35Y MALE WITH 3WEEK OLD C/O K-WIRE FIXATION FOR DISTAL TIBIA +TENDON REPAIR

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS  /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

CHIEF COMPLAIN : 3weeks old P/C/O  k-wire fixation for distal tibia + tendon repair

HISTORY OF PRESENT ILLNESS:
Patient has fallen from the tree accidentally and got injury to his left leg ,
Then  surgery was done  K-wire  fixation for distal tibia+ tendon repair. 


After 15 days patient has now come  with non healing wound over  left ankle.
Now patient is  diagnosed with fungal infection.
Wound of 6×2 cm over left ankle 
Tenderness
No abnormal mobility
No Crepitus
Distal pulse
No sensory loss
Sensations- intact
HISTORY OF PAST ILLNESS
Not a know case of DM,TB,CAD,HTN

PERSONAL HISTORY
Diet - Mixed
Appetite- Normal
Bowel movement- Regular
Bladder movements - Normal
Habit of alcohol consumption (occasional)
No other addictions

FAMILY HISTORY: Not significant

ON EXAMINATION
Patient is conscious, coherent, cooperative
No signs of edema.

VITALS
TEMP: 98.6°F
PR:82/MIN
BP:140/90 MMHG
SPO2: 98%ON RA

SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM : S1and S2 heard, no murmurs heard
RESPIRATORY SYSTEM: Normal vesicular breath sound heard
ABDOMEN: Soft , Non tender



X-ray
TREATMENT:
TAB.POSA CONAZOLE 200MG  PO/OD
TAB.PAN 40MG  PO/OD 
TAB.LINAZOLID 60MG  PO/BD
TAB.HIFINAC      PO/BD
NEOSPORIN POWDER     L/A

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