Case Write Up 1 Sharmila

TILLAI SHARIMALA SUMASUNDRAM CASE WRITE UP ORTHO 1 PUGSOM 17026
Identification Data
Name :M
Age : 75
Sex : Male
Race : Indian
Occupation : Retired Cleaner
Address : Gombak
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Chief Complaint
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Swelling of right shin with pus discharge for past 6 months
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History of Presenting Illness
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Mr. M was previously well until about six months ago when he developed a swelling around
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his right shin. The swelling had risen around the area of the distal third of the shin where a
metal plate which was inserted 5 years ago. About a year ago the metal plate was exposed.
Mr. M recalled that there was a puncture wound at distal third of the shin anteriorly for about
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a year where a metal could be felt. He does not remember having trauma which could have
caused the metal plate to be exposed. There was no pain or swelling initially. Only 6 months
ago the swelling appeared and progressively increases in size. It was a diffuse swelling
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circular in shape with smooth surface about the size of fifty cent coin. Now, the swelling has
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increased the size about the size of his palm (16cm x 8 cm). However, there was no pain. Pus
discharge was only noted about two to three months after the swelling appeared. He was
unable to tell the amount of the pus but mentioned that he had to wipe scanty amounts of pus
every hour or so. There was no blood stain in the pus.
The swelling has not really affected Mr. M’s daily activities. He is still able to walk around
his house independently. He could attend to his basic needs without assistance. He could
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bathe and do some house chores on his own. He could still move his toes. He denied any
numbness, weakness of loss of sensation at his right foot.
Mr. M has been having fever intermittently for past 3 months. The fever was associated with
chills but not rigor. He has fever every week or so but it is not associated to any time of the
day. He did not take any medication for his fever nor did he seek medical attention for his leg
condition.
He was forcibly brought to the hospital by his son when he had a fall at home on the day of
admission. The son thinks that his father’s leg condition has caused the fall. Mr. M however
mentioned that he was dizzy that morning. Upon further questioning, Mr. M experiences
shortness of breath more frequently these days after doing normal gardening activities and
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walking around the house. He does get dizzy occasionally but not to specific times. He has no
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chest pain or palpitations. He also has productive cough for a few weeks now. The sputum is
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clear. He has no sore throat or runny nose. He has lost weight gradually over the years but
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claimed to have to alterations in appetite. He has no vomiting or altered bowel habits.
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However he complains of weak urinary flow which started a month ago. He has occasional
backache which is relieved by rest but no joint pain.
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Past Medical/Surgical History
 2003- Mr. M had a chain saw accident at right leg

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o He had sustained open fracture with lots of bleeding. He underwent surgery to

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fix the fracture with metal plating and screws(at hospital selayang)
o He recalls being wheel chair bound for 6 months after the surgery, then used
crutches and followed by using a cane to assist him walking. Now, he walks
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normally.
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o No blood transfusion done

 Benign prostate hyperplasia-diagnose 1 year ago
o Defaulted follow up at Selayang hospital
Drug and Allergy History
 Mr. M is not on any medication.
 He did not seek traditional healers for his condition.

 He has no known allergies.
Family History
 Both parents died. They died at the age of above eighty.

 There is no history of diabetes mellitus or hypertension among his siblings.
 No malignancy runs in family
Social History
 Mr. M lives alone in his home in Gombak with all basic amenities.
 His wife died six years ago.
 He has 6 children
 His wellbeing is checked by his son who stays next door.
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 Mr. M does not smoke. He consumes alcohol on occasions and does not take any
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illicit drugs
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
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PHYSICAL EXAMINATION
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General Examination
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Mr. M is an elderly gentleman lying in bed, conscious, alert and cooperative. He does not
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seem to be in pain or any respiratory distress. His right shin was bandaged.
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Vital signs
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Pulse Rate : 88 beat per minute with regular rhythm and strong volume
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Blood Pressure : 115/70 mmHg

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Respiratory Rate : 16 breaths per minute

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Temperature : 36.9oC
Hands
Palms were warm and dry. Palms appeared pale. Capillary refill time was two seconds. There
was no deformity, nicotine stain, finger clubbing or koilonychia.
Eyes
Conjunctiva appeared pale. There was no jaundice.
Oral Cavity
There was loss of dentition. Oral hygiene was poor. Hydration was fair.
Neck
There were no enlarged lymph nodes.
Legs
There was no toenail clubbing or pedal edema.
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Systemic Examination
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Cardiovascular System
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On inspection, there was chest deformity or surgical scars. Apex beat was not visible. Apex
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beat was located at the left fifth intercostal space lateral to the midclavicular line. There were
no paraternal heaves. Normal first and second heart sounds were heard on auscultation. There
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were no added sounds or murmurs.

