Presentation

1. Welcome to the morning case presentation
Dr. Mohammad Delower Hossain
MS-Phase B Resident
Violet unit-2

2. Particulars of the patient
 Name : Mrs Liza
 Age: 25 Years.
 Occupation: Housewife
 Address: Kodomtoli, Dhaka
 Registration no: 29627
 Ward: New Building
 Bed: G-979
 Date of Admission: 12/02/2022
 Date of examination: 28/02/2022

3. Presenting Complaints
• Pain & swelling in the right ankle & foot following
twisting injury 16 days back.
• Inability to stand or walk by her right foot for same
duration.

4. History of present illness
According to the statement of the patient she was
reasonably well 16 days back. Then she sustained a
twisting injury to the right foot while cleaning furniture
followed by pain & swelling around the ankle & foot.
She also complaints of inability to stand, walk
and bear weight on her right lower limb for the same
duration . With these complaints she got admitted into
NITOR for better management.

5. History of past illness
 No significant past medical or surgical illness.

6. On examination
General Examination
 Appearance : Anxious
 Body Built : Average
 Nutritional status : Average
 Anaemia : Absent
 Jaundice : Absent
 Cyanosis: Absent
 Pulse rate : 78/min
 Blood pressure :110/60 mmHg
 Resp. rate : 15/min
 Temperature : 98℉

7. Systemic Examination
 Cardiovascular System : Nothing significant
 Respiratory System : Nothing significant
 Gastrointestinal System : Nothing significant

8. Loco-regional examination
• Look :
 Short leg back slab in situ.
 Mild swelling around the right ankle & foot.
 Skin condition: Bruising present over the dorsum of
right foot.

9. • Feel :
 Local temperature- Slightly raised.
 Tenderness: Present over the right ankle.
 Distal neurovascular status intact.
• Move :
 Not elicited due to pain.

10. X-ray

12. Diagnosis
16 days old post-traumatic closed right ankle
fracture-dislocation:
Lauge-Hansen type pronation-external rotation
Danis-Weber type C in a 25 years old female
patient.

13. Unit plan
Open reduction and internal fixation by-
● Small DCP for fibula &
● Two 04mm cannulated half threaded cancellous
screws for tibia

14. Thank You