List of long cases: 1. PLID 2. Knee Knee inst instab abil ilit ity y 3. TB hip 4. TB spine 5. Shol! Shol!e" e" !is !isloc locati ation on #. $%T &. 'ste 'steos osa" a"co co(a (a ). *+in *+ing, g,s s sa"c sa"co( o(a a -. eta etast stat atic ic t(o t(o" "s s 1/.Pe"thes0 11.%P 12.Polio(yelitis 13.%L in"y 14.I% 15.abital !islocation of patella 1#.n6ylosing spon!ylitis 1&.%h"onic osteo(yelitis 1).onnion 1-.Scoliosis
PLID " ha(i!l7 45 45 y"s bsiness(an f"o( chan!p"7 a!(itte! a!(itte! in nito" on on 3.3.15 +ith the co(plaints of a.LBP fo" 1 y" b. Di8clty in +al6ing fo" the sa(e !"ation c. Tingling7 (bness of 9t lo+e" li(b fo" the sa(e !"ation
History of present illness: acco"!ing to the state(ent of the patient7 he +as "elatiely +ell /1 y" bac6. Then he !eelope! lo+ bac6 pain. The pain initiate! !"ing +eight lifting. Initial 3;5 !ays pain +as see"e in nat"e an! g"a!ally pain "a!iate to glteal "egion7 poste"olate"al poste"olate"al thigh7 leg an! !o"s( of foot. Pain agg"aate! by snee
last /1 y". (o"eoe"7 he !eelope! tingling7 n(bness of lt lo+e" li(b fo" the sa(e !"ation. is sy(pto(s a"e +o"sening !ay by !ay. e ha! no histo"y of +t loss7 ano"e=ia7 hea(optysis7 hea(optysis7 cogh7 chest pain o" eening "ise of te(pe"at"e. e is no"(otensie7 no"(otensie7 non asth(atic an! non !iabetic. is bo+el an! bla!!e" habit is no"(al.
isto"y of past illness:S >a(ily histo"y: S Socioecono(ic histo"y: lo+ lle"gic histo"y: S I((ni
On examination: $ene"al e=a(: Plse;&2b0(in BP;12/0&/ (( of g Te(p;no"( Te(p;no"(al al nae(ia;absent
Local exam: look from the front-
shol!e" !"ooping?a=illa"y !"ooping?a=illa"y type;sa(e si!e7 in shol!e" type;opposite si!e@ (scle +asting p"esent in lt thigh patient can +al6 heel +ith !i8clty gait
loo6 f"o( the si!e: l(be" lo"!osis loo6 f"o( bac6: list of lt si!e no sca" (a"6
slight glteal (scle +asting sAatting possible gait;antalgic pelic tilting;lt
>eel:
il! ten!e"ness at lo+e" l(be" "egion
o stepping is p"esent
o +asting of bac6 (scles
oe
eel +al6ing : not possible Toe +al6ing: possible
Senso"y: pa"esthesia at L 47 L57 S1 !e"(ato(e
oto": *L?9%;305@9t >L?9%;505@9t
e"6: an6le e"6;no"(al 6nee e"6;no"(al
Special test
SL9:
9ight;&/ o
Left ;-/ o
%"oss SL9: ?;@e Bo+st"ing test: Ce >a
KNEE INSTABILITY " ha(i!l7 45 y"s bsiness(an f"o( chan!p"7 a!(itte! in nito" on 3.3.15 +ith the co(plaints of a. $iing a+ay of "ight 6nee an! feeling of insec"ity +hile +al6ing fo" /1 y"
History of present illness: acco"!ing to the state(ent of the patient7 he +as "elatiely +ell /1 y" bac6. e gae histo"y of t+isting in"y !"ing playing football an! hea"! a pop son!. e col! not contine the ga(e an! +ith the help of othe" people he +as sent to local clinic. e notice! s+elling at his "ight 6nee i((e!iately afte" the in"y. The"e is no p"oble( on cli(bing stai"s an! no histo"y of loc6ing of "ight 6nee.