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Respiratory System
On inspection, the chest was moving symmetrically with respiration. There were no
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deformities noted. Chest expansion was equal and normal. Vocal fremitus was equal on all
lung zones anteriorly and posteriorly. Auscultation revealed normal vesicular breath sounds
on all lung zones anteriorly and posteriorly. Vocal resonance was equal bilaterally.
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Abdominal Examination
His abdomen was flat and moving with respiration. There were no scars, dilated vein, visible
peristalsis or visible mass. There was no mass or tenderness on both light and deep palpation.
Liver span measured 11cm. There was no fluid shift. Bowel sounds were of normal intensity
and frequency.
Local Examination
His gait was normal. There was hyperpigmentation at the dorsal aspect of the right feet.
Diffuse swelling was noted from the middle third of the shin down to the foot. Previous
surgical scar is not clearly visible. There is a wound anteriorly at the middle third of the shin
measuring 6cm x 3cm. A metal object could be seen through the wound. The margins ragged.
The floor was red with some pus noted.
Neurological examination revealed no abnormal findings. Both posterior tibial and dorsalis
pedis arteries were palpable with equal volume bilaterally.
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Assessment
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Mr M is a 75 years old Indian gentleman presented with swelling of right shin with pus
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discharge for past 6 months. Physical examination shows a wound anteriorly at the middle
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third of the shin measuring 6cm x 3cm with pus discharge and a metal object could be seen
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through the wound suggesting of chronic osteomyelitis.
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Radiological Findings
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Plain radiograph of the right lower limb was taken. X-ray showed the proximal third of the
tibia down to the ankle joint. Soft tissue swelling was seen around the middle third and distal
third of the tibia. There was an oblique fracture at the distal third of the tibia. There was
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internal fixator at the fracture. However, the fracture was not united. There some periosteal
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reaction noted at the middle third and distal third of the tibia above and below the fracture.
There was some bone thickening of the middle third and distal third of the tibia. The tibia
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appears to be fused with the fibula.

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Differential diagnosis
o Cellulitis
o Acute pyogenic arthritis
o osteosarcoma
Diagnosis
Chronic Osteomyelitis
- Previous history of surgery with internal fixation

- Exposure of internal fixation
- Fever with chills
- Soft tissue inflammation with pus discharge
- Periosteal reaction in x-ray
Investigations
1. Full Blood Count, Erythrocyte Sedimentation Rate, C-Reactive Protein level

- To confirm presence of an infection
Result Normal range Comment

Haemoglobin 11.2 11.5 - 15.5 Low
Total white cell 15.6 4.0 – 11.0×109/L High
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Platelet 321 150 – 400×109/L Normal
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- *Given the history, Mr. M has anaemic symptoms like dizziness and shortness of
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breath on ordinary activities. Conjunctival and palmar pallor was noted during
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physical examination. He was confirmed to be anaemic from the blood test. His
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haemoglobin level was 11.2g/dL.
- High WBC shows infection
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2. Blood Culture and Sensitivity

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- To isolate causative organism and initiate appropriate antibiotics

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Plan
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1. Monitor vital sign

2. Sterile wound dressing
3. Wound debridement
4. Surgery to remove internal fixation
5. IV antibiotics followed by oral antibiotics
6. Culture and sensitive of swab of internal fixator during surgery
Pre-Operative Assessments
1. Full Blood Count

