70 yr old with hypovolemia hyponatremia and intertrochantric fracture

12/02/2022

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 70 year old male patient farmer by occupation resident of Chityala came to OPD with chief complaints of swelling and pain in the right thigh since 3 days

Chief complaints :A 70 yr old male came to old with swelling and pain in the right hip region since 3 days .

HOPI : patient was apparently asymptomatic 5years back then he developed fever of low grade which is of Continuous type and not associated with chills and rigor and relievedon medication . And he also developed fatigue and the generalised weakness for which he came to our hospital and diagnosed with hypertension and diabetes Mellitus type 2 .for which he was prescribed glimiperide 1mg and metformin 500mg for twice a day . But on regular check up sugars were uncontrolled. For which he was prescribed insulin (inj mixtard) . For hypertension tab tellima h has started.

Now patient comes with the complaint of swelling and pain in right hip region since 3days . History of trauma is present , patient was slipped in the bathroom in the morning because of which swelling and pain developed . Then he was admitted to the ortho department . They diagnosed it as the closed right intertrocanter fracture for which closed reduction and internal fixation and proximal femoral nailing was planned but on serum electrolytes test electrolytes were abnormal. Then he was sent to the general medicine icu to correct the electro. History of vomiting of 3 episodes is present and delayed response is present.

Patient was complaining of increased thirst dryness of mouth.

No history of loss of consciousness,head trauma ,other joints involvement .

Dialy Routine:

He wakes up at 6:00AM,do breakfast at 8:00AM,Go to field but acutually dont do any work at field.Lunch at 1:00PM and then sleep upto 4 PM,Dinner at 7:00PM,Sleeps at 9:00 PM.

Past history:

history of diabetes and hypertension since 5years.

No history of tb, epilepsy, asthma .

Treatment history:

He is on treatment for diabetes and hypertension.for diabetes glimepiride 1 mg and metformin 500mg and insulin. For HTN telima h (telmisartan)

Personal history:

Bowel and bladder are normal , appetite is normal, no known allergies.

Family history:

No significant family history.

GENERAL EXAMINATION:

Patients is conscious,coherent and cooperative .moderately built and well nourished.

Pallor is present.