On examination Loo6 f"o( the f"ont: a!"iceps +asting $ait no"(al >eel: Local te(p;no"(al Ten!e"ness;oint line absent
Easting e"oascla" stats;no"(al oe: Knee Fe=ion; *=tension;
Special test:
Stan! on one leg: Test fo" hype"e=tension: Varus-valgus stress test: at 3// Fe=ion?isolate! tea" of collate"al liga(ent@ an! 6nee st"aight?capsle7 collate"al an! c"ciate liga(ent@ Anteroposterior stability : 6nee -// loo6 f"o( the si!e;poste"io" sag nte"io" !"a+e" test DT +ith 15 / e=te"nal "otation DT +ith 3/ / inte"nal "otation Poste"io" !"a+e" test Lach(an test c (""ey,st test Thessaly test Piot shift test
ENIS!"S IN#"$Y " ha(i!l7 25 y"s bsiness(an f"o( chan!p"7 a!(itte! in nito" on 3.3.15 +ith the co(plaints of
a. pain in left 6nee fo" /1 y"
History of present illness: acco"!ing to the state(ent of the patient7 he +as "elatiely +ell /1 y" bac6. e gae histo"y of t+isting in"y !"ing playing football. Knee s+elling appea"e! afte" 12 h". +ith "est his sy(pto(s sbsi!e!. 'ccasionally his 6nee loc6s fo" last /) (onths.
On examination Loo6 f"o( the f"ont: a!"iceps +asting $ait no"(al >eel: Local te(p;no"(al Ten!e"ness;oint line p"esent Easting e"oascla" stats;no"(al oe: Knee Fe=ion;fll *=tension;slightly li(ite!
Special test: Knee eGsion;Ce Varus-valgus stress test: at 3// Fe=ion?isolate! tea" of collate"al liga(ent@ an! 6nee st"aight?capsle7 collate"al an! c"ciate liga(ent@ Anteroposterior stability : 6nee -// loo6 f"o( the si!e;poste"io" sag
nte"io" !"a+e" test DT +ith 15 / e=te"nal "otation DT +ith 3/ / inte"nal "otation Poste"io" !"a+e" test Lach(an test c (""ey,st test Ce pley,s g"in!ing testCe Thessaly testCe Piot shift test
TB HIP " ha(i!l7 45 y"s bsiness(an f"o( chan!p"7 a!(itte! in nito" on 3.3.15 +ith the co(plaints of a.Pain in "ight hip fo" /1 y" b. Di8clty in +al6ing fo" the sa(e !"ation
%istory of present illness: acco"!ing to the state(ent of the patient he !eelope! pain in his "t hip fo" /1 y" an! he faces !i8clty in +al6ing fo" the sa(e !"ation. Pain is insi!ios in onset +ith aching in g"oin an! thigh7 continos7 !ll aching an! inc"ease! at night7 +hich (a6e hi( a+a6e f"o( sleep. It is agg"aate! by (oe(ent bt "eliee! +ith analgesic. e also co(plains of li(ping fo" last /1 y". e has histo"y of eening "ise of te(pe"at"e7 night s+eat an! +t loss. On examination: ip is Fe=e!7 a!!cte! an! inte"nally "otate!. scle +asting p"esent ip (oe(ent;all (oe(ent a"e "est"icte!.
x ray:
gene"al "a"efaction bt no"(al oint line an! space fe(o"al epiphysis (ay be enla"ge! bone abscess (ay be isible !est"ction of acetabla" "oof;+an!e"ing acetabl( !est"ction of fe(o"al hea! !est"ction of both?sally@ oint (ay be sbl=e! o" een !islocate! +ith healing bones "ecalcify
TB spine:
" ha(i!l7 45 y"s bsiness(an f"o( chan!p"7 a!(itte! in nito" on 3.3.15 +ith the co(plaints of a. bac6 pain fo" /1 y" an! gene"ali
%istory of present illness: acco"!ing to the state(ent of the patient he !eelope! bac6 pain fo" /1 y" an! he faces !i8clty in +al6ing fo" the sa(e !"ation. Pain is insi!ios in onset +ith continos7 !ll aching an! inc"ease! at night7 +hich (a6e hi( a+a6e f"o( sleep. It is agg"aate! by (oe(ent bt "eliee! +ith analgesic. e also co(plains of abno"(al sensation an! +ea6ness in his both lo+e" li(b fo" last /1 y". e has histo"y of eening "ise of te(pe"at"e7 night s+eat an! +t loss. On examination: Loo6: patient cant stan! co(fo"tably $ait: cl(sy e can sAat >eel: SL9: no"(al
