Welcome To Case Presentation
Dr. Rakib Hasan
FCPS Part-II trainee (Surgery)
Ortho Surgery Unit-III
Particulars of The Patient
• Name: Hazera Begum
• Age : 60 years
• Sex : Female
• Address : Noakhali
• Date of Admission : 11.11.24
• Date of examination: 26.11.24
• Ward No : 206
• Bed No : 16
• Reg No : 26091/61
• Mobile no : 018394553221
Chief
Complaints
• Pain, swelling and deformity in lower part of left
leg for 16 days following trauma by falling on
ground.
• Inability to walk & bear weight for same
duration.
History of present illness
According to the statement of the patient she was
reasonably well 16 days back. Then she sustained
trauma by falling on ground followed by pain,
swelling and deformity in her lower part of left leg.
Initially pain was severe in intensity, constant in
nature ,localized, non-radiating, aggravated by any
sorts of movement & partially relieved by analgesics
& rest. She also noticed inability to walk and bear
weight for same duration. She has no history of any
bleeding from the site of injury.
With these complains she attended in Emergency of
DMCH & got admitted under Ortho Surgery unit III for
better management. Her bowel & bladder habit is
normal.
• History of past illness : She is hypertensive and diabetic &
she has previous history of stroke
• Treatment history : Long leg back slab at left leg was
applied in DMCH emergency.
she was taking bisoprolol 5mg, Telmidip 80/5 mg for HTN,
Linatab 5mg and Dimerol MR 60 mg for DM , Atova 10mg and
Ecosprin Plus for Dyslipidemia.
• Allergic history : No known drug or food
allergy.
• Immunization history : She is immunized as per EPI
schedule and vaccinated against covid 19
• Personal history : Nothing contributory.
General Physical Examination
• Appearance : ill looking
• Body built : average
• Decubitus : supine
• Anaemia : absent
• Jaundice : absent
• Dehydration : absent
• Pulse : 76 beats/min
• BP : 120/70 mm of hg
• Temperature : normal
• RR : 16 breaths/min
Systemic Examination
• Cardiovascular system : Nothing contributory
• Respiratory system : Nothing contributory
• GIT system : Nothing contributory
• Genitourinary system : Nothing contributory
Loco regional Examination
Look :
➢ lower part of left leg is swollen
➢Over lying skin condition is normal
➢No apparent muscle wasting
➢No apparent shorting
Feel:
➢Temperature-Normal
➢Tenderness-Present over lower shaft of left tibia &
fibula.
➢LLD – No LLD present
➢Distal Neurovascular status is intact.
Move:
➢ Left knee & ankle movement could not be elicited
due to pain
Salient Features
Hazera Begum, 60 years old muslim married female
hailing from Noakhali was admitted into DMCH with
the complained of pain swelling and deformity in
lower part of left leg following trauma by falling on
ground 16 days back .Initially pain was severe in
intensity, constant in nature, localized, aggravated by
any sorts of movement & partially relieved by
analgesics & rest. She also complaints inability to
stand & walk for same duration .
With these complains he attended in Emergency of
DMCH & got admitted under Ortho Surgery unit III
for better management. She is hypertensive and
diabetic & she has previous history of stroke. Her
bowel & bladder habits are normal.On general
examination she is Ill looking , anxious but co-
operative average body built, non amaemic, non
icteric , non dehydrated, blood pressure
120/70mmhg others vital parameter was within
normal limit and systemic examination reveals no
abnormality.
On loco-regional examination lower part right leg is
swollen. Overlying skin condition is normal, no muscle
wasting is present. Temperature is normal, Tenderness
is present over distal shaft of left tibia & fibula . Distal
neurovascular status is intact. movement of left hip,
knee & ankle could not be elicited due to pain.
Provisional Diagnosis
A case of 16 days old Closed fracture distal shaft of
left tibia & fibula in a 60 years old female with DM
with HTN with H/O stroke.
X-ray on 11.11.2024
X-ray on 19.11.2024
INVESTIGATIONS
• Hemoglobin - 12 g/dl
• RBS – 7.7 mmol/L
• HbA1C - 6.4%
• S . Creatinine – 0.81 mg/dl
• Chest x ray - normal
• ECG within normal limit.
• S . Electrolytes- Na-145 ,K- 4.0, Cl-105 mmol/l
• Blood group – AB(+)
• HBsAg(ICT) – Negative.
• Anti HCV(ICT)- Negative.
• HIV (I&II) – Negative.
Clinical Diagnosis
A case of 16 days old Closed fracture distal shaft of left
tibia & fibula in a 60 years old female with DM with
HTN with H/O stroke.
Unit Plan
Closed reduction & internal fixation by distal tibial
locking plate and screw in MIPO tecnique and open
reduction & internal fixation by distal fibula locking
plate and screw.
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