A 55 year old female patient -accident case

 GM CASE -2

Hello, I am M.Julia Spencer .This is an online blog book to discuss our patient’s health data after taking his/her consent .This also reflects my patient centered online learning portfolio.

Case sheet- A 55 year old female patient (accident case)

CHIEF COMPLAINT:-

The patient had come with a complaint of pain in the hip and groin region since the last 20 days

There’s slight pain felt even in the wrist 

Accompanied with shoulder pain

General weakness

HISTORY OF PRESENT ILLNESS:-

The patient was apparently asymptomatic 20 days ago .

She had met with an accident where she got hit by a bus (not severe) .

Since the incident she had been facing severe pain in the shoulder and wrist region 

Swelling is seen in the area of injury after 3 days of the incident 

Along with that pain .the patient had complained about severe pain in the hip region since 10 days. Due to which it’s difficult for the patient to sit or stand for a longer duration.

The patient visited a local clinic on the day of the incident.Where she was given pain killers due to which relief was provided for few hours

The pain is not radiating 

Tenderness is felt near the hip region when examined

Xray was taken .But there are no signs of fracture 

PERSONAL INFORMATION:-

Patient is a home maker and has two children. 

The patient was not tested for hypertension nor diabetes previously.

She was diagnosed with covid two years ago due to which she has weakness that persists till now

Diet : normal diet taken 

Bowel and bladder:normal

Addiction:Nil

VITALS:-

BP-120/70

Pulse-80

GENERAL EXAMINATION:-

Pallor-no

icterus:no

cyanosis:no

clubbing:no

lymphadenopathy:no

Jaundice-no

Provisional diagnosis:-the swelling observed could be due to a ligament tear post trauma 

Questions 

1.other reasons for swelling?

2.why is tenderness seen in the hip region

This was an OP case due to which more details couldnt be recorded