Muhammad Redzwan

081303583

Group E2 Batch 25

Profile

Name: Abu Bakar Mat Dawam

Age: 58 years old

Race/Religion/Gender: Malay/farmer/Muslim

Address: Alor Gajah

D.O.A: 11 June 2014

D.O.E: 13 June 2014.

Chief Complaints

On and off FEVER since 11 days ago

PAIN and SWELLING of the left thigh for one week

11 days ago (31st May), he developed intermittent high grade fever with chills and rigors. The fever mainly occurs at night, but also present during day time and subsides with PCM. He did not feel tired or lethargic.

7 days ago, he noticed diffused swelling (mainly on lateral side) of his left thigh above the knee joint. The swelling initially growing in size before becoming static at the current size.

There is also pain accompanying the swelling. The pain is dull, continuous, gradually increase in intensity. It is aggravated by prolonged standing and walking, and slightly relieved by resting and applying massage oil. It started with pain score of 3/10 and increased to 5/10 before admission. After admission, the pain becomes intermittent.

He is also noticed that his left knee become stifffor 3-4 days that limits his daily activity and his works as a farmer. Sometimes the pain disturbs his sleep.

There is no history of trauma, and insect bite. There is no change in bowel and bladder habits, no change in his weight and appetite.

He did not have any other pain and swelling of the joint or other part of his body.

There is no significant finding in systemic review. He also has no previous history of diabetes mellitus, blood disorders, heart disease and no history of surgery done before.

He is not a smoker, does not consume alcohol and abuse drugs. No known allergies.

He is socioeconomically stable, working as a farmer. He lives with his wife in a single storey house about 5 minutes from Klinik Kesihatan, and 40 minutes from MGH.

Family history is not significant.

58 years old Malay farmer from Alor Gajah presents with chief complaints of intermittent high grade fever for 11 days, continuous pain and diffuse swelling of his left thigh for a week. He is also complain left knee stiffness for 4 days.

Currently the fever has subsided, there is mild intermittent pain but the swelling is still not reduced.

He was lying comfortably on the bed. He was alert, cooperative and not in a toxic state. There was no digital clubbing, jaundice, cyanosis or pallor noted. He was also well hydrated, moderately build and well nourished. IV canullainserted on dorsum of his left hand, connected to a stopper.

Vital signs Heart rate :76 bpm, regular, normal volume Respiratory rate :16/ minute Temperature :37o C Blood pressure :130/ 85 mmHg

No cervical and axillary lymphadenopathy and no pedal edema.

The swelling was in the lateral part of the lower left thigh. It was a diffuse swelling with ill defined border. The overlying skin was slightly red without scar or sinus seen.

The swelling was soft in consistency, tender with touch and warm. It was not attach to the skin, not fluctuate and non mobile.

The left mid thigh measured about 3 cm larger in circumference to the normal right side. Transillumination test was negative and no bruit heard.

The skin was normal and no sign of inflammation, no scar and sinus seen. The gait was antalgic gait with persistent left knee flexion. Trendelenberg test was unable to carry out due to the pain.

Palpation- It was not tender, and no increase in temperature.

Movement-All the movements of the hip were normal, and no pain reported

Inspection- The left knee was slightly flexed in position but no fixed flexion deformity noted. There was swelling on the left knee. The skin was normal and no scar or sinus seen.

Palpation- there was no increased temperature over both knees. Tenderness was appreciated on the lateral aspect of theleftknee. The skin was not thickened and patella tap was positive over the left knee.

Movement- movement was 0o to 30o over the left knee while on the right knee the range of movement was 0o

to 130o . Crepitus was not present. Other tests were unable to perform because of the pain. The left side was normal for all the tests.

Neurovascular examination: Normal

On examination revealed a diffuse swelling in lateral aspect of the lower left thigh with enlarge of the mid thigh circumference about 3 cm. The swelling was soft in consistency, tender and warm. It was associated with swelling of the knee joint and limited flexion of the left knee.

1. Full Blood Count:

The white cell and neutrophils count is high. This may indicated there is bacterial infection.

Other parameter (Hb, Platelets) are within normal range.

2. Blood Urea and Serum Electrolyte:

Normal. No impairment of kidney function

3. ESR: Increase (sign of inflammation/infection)

4. Random Blood Glucose: 8.9 mmol/L (high)

5. ECG and LFT are normal

6.Blood Culture and Sensitivity (no result yet)

7. X-ray:

AP and lateral view of left femur and knee

There was periosteal sclerosis and cortical thickening noticed on the shaft of left femur with osteolytic and sclerosis changes seen in the medulla extend to the both end of the bone. Soft tissue swelling was also noted. The knee was normal on x-ray.

OSTEOMYELITIS of left femur.

Differentials:

Cellulitis

Hematoma

After admission, he was given analgesics (tab mefenemic acid), antibiotic (IV cloxacillin), and antipyretic (PCM). He was advised for bed rest and immobilization.

Pain and fever was reduced, but the swelling remains the same.

He can ambulating by himself. MRI was scheduled later.

Osteo-myel-itis = infection and inflammation of bone or bone marrow.

Through 3 routes: Bloodstream

Locally from an infected site (e.g cellulitis)

Penetrating trauma (+ iatrogenic e.g joint replacement, internal fixation)

Tibia, femur, humerus, vertebra, maxilla, and mandibular are susceptible to osteomyelitis.

Common organism: Staph aureus (in sickle cell disease: Salmonella)

Diabetes

Hemodialysis

Poor blood supply

Recent injury

Use of illegal injected drugs

People with sickle cell disease

People who have had their spleen removed are also at high risk of osteomyelitis.

Bone pain

Excessive sweating

Fever and chills

General discomfort, uneasiness, or ill-feeling (malaise)

Local swelling, redness, and warmth

Pain at the site of infection

Swelling of the ankles, feet, and legs

Physical Exam: Bony tenderness, swelling, and redness

Blood cultures and Sensitivity

Bone biopsy (the sample is cultured and examined under a microscope)

Bone scan

Bone x-ray

Full blood count (FBC)

C-reactive protein (CRP)

Erythrocyte sedimentation rate (ESR)

X-Ray and/or MRI of the bone

Needle aspiration of the area of the affected bones

Antibiotics are taken for at least 4 to 6 weeks, orally or IV. Depending on C&S result.

Surgery may be needed to remove dead bone tissue if the infection persist OR to remove metal plate or prosthesis.

In diabetic patient, blood sugar need to be well controlled.

Conservative treatment: bed rest, immobilization.

Symptomatic treatment: Analgesic, antipyretic.

1. J Maheshwari.(2011) Essentials Orthopaedics.

2. Osteomyelitis.(2013) Medline Plus. National Library of Medicine. Retrieved on 23 June 2014. <http://www.nlm.nih.gov/medlineplus/ency/article/000437.htm>

3. Osteomyelitis. Mayo Clinic. Retrieved on 23 June 2014. <http://www.mayoclinic.org/diseases-conditions/osteomyelitis/basics/tests-diagnosis/con-20025518>

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