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Case-01 : Case Study On Soft Tissue Injury

Case Study On Soft Tissue Injury

          A 23 years old male presented to emergency ward with left foot pain following a Road traffic accident ( R TA ).

          He is otherwise well. Complaints of pain over the left foot, which increases on movement. There are a couple of superficial abrasions over his Right Foot.

          No history of Loss of Conscious ( LOC ), Bleeding, Seizures.
          
          Patient is conscious and coherent, A febrile.

          Vitals are stable. 

Investigations :

          Advised X ray Left foot AP View and Oblique.

Impression : 

          X ray Left foot shows no obvious bony fracture. There is gross Soft tissue Swelling.

Treatment :

01. INJ : T.T : 0.5 ML : IM : STAT
02. INJ : TRAMADOL : 50 MG : IM : STAT
03. INJ : PAN : 40 MG : IV : STAT
04. INJ : EMSET : 4 MG : IV : STAT
05. TAB : DOLO : 650 MG : P/O : TID : 5 DAYS
06. TAB : PAN : 40MG : P/O : OD ( BEFORE BREAK FAST )
07. TAB : CHYMORAL FORTE : 50 MG : P/O : BD
08. TAB : BECOSULE ( VIT B12 ) : P/O : BD
09. Advised Rest ( Do not put weight on Left foot
10. Ice pack Application.
11. Crepe bandage application.
12. Elevation of the left foot with pillow.
13. Review with X ray after 5 days.

Nurses Notes :

00.00 Patient came to the emergency ward with the complaint of left foot pain met the Road Traffic              Accident.
00.03 Vitals checked and recorded.
00.05 Emergency ward physician seen the patient.
00.08 Advised medication Analgesics, Proton Pump Inhibitors, Anti emetics, given.
00.10 Informed to Ortho Physician.
00.15 Ortho Physician seen the patient.
00.20 Advised Radio logical investigations.
00.30 X - ray left foot done and shown to Ortho Physician.
00.45 Ortho Physician Proscribed the medication and Advised the discharge.
00.50 Patient discharged.


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