Particulars of thepatient
Name : Shimul
Age: 18 years
Sex: Male
Address: Bagha, Rajshahi
Registration no: 523107/24
Ward/Bed : CA 02, G-45
Date of Admission: 26.09.24
Date of examination: 28.09.24
3.
Chief Complaint
* Dischargefrom lower part of right thigh for 3
year.
* Occasional pain in the lower part of right thigh
for same duration.
4.
HISTORY OF PRESENTILLNESS
According to the statement of the patient,he was
reasonably well 3 years back. Then he had a road tracfic
accident and injured his right thigh. He was diagnosed as a
case of open distal femoral fracture (G-IIIA) and initially
managed with surgical toileting,wound debridement,
primary repair and lower tibial skeletal traction in bohler-
braun frame.
5.
His wound becameinfected and he was treated with
regular dressing and continuous skeletal traction for 1 and
a half month. After two months, patient started walking
using walking aids, but discharge from wound persisted. He
noticed discharge of pus with occasional white bony
specules from medial aspect of lower part of his right thigh.
6.
He also complainsof occassional pain in the right thigh
which is mild, relived by analgesics. Now he got admitted
in NITOR for further management.
On query, he gave no history of prolonged dry cough, fever,
weight loss, evening rise of temperature or intravenous
drug abuse.
7.
HISTORY OF PASTILLNESS-Nothing significant
PERSONAL HISTORY- He is a smoker for last 3
years.
DRUG HISTORY- took several antibiotics but
cannot mention names.
FAMILY HISTORY-Nothing significant.
8.
ON EXAMINATION
General Examination
Appearance: Normal
Body Built : Average
Anaemia : Absent
Jaundice : Non icteric
Pulse rate : 80 b/min
Resp. rate :14 br/min
Temperature : 98.6 degree F
9.
ON EXAMINATION
Systemic Examination:
Cardiovascular System : Nothing significant
Respiratory System : Nothing significant
Gastrointestinal System : Nothing significant
10.
ON EXAMINATION
(Loco regional)
Look:
Apparent shortening of right lower limb.
One discharging sinus measuring about 2*2cm with
seroplurulent discharge from sinus opening present on
antero-medial aspect of lower part of right thigh.
Surgical scar mark, blackish discoloration,puckering of
skin around the sinus opening.
Gait- limping
Squatting- not possible
11.
ON EXAMINATION
(Loco regional)
Feel
Temperature:Normal
Tenderness: mild
On pressure,purulent material comes out
Distal neurovascular status intact
No regional lymphadenopathy
Limb length discrepancy of right lower limb:1 cm
Galleazi test reveals femoral shortening.
Provisional diagnosis
Chronic dischargingsinus over anteromedial aspect
of lower part of right thigh, most likely due to
chronic Osteomyelitis in a 18 years old male.
