General Medicine(1)
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Case: Chronic osteomyelitis
34 year old male came to casualty with cheif complaints of abdominal pain with swelling and right ankle pain, swelling
COMPLAINTS AND DURATION:
patient cause of pain and swling in right ankle since 4 months . History of swelling and discharge since 3 months. Substained injury due to road traffic accident 6months back. Substain the grade 3 B operation with phayngeal and talar dislocation. Patient now with cause of pain and swelling in the right ankle since 3 days. No history of other comorbiditis. No history of diabetes mellitus and hypertension.
History of present illness:On examination a wound of 4×3 cm on the medial aspect of right foot . swelling around the ankle joint. No abdominal mobility.
Personal history: normal
Family history:
There is no similar complains in family members
HISTORY OF TREATMENT:.
-Diabetes: No
-Hypertension: No
-CAD:No
-Asthma: No
-Tuberculosis: No
-Antibiotics: No
-hormones: No
-Blood transfusion: No
-chemo / radiation: No
Personal Examination:
-Pallor is absent
-No icterus
-No cyanosis
-No clubbing of feet and toes
-No pedal edema
-lymphadenopathy: No
-Dehydration:Yes
-Pulse rate :79
-BP mm/ Hg : 120 / 80 lt arm mm/ hg.
ABDOMINAL:
~Shape of abdomin :scaphoid
~Tenderness : no
~Palpable mass : no
~Hernial orifice : normal
~Free fluid :no
~Bruits : no
~Spleen : not palpable
Bowel sounds :no
RESPIRATORY SYSTEM:
•Dysponea : no
•wheeze :no
•Position of trachea : central
•Breathing sound : vesicular
•Adventilous sounds: Rhonchi
CARDIO VASCULAR SYSTEM:
•Thrills : no
•Cardiac sounds : s1 and se are normal.
•Cardiac murmurs : no
CENTRAL NERVOUS SYSTEM:
•Level of consciousness : conscious alert
•Speech : normal
•Signs of meningeal irritation : no
•Central nevers normal. Motor system normal.
DIAGNOSIS: osteomyelitis
Investigations;
Treatment: surgery for the wound debriment ( done on the 26-02-2022) and after three days the another surgery is suggested for the fixation of rods at the right ankle.
