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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 an 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.
24 year old male patient came to the casualty with right tibia Intramedullary nail insitu for implant removal.
History of present illnesses
Patient had a past history of trauma of 4 years back later which he sustained implant over right leg for which nailing was done 4yrs back and he started to walk with help of support 2 months following the surgery patient had pain on walking which was dull aching and non radiating , aggravated on weight bearing, relief on rest .
No history of trauma patient then had operated for non-union for which iliac bone grafting was done.Patient started walking ( weight bearing) 2 months after surgery.
Patient now has pain occasionally dull aches,non radiating aggravated on movement, relief on rest.
History of past illnesses
Patient is not a known case of diabetes, asthma, hypertension, tuberculosis.
He has no history of allergy to antibiotics and hormones
He has not undergone any blood transfusion, surgeries and chemo- radiation before.
Personal History
Single
Appetite- normal
Non vegetarian
Bowels- regular
Micturition- normal
Known allergies- absent
Alcohol history- occasional
Tobacco and bettelnut usage- no
Family history
No case of diabetes, heart diseases, hypertension,stroke,cancer, tuberculosis and asthma
PHYSICAL EXAMINATION
No pallor ,cyanosis, clubbing,icterus,lymphedenopathy and odema
Physical status - Moderately built
Hydration adequate
Vitals -
Temperature: 99F
Pulse rate: 98 beats / min
BP: 130/90mmhg
Respiration rate: 16cpm
Spo2 : 99%
On examination -
Tenderness - absent
Knee rotation: normal
Ankel rotation : normal
No swelling
Scar over right leg near knee 70 degree anterior and over middle third and distal part of left leg
Systemic observation-
CVS :
No murmur
No thrills
S1 and S2 heart sounds heard
Rhythm - normal
Volume - normal
CNS:
- patient is conscious
- speech is present
- reflexes are normal
Respiratory :BAE+ , NCBS heard
Per abdomen : soft , not tender
Investigations:-
Blood group - A+ve
Hemoglobin %- 17 g/dl
ESR-5 mm/hr
Blood urea - 27 mg/dl
Blood sugar - 100 mg/dl
Serology- negetive
Urine albumin - trace
Electrolytes - Na : 135 mmol/L
K : 4.7 mmol/L
Cl:107 mmol /L
Reports:-
Treatment-
Day 1 : Dolo 650 mg sos
Day 2: Dolo 650 mg sos
Provisional diagnosis - 24 year old with right tibia IM nail insitu for implant removal
Plan of care- implant removal
Prognosis- guarded
Postoperative instructions-
NBM till further order
- Inj MONOCEF 2g zu BD
-Inj AMIKACIN 500 mg zu OD
- Inj METROGYL 100 ml zu TTD
- Inj NEOMOL 100ml zu
- Inj PAN 40 zu OD
- Inj ZOFER 4 mg sos
- Inj TRAMADOL 1 amp in 100 ml zu sos
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