45/F WITH LOWER BACKACHE UNDER EVALUATION ? LEFT HIP CHRONIC OSTEOMYELITIS , DM+ SINCE 3 MONTHS.

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Here is a case I have seen

Unit 6:

Case admitted on 20/2/2021.

Interns 

K. Nikhil reddy

M. Swarna 

K. Divya

 B.Manivarma 

Juveria 


Dr. Vinay(pgy1)

Dr. A. Vaishnavi (pgy2) 

Dr. Praneeth(pgy3)

Dr. Hareen (SR)

Dr.Praveen Naik( asst.prof.)

Dr.Rakesh Biswas (HOD)


A 45  yrs old female  daily wager by occupation came with chief complaint of weakness of Left lower limb since 3 months.

 History of present illness :

 Patient was apparently asymptomatic 3 months back, then she complaints of fever 3 months back, associated with chills,continuous ,high grade ,not relieved With medication and went to local hospital for evaluation,Ocassional dry cough present, Vomitings- 2 episodes,  contains food particles,non projectile,non bilious,non blood stained. loose stools -2 episodes ,There,she is diagnosed as Bilateral  pneumonia ,Denovo diagnosed DM II, anemia    relieved on medication of imipinem cilastin 500 mg TID and Amikacin 500 mg OD . She stayed in hospital  for 20 days and came back to home, then She developed weakness of Left Lowerlimb .

    C/O pain in Left Hip joint ,walking with support,after 1 month she is unable to walk alone with support, she observed crepitations in Lt hip joint while walking .she is unable to wake up from bed on her own ,sitting with support. 

She also had complaints of lower backache since 3 months .

C/o pedal edema since 3 months ,pitting type extending  upto knee, not relieved with medication.

No C/o cold, cough.

No C/O chest pain ,palpitations ,syncopal attacks.

No C/O constipation, loose stools, burning micturition. 

Past history :

   DM Denovo diagnosed 3 months back, for which she is  on GLIMI M2 OD.

No H/o HTN , TB , asthma ,epilepsy, CVA, CAD.

 H/o Blood transfusion :  At mamatha hospital 1 PRBC transfusion ,In Nalgonda 2 PRBC transfusion .

Personal history:

Drinks toddy occasionally.

Family history:

 Elder brother has diabetes  .


Local examination:

No pallor,icterus, cyanosis,clubbing, lymphadenopathy .

Pedal edema +

Vitals :

Temperature- afebrile

PR- 84bpm

BP- 130/90 mmHg.

RR-18 cpm

Spo2-98% at room air

GRBS-182 mg/dl.


Systemic examination:

 CNS:

  Patient is conscious, oriented to time,place , person, cooperative.

 Speech- normal

 HMF- normal

Cranial nerves : intact

Motor examination:

    Tone - normal

     Power.                             Rt.                Lt.

1.Shoulder: 

  Flexors-extensors.              4-/5             4+/5

  Adductors.                          4+/5             4+/5

  Abductors.                          4 -/5            4+/5  

Lateral and medial rotator    4+/5             4+/5

2.Elbow:

    Flexors-extensors.            4+/5           4+/5

3. Wrist:

 Dorsi flexors-palmar flexor.  4+/5            4+/5

 Abductors-adductors.          4+/5            4+/5

 Pronators - supinators.        4+/5            4+/5

4. Hand grip.                        100%.          100%

5. Hip:

  Flexors-extensors.             Pain on examination  Lateral& medial rotators    3-/5.             1 /5

 Abductors-adductors.       3-/5.             1 /5

6. Knee:

 Flexors-extensors.           4+/5.             1 /5

7. Ankle:

 Dorsi flexors-plantar flexor 4+/5             4+/5

 Inversors-  eversors.          4+/5             4+/5

8.trunk muscles: 

Unable to  Roll over bed due to pain over left hip.

      Reflexes                               Rt.                Lt.

 1.Corneal                         Present.      Present

 2. Conjunctival                 Present.      Present

 3. Pharyngeal                  Present.      Present

 4 Palatal.                         Present.      Present

 5.plantar                           Flexor       flexor                   

 6.  Biceps                           3+                3+                        

7 triceps                              3+                3+

8.supinator.                         2+                2+

9. Knee.                               -                   -

10. Ankle                             -                  -

 Cerebellar examination : Normal

Sensory examination : Normal

 Spine examination: Tenderness over L-S spine

CVS: S1,S2 hear, no murmurs

 RS : BAE+, NVBS heard 

 P/A:Soft, non tender,a single umbilical hernia of 3*2cm, oval shape  is noted .

INVESTIGATIONS

CHEST X RAY

XRAY PELVIS WITH BOTH HIPS

X RAY RIGHT SHOULDER

X RAY LEFT FEMUR


LS SPINE AP VIEW


LS SPINE LATERAL VIEW

MRI  -BOTH HIPS

USG ABDOMEN


PROVISIONAL DIAGNOSIS:

  LOWER BACKACHE UNDER EVALUATION  ? LEFT HIP CHRONIC OSTEOMYELITIS/INFECTIVE ARTHRITIS? LUMBAR DISC DISEASE DM+ SINCE 3 MONTHS.

