Intertrochanteric femur fracture
February 28 2022
This is online E- blog ,to discuss out patient de-identified health data shared after taking her guardian's signed informed consent.
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E- blog also reflects my patient's centred online learning portfolio.
I have been given This case to solve in ab attempt to understand the topic of "Patient Clinical Data Analysis " to develop my competency in reading and comprehending clinical data including history clinical findings,investigations and come up with a diagnosis and treatment plan.
CHIEF COMPLAINTS
71 year old male came to casualty with chief complaints of pain because he suddenly fall down and hurt his knee .
HISTORY OF PRESENTING ILLNESS
Because of the fall, He had severe pain and unable to bear weight in the lower limb.He took an x-ray at an x-ray center in mahubabad .He found out that he had a fracture and came to this hospital for further treatment.
Appetite is normal,not associated with nausea,vomitings, loose stools, constipation, weight loss.
Pain in the knee ,cannot walk and pain is relieved if lay down. Pain is associated with itching and burning sensation.
HISTORY OF PAST ILLNESS:
Patient had a similar fall 3 years back on the right and had PFN surgery
Patient walks with the help of a walker.
Patient is also diagnosed with BP,tuberculosis
PERSONAL HISTORY
Married
Occupation: toddy tapper
Socioeconomic status: lower middle class
Appetite: normal
Diet: mixed
Bowel and bladder movements: regular
No known allergies
Alcohol history
- intake of whisky every other day but stopped now ,since 3 years.
FAMILY HISTORY
Not significant
PHYSICAL EXAMINATION
The patient is conscious ,cooperative, coherent
No pallor ,icterus ,cyanosis,clubbing, lymphadenopathy,oedema
VITALS:
Temperature : Normal
PR: 80 bpm
BP: 110/80 MG
Sp02: 95%
GRBS: 130 mg/dl
Hb:10.5 g/dl
PROVISIONAL DIAGNOSIS:
Left Proximal femoral nail
FINAL DIAGNOSIS
Surgical correction of long bone fracture surgery
SYSTEMIC EXAMINATION
CVS: no thrills no murmurs ,s1 and s2 is heard
RESPIRATORY SYSTEM: bilateral Air entry present ,NVBS,no crepts
CNS: No Abnormalities detected
TREATMENT
DAY 1
INJ .MONOCEF 1g BD
T. PANLIOM PO OD
T .ULTRACET PO BD
T.SHELCAL CT PO OD
T.TELMA 40 mg PO OD
T.GASOPENTIN 100 mg
DAY 2
INJ MAGNEX FORTE 1.5 gm IV /BD
INJ AMIKACIN 500mgIV /BD
INJ METROGYL 100 ml IV /TID
T.PAN 40 mg /PO /BD
T.GABAPENTIN 100 MG/PO/ TID
T.AMLONG 5MG/PO/BD
DAY 3
INJ MONOCEF 1 GM IV BD
T.ULTRACET PO BD
T.PAN 40 MG PO OD
T.SHELCAL 5 MG PO OD
T.TELMA 4O MG PO OD
DAY 4
INJ MONOCEF 1GM IV BD
T.PAN 40 MG PO OD
T.ULTRACET PO BD
INJ .DICLO IM
