GENERAL MEDICINE
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Vitals
HEMOGRAM
Colour doppler
Treatment
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A 65 yrs old male Presented to Casualty with pain in left hip region after fall from bicycle.
History of presentillness
Pateint was asymptomatic before fall. Patient took alcohol and suffered from injury after fall from bicycle. Then was taken to private hospital and got discharged as he was not maintaining spo2 saturation.
He is having pain in the left hip region and difficulty in walking and weight bearing after the fall.
He had no history of head injury, seizures, constipation, nausea, ent bleeding.
Past history
Patient had an history of tuberculosis 7 yrs back and had a treatment for 6 months.
No history of dm/htm/asthma/leprosy and epilepsy.
Family history
No similar history.
Personal history
Diet - normal
Sleep - normal
Appetite - normal
Addictions - alcohol intake since 2 yrs.He comsumed alcohol before the fall.
Allegries - no allergies.
Local examination
Skin- normal
Tenderness- proximal thigh
No swelling
Range of motion - painfull at hip
Sensations- intact
Left foot is externally rotated.
General examination
Patient is examined under well lit room amd adequate ventilation with his consent taken.
Patient is conscious, coherent and cooperative, well oriented to time space. He is moderately built and well nourished.
No visible pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.
Temperature - afebrile
Blood pressure -160/90mmHg
Pulse rate - 79 bpm
Spo2 - 96%@RA
Systemic examination
Cardiovascular system
S1 and S2 heard no murmurs
Central nervous system
No neurological defecits
Respiratory system
Central position of trachea
Vesicular breath sounds
No wheeze, no dysponea
Stay in hospital
Patient was operated on left thigh with an implantimplant on 15-2-2022.
INVESTIGATIONS
ECG
USG
RFT,
Injection- Monocef
Injection - metrogyl 100 ml
Injection - neomol 100 ml
Injection - tramadol 5 mg in 100 ml
Injection - zofer 40 mg
Tab. Paracetamol 650 mg
Tab. Pantop 40 mg
Tab. Shelcal
Tab.chymerol forte
Tab. Limcee 500 mg
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