48 year old with year old male with compound grade-2 schatzker type 6

48 year old male with compound grade-2 schatzker type 6 

12 /03/22

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment .

A 48 year male us reported at the casualty at 6.00 pm from cheemalagadda on 21 /2/22 after an accident 

History of presentillness
, There was no consumption of alcohol, after the accident he was taken to a local hospital from there he was referred to our hospital 
He got injured in his left leg ,he was enable to walk
He had no History of head injury, seizures,nausea 

Past history 
He has no history of tuberculosis, asthma,leprosy and epilepsy 

Personal history 
Diet_ normal 
Sleep_normal
Appetite_normal
Addictions_occasional alcohol drinker
Allergies _ no allergies

Local examination 
Deformation of leg
Laceration of wound on  knee
Skin is normal

General examination 

Patient is examined under well lit room amd adequate ventilation with his consent taken. 

Patient is conscious, coherent and cooperative, well oriented to time space. He is moderately built and well nourished. 

No visible pallor, icterus, cyanosis, clubbing, lymphadenopathy, 

Deformation of leg
Laceration of wound on  knee
Skin is normal

Vitals 

Temperature - afebrile

Blood pressure -160/90mmHg

Pulse rate - 79 bpm

Spo2 - 96%@RA

Systemic examination 

Cardiovascular system 

S1 and S2 heard no murmurs

Central nervous system

No neurological defecits

Respiratory system 

Central position of trachea

Vesicular breath sounds

No wheeze, no dysponea

Vitals 

Temperature - afebrile

Blood pressure -160/90mmHg

Pulse rate - 79 bpm

Spo2 - 96%@RA

Systemic examination 

Cardiovascular system 

S1 and S2 heard no murmurs

Central nervous system

No neurological defecits

Respiratory system 

Central position of trachea

Vesicular breath sounds

No wheeze, no dysponea

Stay in hospital 
Patient was operated on 26/2/22 ,open reduction with implant fixation plus bicolumnar plating for left Tibia



Investigations 
Liver function 

RFT
ECG


Treatment 


Injection- Monocef 


Injection - metrogyl 100 ml


Injection - neomol 100 ml


Injection - tramadol 5 mg in 100 ml


Injection - zofer 40 mg


Tab. Paracetamol 650 mg


Tab. Pantop 40 mg


Tab. Shelcal


Tab.chymerol forte


Tab. Limcee 500 mg


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