General medicine

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 20 year old Male patient met with an car v/s bike accident near vemlakonda ,
Came to the OPD as chief complaint of pain and deformity in right lower limb  

HISTORY OF PRESENT ILLNESS 
 A 20year male  patient who is student 
 suddenly  met with an  car v/s bike accident near vemlakonda a compound grade 3 distal femur  fracture and undergone  surgery (open reduction  internal fixation with plating)
On last Saturday.  
And has low level of haemoglobin ,blood transfusion is done
And has  pricking and dragging  type of 
Pain and relieved on medication 

PAST HISTORY 
Not a k/c/o hypertension 
Not a k/c/o  diabetesmellitus 
 Family history: patient father has 
Diabetes and BP

PERSONAL  HISTORY 
Present diet: 
Diet : mixed
Appetite : normal
Bowel movements : irregular  after  medication  regular
Bladder movements :  normal
Sleep : adequate 
Addiction : smoking from last 5yrs
Occasionally alcohol, toddy

GENERAL  EXAMINATION 
 Patient is conscious,coherent,coperative 
No history  of  cyanosis, clubbing
Lymphadenopathy, pallor, edema
Physical  status :moderately built
Adequate hydration 

VITALS
 Tempr-98.1F
 PR- 82
RR-16
BP-120/90

SYSTEMIC  EXAMINATION 
CVS  : S1 S2 sounds heard 
Respiratory :  no dysponea 
CNS : consious 
PA : soft ,non tender
Diagnosis :  compound   communicated grade 3 distal femur fracture 
 Investigation :
Low level of haemoglobin  ,
Blood transfusion  is done(Prcb)
              Ct scan
             ECG
Treatment:
Medication chart :
Day 1
Day 2:
Day 3 :
Day 4:
Day 5:
Day 6:
Day 7:
Day 8 :
Day 14:
Day 15 :
Day 16 :
Day 17:
Day 18 :
 Day 19
Day 19
Day 20 
CEFOPERAZONE and SUBLACTAM inj
ACECLOFENAC  tab
PARACETAMOLINFUSION(1000mg/100ml)

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