GENERAL MEDICINE

General Medicine

July 24, 2023.

 

 Case scenario

  Hi, I'm S. Aishwarya, 3rd bds student, this is an online elog book to discuss our patient health data, after taking his consent. This also reflects my patient centered online learning portfolio.

Case history: 

 Patient details: 

A 32 yr old man pharmacist by occupation,  presented with

Chief complaint: 

     Fever since 1 week, and pain on swallowing since 10 days.

History of present illness: 

     Patient was apparently asymptomatic 6 yrs back and met with an accident [ rta] and sustained following injuries: 

      Left femur and tibia fracture and plating was done.

    Due to pain he re visited hospital and knew that the surgery was a failure and underwent revision surgery.

     1 week back developed with fever high grade associated with chills .

Complaints of pain on swallowing and had burning sensation.

History of past illness: 

       Patient is diagnosed with diabetes mellitus 2 and is on medication since 6 months.

Hypertension: no

Asthma : no

Tuberculosis: no

CVA : no

Epilepsy: no

History of surgery: plating was done for tibia.

Family history: 

Not significant

General examination: 

Built: normal 

Consious, coherent and co operative 

Pallor : present

Icterus: no

Lymphadenopathy: no

Cyanosis: no

Pedal edema: no

Clubbing: no

Systemic examination: 

 Abdomen: soft and non tender

 CVS: no murmurs

 Respiratory system: normal

Vitals:

 Temp 98.8F

Respiratory rate : 22 cpm

Pulse rate : 100 bpm

Blood pressure: 110/60 mmHg

Provisional diagnosis: 

   Osteomyelitis of left femur