34 years old male diagnosed with chronic osteomyelitis

 This is an online E- blog, to discuss our patient de-identified health data shared after taking his consent.

This E-blog also reflects my Patient's centerd online learning portifolio.

I have been given this case to slove in an attempt to understand the topic of "patient clinical data analysis" to develop my competence in reading and comprehending clinical data including history, clinical findings, investigation and coming up with a diagnosis and treatment plan.

34 year old male came to casualty with cheif complaints of  abdominal pain with swelling and right ankle pain, swelling.                                           COMPLAINTS  AND DURATION: patient cause of pain and swling in right ankle since 4 months . History of swelling and discharge since 3 months. Substained injury due to road traffic accident 6months back. Substain the grade 3 B  operation with phayngeal and talar dislocation. Patient now with cause of pain and swelling in the right ankle since 3 days.                                    No history of  other comorbiditis. No history of diabetes mellitus and hypertension.

 HISTORY OF PRESENT ILLNESS:On examination a wound  of 4×3 cm on the medial aspect of right foot . swelling around the ankle joint. No abdominal mobility.

HISTORY OF TREATMENT:.                                          Diabetes : no 

Hypertension: no 

CAD: No 

Asthma : no 

Tuberculosis: no 

Antibiotics: no 

Hormones: no 

Blood transfusion: no 

Chemo /radiation: no.

 PERSONAL HISTORY : NORMAL.

FAMILY HISTORY : Not significant.

PERSONAL EXAMINATION: 

Pallor : no

Icterius : no

Cyanosis: no  

Clubbing of fingers and toes : no

Lymphadenopathy : no

Odema of feet : no

Dehydration: yes 

Pulse rate :79

BP mm/ Hg : 120 / 80 lt arm mm/ hg.

CARDIO VASCULAR SYSTEM: 

Thrills : no

Cardiac sounds : s1 and s2 are normal.

Cardiac murmurs : no 

RESPIRATORY SYSTEM: 

Dysponea : no

wheeze :no

Position of trachea : central

Breathing sound : vesicular

Adventilous sounds: Rhonchi 

ABDOMINAL : 

Shape of abdomin ; scaphoid 

Tenderness : no

Palpable mass ; no 

Hernial orifice : normal

Free fluid ; no

Bruits : no 

Spleen : not palpable

Bowel sounds ; no

CENTRAL NERVOUS SYSTEM 

Level of consciousness : conscious   alert 

Speech : normal 

Signs of meningeal irritation : no 

Central nevers normal. Motor system normal .

DIAGNOSIS: Chronic osteomyelitis.

INVESTIGATION S; 




TREATMENT : surgery for the wound debriment ( done on the 26-02-2022) and after three days the another surgery is suggested for the fixation of rods at the right ankle.







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