Accident case

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

A 45 yrs old male patient was bought to our hospital after RTA at 5.30pm on 24th March.


HISTORY OF PRESENT ILLNESS 

A 45 yrs old patient (daily labour by occupation) was completely fine and was able to do his daily activities well until he met with an accident on 24th March .Patient complains of pain in left shoulder ,left ribs,left scapula and restricted movements.

PAST HISTORY 
Not a K/c/o Hypertension.
Not a k/c/o diabetesmellitus.

PERSONAL HISTORY 
Diet - mixed 
Appetite - Regular
Sleep - adequate 
Bowel movements : regular .
Bladder movements : regular.

GENERAL EXAMINATION 
patient is conscious, coherent, coperative.
Afibrile,
No history of cyanosis, clubbing, lymphadenopathy,Pedal edema,pallor. 

Vitals:

Temp- 97.7 F
PR- 78
RR-20
BP-140/80mm of Hg
Tenderness along the left thoracic cage.
 
Systemic examination :

CVS: S1,S2 heard ,no murmurs  
Respiratory : BAL positive
P/A : soft non tender
Cns: no abnormalitys detected 




DIAGNOSIS:

 BLUNT INJURY OF CHEST WITH FRACTURE OF LEFT 2nd,3rd, 4th,5th and 9th RIBS AND FRACTURE OF LEFT SCAPULA.

Rx:

SOFT DIET
INJ.MONOCEF 1g/IV/BD
INJ.METROGYL 100ML/IV/ TID
INJ.PAN 40mg/ID/OD
INJ.TRAMADOL 2amp in 100ml IV/BD
INJ.ZOFER 4mg/IV /BD
ARM SLING POUCH
MONITOR VITALS




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