1. MODILON GENERAL
HOSPITAL
SURGICAL WARD (GENERAL WARD )
CASE PRESENTATION
Presenter: Korki MIAN
ID#: 6414

2. Patient ID
Patient ID
Name X
Sex Male
Age 19
Residence Gonowa
Religion Lutheran
Date of Admission 10th/06/2015
Time of Admission 11:45am

3. Presenting Complain
 Knife wound at left lower limb 6/7
 Swelling
 Painful

4. History of Presenting Complaint
The patient was well until 6/7 ago cut his foot
with a sharp bush knife while cutting timbers
for building a new house. The cut was deep so
pressure was applied to control bleeding.
However, while at home he continued to loose
blood and eventually the foot started swelling.
Therefore, he was unable to walk so was
brought in by his mother to MGH for further
investigation and management.

5. Specific Interrogation
 Bleeding +
 Swelling +
 Pain ++
 Ambulating with support
 Good appetite
 Nil fever

6. Past Medical History
 First admission to surgical ward with the
above complaint

7. Family History
 No history of major illness (Asthma, TB) in
the family.

8. Social History
 Non smoker
 Never chew betel nut
 Non alcoholic
 Lutheran by faith

9. Examinations:
 On Examinations:
 Adult male, alert and conscious
 Sitting on bed at 45 degrees
 Not in any obvious distress
 Pale ++
 Vitals:
 BP: 106/66 mmHg
 Pulse: 89 bpm
 RR: 28 per minute
 Temperature: 36.8 ̊C

10. Systemic Examination:
Local:
 Knife wound at 1st digit (left lower limb)
 Swollen +
 Bleeding +
 Pain +

11. Systemic Examination Cont…
CVS:
 2 heart sounds
 No murmur
 Nil clubbing/
peripheral cyanosis
CNS:
 Sensation intact
Abdomen:
 No surgical scars
 No splenomegaly
Other systems not
assessed

12. Problem List:
 Painful +
 Swelling +
 Bleeding +
 Pale ++
 Ambulating with support

13. Summary:
Patient x, M/19 from Gonowa was presented as
a case of:
PDx: Knife wound to 1st digit of the left
lower limb
DDx: Anemiac
Plan of Management
Investigations:
 Platelets count chase results
 FBE

14. Management:
 Admit to ward
 Debridement (done)
 Interrupted stitch (x1)
 Chloramphenicol 500mg IV QID
 Gentamicin 160mg IV Daily
 Flagyl 500mg ‘O’ QID/PRN
 Fefol 2 tabs ‘O’ Daily
 Tetanus Toxoid 0.5ml subcutaneously stat
 Daily dressing
Patient Education:
*Advice the patient to elevate foot and protect wound from
infection.
*Encourage the patient to eat plenty of protein (meat, fish, peanut)
and protective foods (dark green vegetables and fruits)

15. Progressive Notes
11th/06/2015 Ward Round
with Dr. Maihua
 Afebrile
 Swelling still
 Pain still
 Ambulating with
support
Assessment:
 Not improving
Plan:
 Chase bloods
 Keep and cont all
treatment
 Elevate the limbs
 Change dressing

16. Cont…
12th/06/2015 Ward Round
with Dr. Maihua
 Afebrile
 Decreased swelling
 Pain still
 Still ambulating with
support
Assessment:
 Slightly improving
Plan:
 Keep and continue all
treatment

17. Presenter: Korki MIAN
Rural Health- Year (4)
ID#: 6414
Thank
You