Case presentation

1. Preoperative Case Presentation
Dr. Md. Rajib mahmud
MS Resident phase-B
Yellow unit-1
BSMMU

2. Particulars of the patient:
• Name: Shirin
• Age: 35 years
• Sex: Female
• Address: Doulotkhan,Bhola.
• Date of admission: 08/03/22
• Date of examination: 20/03/22

3. Presenting complaints:
• Difficulty to move right elbow and gradual lateral
deviation of right forearm for 1 and half year
• Pain in the right elbow joint for 1 year.
• Swelling over the right elbow joint for last 6
months.

4. History of present illness:
• She was quite well 1 and half year back.
• Then she developed difficulty to move right elbow
joint with gradual lateral deviation of rt forearm.
• Which was associated with pain for last 1 year. Pain in
moderate to severe in nature, aggravated by
movement and relieved by taking rest and medication
• She also complained of swelling over the right elbow
for last 6 months which is gradually increasing in size.
• She was visited to the several physician and treated in
the from of physiotherapy and analgesics.

5. History of present illness (Cont):
but her condition gradually became worsen day by
day then she was referred to BSMMU for further
management.
• She gave no history of trauma, cough, hemoptysis,
weight loss, and other constitutional symptoms.
• She is normotensive and non diabetic and her
bowel & bladder habit is normal.

6. History of past illness:
• Nothing significant

7. General Examination:
• Appearance : Ill looking
• Body build : Average
• Nutritional Status : Average
• Anemia : Absent
• Pulse: 68 b/min
• BP : 110/70 mmHg
• All other vital parameters are within normal limit.

8. Look:
 Right elbow is on flexed attitude
 Cubitus valgus deformity present in
right elbow.
 A globular swelling, about 7*8 cm in
size, situated on anterio-medial aspect
of right elbow with extension to upper
part of right forearm.
 Visible muscle wasting present over
right arm and forearm
 Skin condition normal, no engorged
vein ,no scar mark.
Loco Regional Examination:

9. Feel:
 Temp: Normal
 Tenderness: Present over the joint line but swelling is non
tender.
 Right arm and forearm muscle both are 1 cm wasted than left
 swelling is 8*9 cm, surface is smooth, margin ill defined,
consistency soft, overlying skin free and free from underlying
structures, LNs are not enlarged.
 Distal neurovascular status: Intact.
Move:
 ROM of shoulder and wrist found normal
 But movements of elbow could not be elicited due to pain.

10. Provisional Diagnosis:
Soft tissue swelling over right elbow of a 35 years old
right hand dominant female

11. Radiology:
AP and
Lateral
view

12. Xray findings
AP view
x-ray rt elbow joint including distal
humerus and proximal forearm A/P
view showing –
1.Hazy osteolytic lesion involving
lower end of rt humerus, radial head
and upper part of ulna.
2.Loss of normal bony alignment.
3.Joint space lost.
4.Valgus deformity of rt elbow
5.Soft tissue shadow
Lateral view
x-ray rt elbow joint including distal
humerus and proximal forearm
lateral view showing –
1. osteolytic lesion involving lower
end of rt humerus, radial head and
upper part of ulna
2. 3.Joint space lost.
3.Soft tissue shadow

13. Radiology:
CXR AP view

14. MRI:
Saggital view Axial view

15. Diagnosis:
A case of tubercular osteoarthritis of right elbow of a
35 years old right hand dominant female .

16. Unit Plan:
Arthotomy and biopsy