GM CASE-3
Hi,I am G.Manogna,3rd BDS student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio
A 32-year-old man, pharmacist by occupation presented to the outpatient department with the,
CHIEF COMPLAINTS:
1. Fever since 1 week.
2. Difficulty in swallowing since 1 week.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 6 years back when he met with an accident (RTA - bike vs lorry) and sustained following injuries:
- Left femur fracture: Intramedullary Nailing done
- Tibia fracture: Plating done
2. Patient went for follow up after 4 months because of constant pain and was informed about nonunion of femur shaft fracture and tibial fracture.
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Underwent revision surgery under another doctor for Intramedullary nailing without any bone graft.
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1-2 days after the revision surgery, patient noticed relative motion of Femur nail and underwent revision surgery for screw tightening.
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The patient gradually started walking with support but complained of pus discharge from the operated site over femur, intermittently since 6 years.
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In 2018, patient noticed discharging sinuses - 2 in proximal near left gluteal region and 2 in distal femur and was treated with Inj Peptaz, intravenous amikacin and intraosseous gentamicin for 20 days.
3. 3 months back Nails and plates were removed as the patient’s doctor had advised in view of delayed bone healing.
4. 1 week back developed fever, high grade, associated with chills and rigors
- No h/o fever spikes since 2 days.
5. C/O difficulty in swallowing since 1 week, both to liquids and solids, associated with burning sensation in throat.
DAILY ROUTINE:
Prior to the accident patient worked in a medical shop near his house.
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He used to wake up at 6AM, have tea/coffee, eat breakfast and leave for work.
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He left for work around 9Am by walk and used to return home by evening 6PM.
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Post the accident, patient was initially bed ridden for 1 year, and then gradually started walking with support.
PAST HISTORY:
Patient is a known case of Diabetes Mellitus type 2, since 6 months, on T Glimiperide 1mg + T Metformin 500mg.
Patient is not a known case of Hypertension, Thyroid disorders, Seizures, Tuberculosis, Asthma, stroke or any cardiac disorder.
History of previous surgery - Nailing for Femur fracture and Plating for Tibia fracture, 6 years ago.
PERSONAL HISTORY:
- His appetite has decreased since past 1 week, he consumes a mixed diet, sleep is disturbed
- Bowel movements are normal but Decreased urine output since the last couple of days whenever fever spiked.
- No history of smoking or alcohol.
- No known food or drug allergies.
FAMILY HISTORY:
No similar complaints in the family members.
GENERAL PHYSICAL EXAMINATION:
Examination has been done in a well-lit room in supine and sitting posture after taking informed consent and after reassuring the patient.
Patient was conscious, coherent, co-operative and well oriented to time, place and person.
Moderately built and nourished.
Pallor present.
No signs of Icterus, Cyanosis, Clubbing, Pedal edema, Generalized Lymphadenopathy.
JVP normal.
SYSTEMIC EXAMINATION:
Central Nervous System: No abnormality detected.
Per Abdomen: Soft and nontender, no organomegaly.
Cardiovascular System: S1, S2 heard, no murmurs
Respiratory System: BAE+, NVBS +
PROVISIONAL DIAGNOSIS:
Sepsis with ( AKI resolved) (ALI resolved)
- Chronic osteomyelitis of Left Femur TREATMENT:
1. IVF NS @150ml/hr
2. Inj NEOMOL 1g/IV/SOS ( if temp > 101F)
3. Inj LINEZOLID 600mg/IV/BD
4. Inj TRAMADOL 1amp in 100ml NS IV/BD
5. Inj HAI/SC TID and Inj NPH S/C BD according to GRBS
6. Inj NORADRENALINE @ 5ml/hr accordingly to maintain MAP > 65mmhg
7. Inj KCL 2 amp in 1 unit NS over 5 hours
8. Inj Clexane 45 units S/C OD
9. Soft diet, egg whites
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