L GT FRACTURE
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: Patient met with an accident on 26th of Feb and admitted to the hospital due to severe injuries.
HISTORY OF PRESENT ILLNESS
Patient is a bus driver by occupation and he drives mostly during the night.He was driving from srikakulam to hyderabad on 26th Feb around 2.30 am .suddenly a lorry came and hit the bus on the narketpally flyover. Then the patient was admitted to the hospital because he had severe injuries on the right leg .
HISTORY OF PAST ILLNESS:
Patient met with similar accident in the past and he has 3 Rods in his left leg.
PERSONAL HISTORY:
DIET: MIXED
APPETITE: NORMAL
SLEEP: NO SLEEP DURING NIGHT
ADDICTIONS : EATS GUTKHA DURING DRIVING TO AVOID SLEEP
NO KNOWN ALLERGIES
FAMILY HISTORY:
NO RELEVANT FAMILY HISTORY
GENERAL EXAMINATION:
PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE
SPEECH IS NORMAL
NO VISIBLE PALLOR ICTERUS CYANOSIS CLUBBING LYMPHADENOPATHY
VITALS:
TEMPERATURE: AFEBRILE
BP: 120 / 80 mmHg
PR: 80 bpm
SYSTEMIC EXAMINATION
CVS: S1 ,S2 SOUNDS ARE HEARD
RESPIRATORY SYSTEM
NO WHEEZE
NO DYSPNOEA
CNS:
NO NEUROLOGICAL DEFECTS
L/E:
NO WOUND SOAKAGE
ACTIVE TOE AND ANKLE MOVEMENTS OF BOTH LL
DISTAL PULSE +
INVESTIGATIONS
GRBS
DIAGNOSIS: Rt distal femur fracture
TREATMENT PLAN:
Inj MONOCEF 1g BD
Inj NEOMOL 100ml IV TID
Inj PANTOP 40 mg IV OD
T.SHELCAL PO OD
