A 65 yrs old male presented with pain in left hip region.

 27-2-2022

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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.

 

Vitals 

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

Heamogram

Colur doppler

RFT

Treatment 

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