A CASE OF COMPOUND FRACTURE:

 This is 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 patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

A 40 years old male patient presented with a road accident - bus vs lorry collision that took place on a highway . 

HISTORY OF PRESENT ILLNESSES:

Patient is a 40 year old male .he was a driver by occupation.

Right -compound grade -I distal femur + patella communited fracture + 

Left -Ankle bimalleolar fracture grade -3b compound

PAST HISTORY:

• The patient underwent no surgeries in the past. 

• There is no history of Tuberculosis, Diabetes Mellitus, Hypertension, Epilepsy, Asthma.

• The patient was never a victim of any kinds of accidents.

DRUG HISTORY:

• Patient was on anti-diabetic drugs prior to coming to the hospital.

PERSONAL HISTORY:

• Patient is of mixed diet. 

• He was well-nourished.

• His appetite is good

• Her bladder function is good.

•No insomnia

• No smoking .

•Chews Tobacco daily (3-4 times)

• Patient is an occasional drinker. (1 or 2 times a month.)

GENERAL  EXAMINATION:

• The patient is concious, coherent and cooperative.

• On examination, patient appears to be a little fatigued. 

• Patient appears to be responsive and attentive on command.

• His attitude is good

•No polyphagia ,No polydypsia ,No nocturia

• No nausea and No vomiting

• Patient appears to be mildly dehydrated.

• Vitals (on examining)

  - Afebrile

  - Temperature- 98.3°F

 -  Pulse Rate- 84bpm

 - SpO2 :98%@RA

  - RR : 18

  - RS : BAE+

   - S1 and S2 are heard. 

   - Breathing sounds are normal.

   - Blood Pressure is 110/80mmof Hg

LOCAL EXAMINATION :

 • Pain at the site injured.

SYSTEMIC EXAMINATION: 

PROVISIONAL DIAGNOSIS:

•This is a case of 40year old male patient with compound Grade 36 Malleolar # + (RF)

Distal femur+ patella comminuted #

© K/c/o DM II ( Not on medication) referred in v/o High sugars (GRBS - 450mg/dl).

INVESTIGATIONS:

 • HIV : non reactive

 • HBSAG : Negative

 • HCV : Negative

1) ECG 

2) ULTRASOUND REPORT (No ultrasound picture was found in pt files.) 

3) patient was diabetic positive for ketones in urine

ALLERGY HISTORY:

• Patient is not allergic to any known drug or food.

• There is no known allergy to dust or pollen in the patient.

TREATMENT:

SURGERY :

 • planning ORIF + plating femur and cc screw fixation for left ankle.

MEDICATION:

• 1) STRICT DIABETIC DIET

2)  INJ MONOCEF 1g IV/BD

3) INJ METROGYL 100ml IV/TID

4) INJ NEOMOL  100ml IV/TID

5) INJ PANTOP 40mg/OD

6) INJ HAI S/C according to sliding seal /TID

7) Tab-LIMCEE 500mg PO/BD

 8) Tab-CHYMORAL FORTE PO/TID

 9)Tab-SHELCAL CT PO/OD

 10)GRBS MONITORING

 11)IVF 20NS@ 100ml/hr

 12) Fluid intake and urine output monitoring for every 4 hourly period

 13) IVF NS @urine output + 30ml/hr