination was completed and found no additional injuries. Further imaging was ordered, including CTA of the head and neck and bilateral lower extremity duplex studies to rule out vascular injury and deep vein thrombosis (DVT). Jane Doe had a suspected left lower extremity thrombus noted on duplex imaging from mm/dd/yyyy, for which she was receiving Lovenox prophylaxis. She was uncertain if this was related to prior sclerotherapy in the same extremity. Dr. [PHYSICIAN B] was consulted for definitive internal fixation of the right ankle fracture. Jane Doe was placed on a regular diet, with NPO after midnight in preparation for potential orthopedic procedures.