 TREATMENT GIVEN:

1.TAB. GLIMI M1 PO/OD

2. TAB. METFORMIN SR 500 MG /PO/OD

3.GRBS CHARTING 8TH HOURLY

4. INJ. TRAMADOL 1 AMP IN 100ML NS / IV/BD

5. INJ. ZOFER 4MG /IV/OD


  ON 21/2/2021.

S: Patient complaints of pain in left hip region.

    No fresh complaints

O: Patient is conscious, coherent, cooperative.

    Temp:  afebrile

    PR:76 bpm

    RR: 18 cpm

    BP:130/80 mm hg.

    CVS:S1, S2HEARD ,NO MURMURS

     RS: BAE+, NVBS HEARD.

    P/A: SOFT, NON TENDER.

A:   LOWER BACKACHE UNDER EVALUATION  ? LEFT HIP CHRONIC OSTEOMYELITIS/INFECTIVE ARTHRITIS? LUMBAR DISC DISEASE DM+ SINCE 3 MONTHS.

P: 1.TAB. GLIMI M1 PO/OD

2. TAB. METFORMIN SR 500 MG /PO/OD

3.GRBS CHARTING 8TH HOURLY

4. INJ. TRAMADOL 1 AMP IN 100ML NS / IV/BD

5. INJ. ZOFER 4MG /IV/OD

6. INJ. MONOCEF 1 GM/IV/ BD.


On 22/2/2021.

S:  Patient is  felling better, decreased pain in left       hip, no fresh complaints.

O: Patient is conscious, coherent, cooperative.

    Temp:  afebrile

     PR:72 bpm

     RR: 19 cpm

     BP:130/90 mm hg.

    CVS:S1, S2HEARD ,NO MURMURS

     RS: BAE+, NVBS HEARD.

    P/A: SOFT, NON TENDER.

A:   LOWER BACKACHE UNDER EVALUATION  ? LEFT HIP CHRONIC OSTEOMYELITIS/INFECTIVE ARTHRITIS? LUMBAR DISC DISEASE DM+ SINCE 3 MONTHS.

P: 1.INJ. TRAMADOL 1 AMP IN 100ML NS / IV/BD

2. INJ. ZOFER 4MG /IV/sos

3. INJ. PAN 40 MG IV /OD

4.. INJ. CEFTRIAXONE 1GM /IV /BD.

5. TAB. GLIMI M1 PO/OD

6. TAB. METFORMIN SR 500 MG /PO/OD

7. Bp and PR CHARTING 8TH HOURLY



On 23/2/2021

S: Patient complaints of pain in left hip region, anterior thigh.

    No fresh complaints

O: Patient is conscious, coherent, cooperative.

    Temp:  afebrile

    PR:78 bpm

    RR:  20cpm

    BP:130/90 mm hg.

    CVS:S1, S2HEARD ,NO MURMURS

     RS: BAE+, NVBS HEARD.

    P/A: SOFT, NON TENDER.

     Left side - SLRT+ , TENDERNESS AT LEFT SIJ          AND ANTERIOR THIGH REGION.

A:   LOWER BACKACHE UNDER EVALUATION  ? LEFT HIP CHRONIC OSTEOMYELITIS/INFECTIVE ARTHRITIS? LUMBAR DISC DISEASE DM+ SINCE 3 MONTHS.

P: 1.INJ. TRAMADOL 1 AMP IN 100ML NS / IV/BD

2. INJ. ZOFER 4MG /IV/sos

3. INJ. PAN 40 MG IV /OD

4.. INJ. CEFTRIAXONE 1GM /IV /BD

5. TAB. GLIMI M1 PO/OD

6. TAB. METFORMIN SR 500 MG /PO/OD

7. Bp and PR CHARTING 8TH HOURLY



24/2/2021

S: Patient complaints of pain in left hip region, anterior thigh.

    No fresh complaints

O: Patient is conscious, coherent, cooperative.

    Temp:  afebrile

    PR:102 bpm

    RR:  20cpm

    BP:130/100 mm hg.

    CVS:S1, S2HEARD ,NO MURMURS

     RS: BAE+, NVBS HEARD.

    P/A: SOFT, NON TENDER.

     Left side - SLRT+ , TENDERNESS AT LEFT SIJ          AND ANTERIOR THIGH REGION.

A:   LOWER BACKACHE UNDER EVALUATION  ? LEFT HIP CHRONIC OSTEOMYELITIS , DM+ SINCE 3 MONTHS.

P: 1.INJ. TRAMADOL 1 AMP IN 100ML NS / IV/BD

2. INJ. ZOFER 4MG /IV/sos

3. INJ. PAN 40 MG IV /OD

4.. INJ. CEFTRIAXONE 1GM /IV /BD

5. TAB. GLIMI M1 PO/OD

6. TAB. METFORMIN SR 500 MG /PO/OD

7. Bp and PR CHARTING 8TH HOURLY


 Patient shifted to orthopedic department for further management of CHRONIC OSTEOMYELITIS OF HIP.

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