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CH.Snehitha

Roll no.31

5th semester

July 21, 2022

GENERAL MEDICINE.

CASE REPORT:

An 86years old male patient, farmer by occupation came to OPD with chief complaints of CHEST PAIN since 1 month.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 month ago after which he had developed CHEST PAIN in the retrosternal region lateralised to both the shoulders.  The pain is non exertional, radiating type. It radiates to back of the neck and the pain lasts for about 1-2 min. Number of episodes of chest pain in a day were 3-4 with no aggravating or relieving factors. 

He also complaints of DIMINISHED VISION in the left eye.

When admitted in the medical ward at kims hospital for evaluation of chest pain, he has had a slip and fall in the bathroom after which he was not able to stand or bear weight on left leg as the fall has caused  FRACTURE TO THE LEFT FEMUR.

HISTORY OF PAST ILLNESS:

Patient has a history of use of analgesic medication since 8 years and was diagnosed with AKD and stopped using them since 6 months. 

Patient has developed BLEBS in rt lower limbs which is followed by CELLULITIS 3 yrs back. Later after 6 months, the same happened to the left lower limb.

K/c/o HTN since 3 years and is on regular medication. 

N/k/c/o DIABETES, THYROID, TB, EPILEPSY.

TREATMENT HISTORY:

For cellulitis, Skin grafting was done to both the legs.

On ANTI-HTN medication :

• NICARDIA 20mg
• ASPIRIN 
• NODOSIS 500mg

Past medical and surgical history:

• Diagnosed as AKI secondary to analgesic abuse.

PERSONAL HISTORY:

Diet: Mixed

Appetite: Normal

Bowel and Bladder movements: Regular

Sleep: Adequate 

Addictions: ALCOHOL INTAKE around 90-180 ml since 30 years. SMOKING since 30 years.

FAMILY HISTORY:

Nothing significant. 

PHYSICAL EXAMINATION: 

• GENERAL EXAMINATION : 

Patient is conscious, coherent and co-operative

Well oriented to time, place, person.

Moderately built and Moderately nourished.

Pallor: Present.

NO Icterus.

NO Clubbing of fingers or toes.

NO lymphadenopathy, malnutrition and dehydration. 

Oedema of feet +ve , PITTING type

VITALS: 

Temp- afebrile.

Pulse rate - 80 bpm.

Respiration rate- 18/min

Bp- 180/70 mm hg.

Spo2: 98% at room temperature. 

• SYSTEMIC EXAMINATION: 

CVS: 

Chest wall: Bilaterally symmetrical

JVP: normal 

S1,S2 ++ 

No Murmurs

No Thrills

RESPIRATORY SYSTEM: 

Dyspnoea - no

Position of trachea - Central 

Breath sounds - normal vesicular breath sounds and no added sounds 

ABDOMEN :

Shape of abdomen - scaphoid 

Tenderness - no

Palpable mass- no 

Hernial orifices - normal 

Free fluid - no 

Bruits- no 

Liver- not palpable 

Spleen - not palpable. 

Bowel sounds - Not heard 

CNS: 

Level of consciousness: Conscious 

Speech- Normal 

Signs of meningeal irritation- None 

Motor and sensory system: Normal

Reflexes: Present 

Cranial nerves: Intact

INVESTIGATIONS ORDERED:

COMPLETE BLOOD PICTURE

ECG

BLEEDING AND CLOTTING TIME

LFT

RFT

HIV 1/2 RAPID TEST

HBSAG

ANTI-HCV ANTIBODIES

X-RAY : (pelvis with both hips AP view)

Shows comminutes inter-trochanteric fracture of left femur.

PROVISIONAL DIAGNOSIS:

?

TREATMENT:

19.7.20

(**referred to orthopedic dept to examine the accidental fall)

Impression and Diagnosis: Left lower limb externally rotated. Comminuted fracture of femur.

Management: 

Skin traction with 3 kg weight to left lower limb.

• INJ. TRAMANOL 50mg in 100ml/IV/BD
• FOLEYS CATHETERIZATION 
• Monitor VITALS AND REVIEW SOS
• Continue ANTI-HTN DRUGS as advised by physician. 

20.7.20

• TAB ULTRACET PO/BD
• TAB PANTOP 40mg PO/OD
• TAB SHELCAL CT PO/OD
• TAB CHYMORAL FORTE PO/TID
• SKIN TRACTION to left lower limb with 3kg weight 
• ANTI-HTN DRUGS as advised by physician 
• Review SOS