- To assess haemoglobin status
2. Blood Urea and Serum Electrolytes
- To ensure all electrolytes are within normal range
3. Serum Creatinine
- To assess patient’s renal function test given patient’s age
4. Liver Function Test and Coagulation Screen
- To screen for any bleeding disorders to prevent excessive blood loss
5. Fasting Blood Glucose
- To check if patient has diabetes mellitus which could complicate wound healing
6. Electrocardiography
- To ensure patient has no arrhythmia
7. Blood Grouping and Crossmatch
- Prepare blood according to patient’s type in case of excessive blood loss during
surgery
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Discussion
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Mr. M had a fracture of the distal third of his left tibia after sustaining injury from a chain
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saw accident over ten years ago. An internal fixator was inserted. Mr. M has very vague
memories about his treatment then and is unable to tell what exactly happened then. Now, Mr.
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M presented with a swollen right shin, with some pain and pus discharge. Not only that his
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internal fixator of the right tibia was exposed. He has been having these symptoms for about
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a year and has just sorted medical help. Why did Mr. M just come in for treatment although
he has been suffering for about a year?
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His answer was, “I don’t want to bother my children. I’m old and counting my days to the
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grave.” He is able to take care of himself, walk around and do some vegetable farming. He
did not see the need for him to get treatment for his leg. He was brought to the hospital by the
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concerned son who finally got tired of seeing his father walk around the house with a
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wounded leg.
After the assessment of his condition, Mr. M was given antibiotic for the infection. The initial
idea of management was to remove the internal fixator and replace it with and external
fixator (Ilizarov) with wound dressing as the fracture has not united. But, later the decision
was made that there will no external fixation made for Mr. M and removal of the internal
fixation will be done. The explanation behind this decision comes from the history and
radiological findings. From the history it is known that Mr. M has been able to walk
independently for many years without pain, limp or any other complaints. Plain radiograph of
the affected limb showed that the fracture has not united and the internal fixation is actually
not holding the two pieces of the broken bone together. Clinically, Mr. M is able to lift his
affected leg in full extension with no depression noted at the site of fracture. From the x-ray,
it also seems that the broken tibia has now fused with the fibula but this finding is not
conclusive. If patient has no problem walking even when the fracture is not united why put
him through a procedure which will make mobilisation a difficult task and also give some
pain? Therefore, the management aims to clear the patient from infection which is giving rise
to his symptoms.
Mr. M is about to undergo surgery under general anaesthesia. Many investigations should be
done to ensure that he is actually fit for surgery. Pre-operative investigations such as Full
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Blood Count, Blood Urea and Serum Electrolytes, Serum Creatinine Levels, Liver Function
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Test, Coagulation Screen, Blood Grouping and Crossmatch and Electrocardiography should
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be done. These investigations ensure that patient haemoglobin levels are adequate, patient has
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no bleeding tendency, has good renal, liver and cardiac function before surgery.
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Mr. M has urinary symptoms such as weak urinary flow and terminal dribbling. It is known
that he has benign prostatic hyperplasia. Extra interest should be taken for catheterisation
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procedures in this patient.

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It is known that Mr. M has anaemia. It is important to maintain his haemoglobin levels to
avoid any catastrophic events. Inadequate oxygenation to the tissues could delay wound
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healing. It is also necessary to investigate on the cause of the anaemia and provide a long
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term solution which would alleviate his symptoms and make him a lot better.
Complications such as hospital acquired pneumonia, deep vein thrombosis, orthostatic

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hypotension, pressure sores, urinary tract infections and acute renal failure should be looked
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out in the elderly. From the history it is known that Mr. M has some upper respiratory tract
infection symptoms. It could make him more susceptible to lung infections. Sometimes it is
not the disease per se that causes the patient to lose cheer but the hospital atmosphere and
complications that arise from the hospitalisation that do. Post-operative complications such as
acute pulmonary, cardiovascular and fluid derangements could be life threatening in the early
period. Airway, breathing and circulation monitoring is the main priority in the immediate
post-operative care.
At the age of above sixty the most common problem encountered in men is urinary symptoms
due to benign prostatic hyperplasia. Mr. M did complain of weak urinary flow and terminal
dribbling. He has no other joint pain but suffers from backache occasionally. Not only that, he
has symptoms of upper respiratory tract infection. Though the primary concern is the affected
limb, symptomatic treatment of these conditions could actually make Mr. M happier.
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TILLAI SHARIMALA SUMASUNDRAM CASE WRITE UP ORTHO 1 PUGSOM 17026

Occupation : Retired Cleaner

Past Medical/Surgical History

 2003- Mr. M had a chain saw accident at right leg

o He had sustained open fracture with lots of bleeding. He underwent surgery to

o No blood transfusion done

Drug and Allergy History

 Mr. M is not on any medication.

 He did not seek traditional healers for his condition.

 Both parents died. They died at the age of above eighty.

Blood Pressure : 115/70 mmHg

Respiratory Rate : 16 breaths per minute

Conjunctiva appeared pale. There was no jaundice.

There were no enlarged lymph nodes.

There was no toenail clubbing or pedal edema.

were no added sounds or murmurs.

appears to be fused with the fibula.

- Previous history of surgery with internal fixation

1. Full Blood Count, Erythrocyte Sedimentation Rate, C-Reactive Protein level

Result Normal range Comment

2. Blood Culture and Sensitivity

- To isolate causative organism and initiate appropriate antibiotics

1. Monitor vital sign

1. Full Blood Count

procedures in this patient.

Complications such as hospital acquired pneumonia, deep vein thrombosis, orthostatic

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