Patient 1: A 21-year-old male presented with discolored skin on his right arm for 4 months and weakness in his right wrist for 1 month. Examination found a hypo pigmented lesion on his arm and an ulnar claw deformity. Tests were positive for leprosy and he was diagnosed with tuberculoid leprosy with ulnar claw. He was prescribed multi-drug therapy and physiotherapy. Patient 2: A 14-year-old girl presented with fever for 4 days and right knee pain and swelling for 4 days after an RTA one week prior. Examination found swelling and restricted mobility in her right knee. Tests showed leukocytosis, elevated CRP and ESR, and

1. PBL WRAP UP
CASE 1

2. Patient Particulars
• Mr. Shah, 21 years male from janakpur, working as a labour presented
to DH with chief complaint of,
• Discoloration of skin over right arm since 4 months
• Weakness of right wrist since 1 month

3. HISTORY OF PRESENT ILLNESS
• According to patient he was apparently well 4 months back when he
developed, Discoloration of skin over right arm, which was single in
number, over anterior aspect, shiny white in appearance. It was
associated with numbness of skin around that lesion.
• He also complained of weakness of right wrist, which was gradual on onset
associated with numbness of skin over little finger and ring finger and
claw like deformity. It was severe enough to restrict his daily activities.
• .

4. FAMILY HISTORY
• There are 8 members in his family. No history of chronic illness.
• History of similar illness in his brother 1 year back, for which he had
taken some medications.

5. EXAMINATION
• A well looking, thinly build, cooperative, oriented to time place and
person is sitting comfortably without any particular decubitus of
choice.
• No pallor, icterus, Cyanosis
• Assessable lymph nodes not palpable
• No clubbing, edema, dehydration
• Vitals within normal limits

6. LOCAL EXAMINATION
• A well-defined, about 5*2.5cm in size, single, hypo pigmented patch
with erythematous border present over right arm
• Decreased sensation to touch and pressure over the lesion
• Thickened, hard cord like structure palpated over medial epicondyle.
• Ulnar claw present.

8. INVESTIGATIONS:
• Slit smear taken from skin lesion, positive for AFB
• Histopathology, Showing epidermal atrophy and presence of
epitheloid cell granuloma with gaint cell
• Lepromin test: Positive

9. • Provisional diagnosis: Tuberculoid leprosy with ulnar claw.
• Patient was then prescribed with Multi Drug Therapy.
• Patient then progressed and was regaining normal function after
physiotherapy.

10. CASE 2

11. PATIENT PARTICULARS
• Ms Sharma, a 14 years Hindu girl from Dhulikhel-9, Kavre, student,
presented to the Dhulikhel Hospital Orthopedics Out-Patient
Department (OPD) with the chief complaints of:-
• Fever since 4 days
• Right knee pain and swelling for 4 days

12. HISTORY OF PRESENT ILLNESS
• According to the patient, she was apparently well 4 days back when she started having fever,
which was continuous, acute in onset, max temperature recorded was 101 F, a/w chills and rigors
and sweating. The fever was relieved on taking oral medications and cold sponging.
• She also complains of Right knee pain and swelling for 4 days, that was acute on onset, dull
aching, non radiating, aggravated on walking, relieved on taking rest and medications, severe
enough to affect her daily activities. It was associated with diffuse spasm of legs over backside
• The pain was associated with swelling over right knee, acute on onset, increasing in size since
past 4 days.

13. HISTORY OF PAST ILLNESS
• History of RTA 7 days back, after which she had sustained injury over
lower limbs.
• No history surgery

14. EXAMINATION
• An ill-looking, thinly built girl is sitting on the chair. She is conscious, co-
operative and well-oriented to time, place and person.
• PILCCOD: No pallor, icterus, cyanosis, assessable lymph nodes not palpable, no
clubbing, edema, dehydration
• Vitals: She is having fever of 100 F.
• Pulse, BP, JVP and Respiratory Rate are within normal limits

15. LOCAL EXAMINATION
• A well defined, about, 4*3cm in size, swelling present over right knee, reddish,
raised temperature, tender, with no any rashes.
• Soft in consistency, not attached to skin
• Non fluctuating, non mobile
• Restricted joint mobility

16. INVESTIGATIONS
• Blood examination revealed polymorphonuclear leukocytosis.
• CRP : raised ESR:raised
• X-ray of the limb revealed lytic area with surrounding sclerosis in the metaphyseal region of tibia.
• Aspiration from the swelling was sent for culture and sensitivity

17. Patient Progression
• The reports from culture , Staph aureus was isolated and sensitive to
Cloxacillin.
• Treatment: The child was admitted In Ortho ward and planned for
conservative management with IV antibiotics and fluids support.
• Provisional diagnosis: 14 yrs old girl with Acute Osteomyelitis