A 50yrs Male With Right Ankle Trimalleolar Fracture

 February 28,2022

February 28,2022

THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT 

CHEIF COMPLAINTS:

C/O pain in right ankle: 1 day 

H/O trauma (slip &fall) at vijayawada on 11 February 2022

C/O pain & swelling over right ankle 

No H/O any head injury/LOC/seizures/ENT bleed 

K/C/O DM: 6 years (on regular medication)

HISTORY OF PRESENT ILLNESS:-

Pt - conscious/coherent/co-operative 

Pulse rate-84

BP-138/80

L/E of right ankle

Skin- normal

Swelling- Positive diffuse around right ankle 

Tenderness- Positive over lateral & medial malleoli

Crepitus- Positive 

Deformity- Positive 

Distal Pulses- Positive 

Sensations- intact 

 HISTORY OF PAST ILLNESS:-

Temp- afebrile

CCT- negative 

PCT- negative 

PERSONAL HISTORY:-

He is an contract business and married ,no habit of drinking alcohol. 

Appetite-normal 

Bowels- regular 

Micturition- normal 

Addictions-5 cigs/day for 2 yrs but stopped smoking 5yrs ago

H/O - Diabetes for 6 yrs

FAMILY HISTORY:-

no significant family history 

GENERAL EXAMINATION:-

Pt is concious,co-operative, coherent 

no pallor, cyanosis,lymphadenopathy

no icterus,oedema of feet, clubbing of fingers/toes

no malnutrition, dehydration 

VITALS:-

bp-138/80

Pr-84bpm

Temp-98.6C/F

Spo2-99

INVESTIGATIONS:-

ECG

BLOOD SUGAR FASTING LEVELS:-

POST LUNCH BLOOD SUGAR LEVEL:-

GLYCATED HAEMOGLOBIN LEVEL:-

CBP:-
CLINICAL PICTURES:-

DIAGNOSIS:-
Right ankle bimalleolar# disslocation 

TREATMENT:-

1.tab ULTRACET-40 mg/bd

2.tab Pan -40 mg/od

3.tab shelcalct-40 mg/od

4.tab ceftas-cl- 250 mg po/bd

5.GRBS monitoring every 6 hourly.

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