Pain and swelling in Right Leg
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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 diagnosis and treatment plan.
A 70 year old male patient farmer by occupation resident of Chityala came to OPD with chief complaints of swelling and pain in the right thigh since 3 days
HOPI:
Patient was apparently asymptomatic 5 years back then he developed fever which was of low grade,continuous type, not associated with chills and rigor, relieved on medicationand along with History of Dizziness and weakness of which he went to local hospital and was diagnosis to be having diabetes and hypertension 5years ago, started Glimipiride and Metformin.From 1year onwards he occasionally take Insulin Injection.
On monday he had history of Fever which is of Low grade,continous,Not associated with chills and rigor relieved after taking Medication and History of vomiting 3 to 4 episodes non bilious,non blood stained,Non foul smelling Food as contents.
On Tuesday morning,He had history of fall while opening the door then he developed Pain and swelling in Right thigh(proximal thigh)
Pain is progressive,non radiating,aggregated on walking,relieved on rest so they came to our Hospital.
Patient attender told that patient was in altered sensorium while travelling through hospital.
No History of other joints involved,Head injury,loss of consciousness.
When his blood tests was done to undergo surgery ,They were Found to be abnormal and Grbs is 248mg/dl
Patient complaining of increased thirst and dry ness of mouth since yesterday.
Dialy Routine:
He wakes up at 6:00AM,do breakfast at 8:00AM,Go to field but acutually dont do any work at field.Lunch at 1:00PM and then sleep upto 4 PM,Dinner at 7:00PM,Sleeps at 9:00 PM.
Past History:
He was a known case of Hypertension and Diabetes since 5 years.
History of trauma 30 years back on right leg.
No history of Tuberculosis,Epilepsy,Asthma.
Personal History:
Sleep adequate
Appetite normal
Diet mixed
Bowel and bladder regular
No addictions.
Family History:
No signifcant Family History.
Clinical images:
General examination:
Patient is consicous,coherent,cooperative.
Pallor-present
Icterus - absent
Clubbing - Absent
Cyanosis- Absent
Lymphadenopathy- absent
Edema - absent.
VITALS:
TEMP:98.5F
PR:90bpm
RR:20cpm
BP:110/90mm of Hg
Systemic Examination:
CNS:
Higher mental Functions are normal
Motor system:
Bulk of muscles are normal
Tone of limbs are normal
Power of limbs are normal
Reflexs:
Right Left
Biceps 2+ 2+
Triceps 2+ 2+
Knee not done 2+
Ankle not done 2+
meningeal signs:
No neck stiffness
Kernigs and Brudzinski's not done as right leg is under traction
Abdomen:
Distended,
No scars
No visible pulsations
No engorged veins
Palpation:
Tenderness in Right iliac region.No Hepatomegaly and spleenomegaly.
Percussion:
No shifting dullness
No fluid thrill
Auscultation:
Bowel Sounds - heard
CVS:
Appear normal
Trachea is central.
No palpable murmurs
S1; S2heard
Respiratory system:
Trachea is central
Bilateral Airway present
Resonant on percussion
Normal breath sounds heard
Provisional Diagnosis:
Intertrochanter Fracture of femur
Hypovolemia?
Hyponatremia?
Secondary to Tubular Injury?
Liver failure?
Investigations:
On 29-11-22
Treatment:
Inj Neomol
Inj HAI
Tab Telmi H
Inj Monocef
Tab Pantoprazole
IV fluids
Monitor BP 2 hourly
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