Ward E – ZDH

Room 222 – Amilhamja, A./ Antao, V.G

NAME : MR.S.K.R • AGE/SEX : 40YRS/MALE • IP NO : 196279 • DATE OF ADMISSION : 09/02/13 •

COMPLAINTS : MULTIPLE LACERATED WOUNDS IN RT LEG,PAIN IN RT WRIST,TENDERNESS OVER LT KNEE
• DIAGNOSIS : COMMINUTED TIBIAL SHAFT FRACTURE • DISCHARGED ON :30/12/12

PHYSICAL ASSESMENT GENERAL APPEARANCE • Patient was drowsy for several minutes • Unable to
mobilize his rt lower extremity. VITAL SIGNS OF THE PATIENT ARE BP : 120/80 mm of hg PR :86/mt
RR :16/mt SPO2 : 98%

Skin is warm to touch. • Tenderness over rt ankle • Laceration on rt toes • Noted abrasions on rt lower
limb. • HEAD AND NECK • Hair Is Equally Disrtibuted. • Absence of Dandruff. EYES • Able to move both
eyes

EARS • Patients pinna is same color as facial. • Able to hear sounds clearly . • No discharges • NECK AND
THROAT • Lips are pink but dry. • Teeth is properly aligned with no dentures. • No tenderness of node.
THORAX The Thorax Is Symmetric On Inspection

CARDIO VASCULAR • Absence Of Chest Pain • Heart sounds are clear. • Upon auscultation his Bp is
120/80mmof hg. GENITO URINARY • Normal pubic hair GASTRO INTESTINAL • No Tender Ness Of
Abdomen and its soft .

MUSCULOSKELETAL • Unable To Mobilize His Lt Lower Limb. • Has Pain During Examination. •
Tenderness at site of fracture • Lower extremity appear shortened NEUROLOGIC • To Follow
Commands. • No neurovascular deficit.

Patient History • PRESENT MEDICAL HISTORY Patient was brought to E.R by REDCRESCENT ambulance
after he was involved in R.T.A with complaints of : • MULTIPLE LACERATED WOUNDS IN Rt LEG, PAIN IN
RT WRIST,TENDERNESS OVER LT KNEE. Patient was diagnosed with comminuted fracture on tibial shaft
rt leg. • PRESENTSURGICAL HISTORY • He underwent external fixation of tibia on the same day of
admission as an emergency case • PAST MEDICAL AND SURGICAL HISTORY No past history

Investigations Done For The Patient 1. X-Ray skull ,chest ,hand and ankle 2. CT Scan
(lumbosacralspine,lower extremity) 3.Blood investigations like • PT INR • SERUM ELECTROLYTES • RH
TYPING and ABO • CBC

TREATMENT DONE FOR THE PATIENT • SURGICAL INTERVENTION_ EXTERNAL FIXATION OF RT TIBIA. •
Medications IV FLUIDS • N.S 0.9% Dextrose 5% ANTIBIOTICS • inj . augmentin 1.2 gm iv tid • inj. flagyl
500mg iv bd • inj .amikacin 500mg iv bd • ANALGESICS • diclofenac 75mg im . • pethedine 50 mg im.

CONCLUSION • A CASE OF RTA PATIENT WITH FRACTURE OF TIBIAL SHAFT WAS UNABLE TO MOVE HIS
LEFT LOWER EXTREMITY. • PATIENT HAD UNDERGONE EXTERNAL FIXATION OF TIBIA AND D FIBULA ON
SAME DAY OF ADMISSION (09/02/13) AS AN INITIAL EMERGENCY CARE AND LATER HE HAD
UNDERGONE IM NAILING OF TIBIA • PATIENT WAS DISCHARGED ON 24/02/13 • PATIENT WAS
INSTRUCTED FOR FOLLOW-UP AFTER 2 WEEKS.