General Medicine Blog
March 21, 2022
A 32 year old male patient, resident of Annaparthy, Lorry Driver by occupation, came to our hospital with chief complaint of accident with leg fracture.
Date of admission:-06-03-2022
History of present illness:-
Patient was apparently asymptomatic 10 days back and developed pain in wrist of right hand which was sudden in onset, gradually progressive with no aggrevating and relieving factors and he couldn't control driving and met with an accident.
History of past illness:-
Not a known case of Diabetes, hypertension, tb, epilepsy.
Personal history:-
Patient has normal eating habit with mixed diet.
Chronic alcoholic and smoker.
Takes tobacco occasionally.
Daily routine:-
Patient used to wake up at 5.00AM , takes breakfast in between 8.00AM-9.00AM. Then goes to his work, and takes rice in between 1.00PM-2.00PM and dinner at 8.00PM and goes to bed by 1.00AM.
Family history:-
No significant family history.
General examination:-
Patient is conscious, coherent, cooperative and well oriented to time, place and person.
No pallor
No icterus
No clubbing
No Lymphedenopathy.
Vitals:-
Temperature-98.2 F
Pulse rate-120 bpm
RR-20 cpm
BP-110/80mmhg
SPO2-96% at room temperature
RBS-290mg/dl
Investigations:-
CBP
RBS
Provisional diagnosis:-
Compound grade 3 right proximal tibia lateral condyle fracture and right fibula fracture.
Treatment:-
Inj. Monocef 1gm × IV × BD
Tab. Hifenac PO × BD
Tab. Pantop 40mg × PO × OD
Tab. Shelcal CT × PO × OD
Tab. Limcee 500mg × PO × OD
Tab. Neurokind LC × PI × OD
Tab. Pregaba 70mg × OD × H/S
Syp. Cremaffin plus 10ml × OD
Surgery done (Debridement and external fixation for compound grade 3 right proximal tibia lateral condyle fracture and right fibula fracture)
Comments
Post a Comment