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Simon owns his own business as a project manager, and lives with his  wife, Rachel, who works part-time as a school teacher. They have two children a

Assignment Task:

Social history: Simon owns his own business as a project manager, and lives with his  wife, Rachel, who works part-time as a school teacher. They have two children aged 15 and  13, who are both at their local secondary school. 

Relevant family history: Simon’s mother has osteoporosis. 

Allergies and Current medications: See?charts 

Clinical course whilst in hospital: Yesterday evening Simon was brought in by ambulance to  the emergency department after riding his bike back from work, and his front tyre got caught  in the tram tracks. He was thrown off his bike and the bike subsequently landed on his left  ankle. He reported he did not hit his head. He complained of severe pain in his left ankle,  there was visible malformation of the ankle and 6cm x 4cm dermal and epidermal tissue loss  over the medial malleolus. An Xray confirmed a comminuted fracture of his left distal tibia  and medial malleolus, with the wound primarily caused by the bike pedal landing on his ankle.  His left ankle was immobilised, his wound irrigated, then dressed in normal saline soaked  packing gauze. This morning Simon underwent an open reduction and internal fixation (ORIF)  of his left ankle, cleaning and suturing of his wound. Simon has just returned post operatively  to the ward.  

Post-operative assessment findings on admission to the ward: 

Central nervous system: GCS 14/15, equal pupils, size 3mm and both reactive to light.  Equal upper limb strength, normal strength neurovascular observations in right  leg. Bandages cover and stabilise the left foot up to the knee and is able to bend the left knee  slightly and move toes.  

Pain assessment (OLDCARTS): Onset of pain occurred at the time of the accident. The  primary location of pain is the left ankle, however Simon complained of pain on his left  shoulder, over the deltoid, since this morning. The pain in the left shoulder is a dull ache on  movement, but this is tolerable. The ankle pain has yet to be relieved, despite analgesia. The  pain is sharp in nature in the left ankle, ‘it takes my breath away’ on the slightest of  movement. Pain in the ankle is 8/10 at rest, and is worse on movement, especially when the  analgesia wears off and at night. Relieving factors include rest, elevation and cryo-cuff cooling  device, along with regular prescribed analgesia and break through analgesia when required.  

Cardiovascular system and neurovascular observations: See chart 

Respiratory: See chart. Chest auscultation: chest sounds clear and quiet to both bases, no  shortness of breath noted, or adventitious sounds.

Gastrointestinal: Simon is complaining of constant nausea. Surgeon’s  orders state to remain nil by mouth for 4 hours post op, however ice chips can be  given once Simon becomes more alert. After four hours and once Simon is tolerating fluids,  he can start a light diet. A full balance chart is required, and Simon has Compound?Sodium  Lactate (CSL) running currently. He has not had his bowels open since his admission to  hospital. On abdominal auscultation the bowels sounds are quiet in all abdominal quadrants. 

Renal: Simon has not passed urine since his surgery; no indwelling catheter was inserted  during surgery. 

Integumentary: He has 2 peripheral cannulas, one in each cubital fossa. The one in his  right arm was inserted yesterday, the left one was inserted during surgery. His left ankle was  sutured in theatre, requiring 8 sutures. It is currently dressed with a non-adhesive dressing,  combine dressing and secured with a crepe and cotton padding bandage from his toes to  below his knee. No ooze is present on the dressing and he has one?Bellovac?Drain Tube (on  suction) which has drained 10ml so far. On skin inspection there is visible bruising to left  shoulder. See pressure risk assessment (Braden score) in the charts.

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