GENERAL MEDICINE

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A 61 years old male patient came to the Casuality with 

A/H/O RTA  around 7.am at lingotam on 14/3/22.

HISTORY OF PRESENT ILLNESS:

Normal routine of the patient:

He used to get up at 5 am in the morning, used to have tea and did some household work, then breakfast at 8 (rice) then used to go for fishing, he used to have lunch at 2 which is rice again. He used to return home by 6 in the evening then he used to freshen up and have dinner at 8 PM and sleep after that.

.Patient sustained injury to right sided head

.patient c/o of pain and swelling over left wrist

.H/o Head injury,

.  Nose bleeding 

.swelling is present , Tenderness is present , movements is painful and restricted,  crepitus is present 

.lacerations of 4×2×1 cms over the right eyebrow 

.right periorbital edema

.Abrasions of 4×3 cms over knee

HISTORY OF PAST HISTORY 

The patient is not a known case of diabetes, epilepsy,tuberculosis,

. Patient having hypertension Since past 4 years and under medication 

.HISTORY OF Asthma since 3 years and under medication 

PERSONAL HISTORY:

- the patient has no loss of appetite

- bladder movements are normal

-no sleep disturbances 

He has the deleterious habit of consuming Alcohol 90ml/day since 30years and 

FAMILY HISTORY:

There are no similar complaints in the family members

GENERAL EXAMINATION:

-Patient is conscious,coherent and cooperative at the time of joining 

-No pallor 

-No icterus

-edema is present 

VITALS - temperature:98.4F

-pulse rate:84bpm

-respiration rate:22/min

-bp:110/80

-spo2-98%

SYSTEMIC EXAMINATION:

CVS

-no thrills 

-no cardiac murmurs

S1&S2 sounds are heard

RESPIRATORY SYSTEM 

- Position of trachea is central 

- Bilateral air entry is normal

- Normal vesicular breath sounds heard

- No added sounds

CNS

- Patient is conscious

- Speech is present

- Reflexes are normal

Abdomen:

abdomen is not tender

- no palpable mass or free 

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS / DIAGNOSIS:

closed distal radius #+ Ulna styloid 

ORAL AND MAXILLOFACIAL EXAMINATION.

EXTRAORAL EXAMINATION

INSPECTION: Facial asymetry

- due to swelling periorbital edema (+)

→ sustained laceration over rt supraorbital rim region:

* mouth opening is in adequate (20 mm).

→ subconjuctival hemorrhage right eye

→ No restricted eye movements. 

Abrasion over the nose (3x4m) approx.

 PALPATION:

"Tendesness present over the (Rt) Frontal suture, Rt maxillary region,Rt Zygomatic arch region

INTRAORAL EXAMINATION;

Partially edentulous upper arch

No of teeth present-19

Fissured tongue is present 

TREATMENT 

1) In- MONOCEF IT BD

2) I- METRO4 76 100ml 70Th 3.) 2 PAN Lion Tv OD

4) I... NEOMOL (cone Fut 5) T-Shukcal IT PO OD

6)T CHYMERAL FORTE PO 7)1T· utact PO BA

8)T-AM INDA PO O

9) Neb & Dudlin 64 / hov Budicot 12th half

10) T · PCM 6 som sos.