History taking of a traumatic patient in ward
Name - Muhammad Ashad Age / Sex - 9 yrs / m wt. - 20 kgs
Gr II stduent , Lahore, Pakistan History Teller - Father
Site of taking history - Orthopaedic Dept., XYZ Hospital , Lahore , Pakistan
Date of examination - 1 July, 2017
C/C - Pus discharge left leg with limping gait for 18 months
HOPI - M. Ashad was involved in RTAin Jan 1 , 2016. He was a pilon rider and hit by a bus from
the side and fell down. He had a shear injury on the leg and foot. Bike rider did not have any major
injury and walked immediately. Ashad had unbearable pain on foot and leg with a large wound on
dorsum of the foot, shin and lateral side of the leg.Leg was deformed with bone exposed on the shin.
He was soon taken to Emergency Dept., ABC Hospital in Gujrawala,Lahore within 45 minutes in a
taxi with leg wrapped using a handkerchif. He was in shock when they reached the hospital.He had
no LOC, ENT bleeding and vomiting . Left leg was bandaged to control bleeding after dressing .
Bloodwas arranged.III pint of colloid was given. II pint of B + ve group whole blood was given
there after recieving blood. Back slab was applied upto mid-thigh. After stabilization over 6 hours he
was referred to XYZ hospital.Patient reached Emr Dept. XYZ Hospital in next 6 hours. He was
further resuscitated with IV fluids.There he underwent x-ray evaluation for PRIMARY TRAUMA
SERIES which were normal.FAST-scan was normal. Hb was 9.0 gm %. X-ray of the left leg
inculding knee and ankle was done which showed shaft of tibia / fibula fracture. X-ray of the foot
was normal. He was diagnosed as Gu IIIb Shaft of Tibia/ Fibula fracture with Degloving injury of
left leg on calf , shin and foot with Shock.He was given Inj. TT 1 ampoule im stat.Then he was
admitted in ICU for 2 days. Wound irrigation and lavage followed by dresssing was done in ICU. He
was given Inj. Gentamycin 100 mg iv .od , Inj. Cefazolin 150 mg iv tds. , inj . ketolak 5mg iv tds.
His lab reports (CBC, LFT,RFT, Urine R/e , RBS , Viral markers for HIV I and II , Hepatitis B and C
) were normal.Then patient underwent serial wound irrigation and lavage followed by dressing for
next 2 days in ICU with IV midazolam 5mg.
In Jan 3 , 2016 he underwent Skin Grafting and external fixator application with skin donation from
opposite thigh. He was transferred to ward in post-operative period.The outcome was uneventful
during course of treatment. Skin graft was uptaken on 5th day.He had no any post- operative
complication.He was discharged on 7th post- op day. External fixator was removed after 6 weeks
visit in Feb 21,2016 in theatre and discharged same day with back slab. Slowy pin tracts healed.
In April 1,2016 (12 weeks after injury ) he was admitted and underwent IMILfixation for Shaft of
tibia fracture next day electively.It was also uneventfull. IV medications (Inj. Cefazolin and
Gentamycin , Ketolak ) were given.On 7th day he was discharged.
3 months after surgery (IMIL ) pus discharge was distally on medial side on the leg in follow up
which is persisting.He had no fever. ESR was raised to 30. He was advised to do dressing daily.
Now he has limping gait which is progressive. His left leg is shorter which is worsening .He walks
around 1 hour and then feels tired. He can walk up and down the ladder with the support on the side
bar. He has no difficulty using toilets.He has no fever.He sleeps well .His appetite is normal and
gaining weight.
Past History - No known drug allergy ; no known illnesses in the past.
Family Hx. - 5 memebers in family. 2 brother and 1 sister. They have a 1 storoyed building. His
father is a bus driver.
Personal Hx. - Student of Gr II . He is non-vegeterian.
Birth and Dev. Hx - He has normal growth and developmental milestones.
Vaccination hx. He has completed all the vaccines as per EPI schedule.
Expectation -Limb length Equlalization and go to school .
Based on History - Diagnosis is
Chronic Osteomyelitis Lt Tibia with Limb Length inequlity as a sequelae of post traumatic lt shaft
of tibia / fibular fracture with IMIL in situ
Gr II stduent , Lahore, Pakistan History Teller - Father
Site of taking history - Orthopaedic Dept., XYZ Hospital , Lahore , Pakistan
Date of examination - 1 July, 2017
C/C - Pus discharge left leg with limping gait for 18 months
HOPI - M. Ashad was involved in RTAin Jan 1 , 2016. He was a pilon rider and hit by a bus from
the side and fell down. He had a shear injury on the leg and foot. Bike rider did not have any major
injury and walked immediately. Ashad had unbearable pain on foot and leg with a large wound on
dorsum of the foot, shin and lateral side of the leg.Leg was deformed with bone exposed on the shin.
He was soon taken to Emergency Dept., ABC Hospital in Gujrawala,Lahore within 45 minutes in a
taxi with leg wrapped using a handkerchif. He was in shock when they reached the hospital.He had
no LOC, ENT bleeding and vomiting . Left leg was bandaged to control bleeding after dressing .
Bloodwas arranged.III pint of colloid was given. II pint of B + ve group whole blood was given
there after recieving blood. Back slab was applied upto mid-thigh. After stabilization over 6 hours he
was referred to XYZ hospital.Patient reached Emr Dept. XYZ Hospital in next 6 hours. He was
further resuscitated with IV fluids.There he underwent x-ray evaluation for PRIMARY TRAUMA
SERIES which were normal.FAST-scan was normal. Hb was 9.0 gm %. X-ray of the left leg
inculding knee and ankle was done which showed shaft of tibia / fibula fracture. X-ray of the foot
was normal. He was diagnosed as Gu IIIb Shaft of Tibia/ Fibula fracture with Degloving injury of
left leg on calf , shin and foot with Shock.He was given Inj. TT 1 ampoule im stat.Then he was
admitted in ICU for 2 days. Wound irrigation and lavage followed by dresssing was done in ICU. He
was given Inj. Gentamycin 100 mg iv .od , Inj. Cefazolin 150 mg iv tds. , inj . ketolak 5mg iv tds.
His lab reports (CBC, LFT,RFT, Urine R/e , RBS , Viral markers for HIV I and II , Hepatitis B and C
) were normal.Then patient underwent serial wound irrigation and lavage followed by dressing for
next 2 days in ICU with IV midazolam 5mg.
In Jan 3 , 2016 he underwent Skin Grafting and external fixator application with skin donation from
opposite thigh. He was transferred to ward in post-operative period.The outcome was uneventful
during course of treatment. Skin graft was uptaken on 5th day.He had no any post- operative
complication.He was discharged on 7th post- op day. External fixator was removed after 6 weeks
visit in Feb 21,2016 in theatre and discharged same day with back slab. Slowy pin tracts healed.
In April 1,2016 (12 weeks after injury ) he was admitted and underwent IMILfixation for Shaft of
tibia fracture next day electively.It was also uneventfull. IV medications (Inj. Cefazolin and
Gentamycin , Ketolak ) were given.On 7th day he was discharged.
3 months after surgery (IMIL ) pus discharge was distally on medial side on the leg in follow up
which is persisting.He had no fever. ESR was raised to 30. He was advised to do dressing daily.
Now he has limping gait which is progressive. His left leg is shorter which is worsening .He walks
around 1 hour and then feels tired. He can walk up and down the ladder with the support on the side
bar. He has no difficulty using toilets.He has no fever.He sleeps well .His appetite is normal and
gaining weight.
Past History - No known drug allergy ; no known illnesses in the past.
Family Hx. - 5 memebers in family. 2 brother and 1 sister. They have a 1 storoyed building. His
father is a bus driver.
Personal Hx. - Student of Gr II . He is non-vegeterian.
Birth and Dev. Hx - He has normal growth and developmental milestones.
Vaccination hx. He has completed all the vaccines as per EPI schedule.
Expectation -Limb length Equlalization and go to school .
Based on History - Diagnosis is
Chronic Osteomyelitis Lt Tibia with Limb Length inequlity as a sequelae of post traumatic lt shaft
of tibia / fibular fracture with IMIL in situ
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