Senso"y: !i(inishe! f"o( L2 leel oto": all (scle of lo+e" li(b +ea6: ("c;305 Tone; inc"ease! e"6s;e=agge"ate! %lons;p"esent P(p han!le test ip (oe(ent oe: (oe(ent of spine is no"(al
x ray: early: local osteopo"osis of t+o a!acent e"teb"ae an! na""o+ing of inte"e"teb"al !isc7 f<
Pro&ressi'e: sign of bone !est"ction an! collapse of a!acent e"teb"al bo!ies. Pa"aspinal soft tisse sha!o+ %hest = "ay. 9I %T scan anto= test *S9 >% !0!: pyogenic infection (alignant !isease pa"asitic infection
$E!"$$ENT SHO"LDE$ DISLO!ATION
" ha(i!l7 25 y"s bsiness(an f"o( chan!p"7 a!(itte! in nito" on 3.3.15 +ith the co(plaints of a. !islocation of "t shol!e" !"ing oe"hea! actiities fo" 5 ti(es in last /3 (onths
%istory of present illness: acco"!ing to the state(ent of the patient he !eelope! "ec""ant !islocation of "t shol!e" fo" last /5 y"s. In last y" his shol!e" !islocate! fo" /5 ti(es !"ing oe"hea! actiities. /5 y"s bac6 his shol!e" !islocate! !"ing playing an! fall on g"on!. It +as painfl an! "e!ce! by an o"thopae!ic s"geon. e i((obili
>eel: !eltoi! +asting 1 c( Local te(p;no"(al Ten!e"ness;no"(al oe: (oe(ent of shol!e" is no"(al Special test: app"ehension test;Ce >lc"( test:apley 355 D"a+e" test:apley 355
x ray: Hill sac%s lesion* P ie+ +ith ab!ction an! inte"nal "otation 9I
+!T $ADI"S
" ha(i!l7 25 y"s bsiness(an f"o( chan!p"7 a!(itte! in nito" on 3.3.15 +ith the co(plaints of a. pain an! s+elling a"on! his "t +"ist fo" /2 (onths
%istory of present illness: acco"!ing to the state(ent of the patient he !eelope! pain an! s+elling a"on! his "ight +"ist fo" /2 (onths On examination: ,rist Loo6: s+ollen7 (ass 3=3 c(
>eel: Local te(p;"aise! Ten!e"ness;absent Palpable (ass 3=3 c(7 s"face s(ooth7 (a"gin ill !eHne!7 bony ha"! in consistency7 f"ee f"o( s6in7 H=e! +ith bone. oe: (oe(ent of +"ist is no"(al
x ray: "a!iolcent a"ea locate! eccent"ically bon!e! by sbchon!"al bone plate soap bbble appea"ance co"te= thin 9I
OSTEOSA$!OA -t%i. .orte %o/eapley 012 " ha(i!l7 25 y"s bsiness(an f"o( chan!p"7 a!(itte! in nito" on 3.3.15 +ith the co(plaints of a. pain an! s+elling a"on! his "t 6nee fo" /2 (onths
b. fee"7 ano"e=ia an! +t loss fo" the sa(e !"ation
%istory of present illness: acco"!ing to the state(ent of the patient he !eelope! pain an! s+elling a"on! his "ight 6nee fo" /2 (onths. Pain is continos7 see"e inc"ease! in night7 agg"aate! by (oe(ent an! "eliee! +ith (e!ication. S+elling is "api!ly inc"easing. o"eoe" he !eelope! fee"7 ano"e=ia an! +t loss fo" last /2 (onths. On examination: ,rist Loo6: s+ollen7 (ass 3=3 c(
>eel: Local te(p;"aise! Ten!e"ness;absent Palpable (ass 3=3 c(7 s"face s(ooth7 (a"gin ill !eHne!7 bony ha"! in consistency7 f"ee f"o( s6in7 H=e! +ith bone. oe: (oe(ent of +"ist is no"(al
x ray: "a!iolcent a"ea locate! eccent"ically bon!e! by sbchon!"al bone plate soap bbble appea"ance co"te= thin 9I
HABIT"AL DISLO!ATION O3 PATELLA
PARTICULARS OF THE PATIENT
Name-Abdul Jalil Age- 30 yrs Sex-male Occupation-Medical asst Address-Netrokona Date of admission-!-0!-"# Date of examination-0!-0$-"#
CHIEF COMPLAINTS:
a% displacement of rig&t knee cap '&en &e flexes &is knee and it relocates automatically since &is c&ild&ood%
HISTORY OF PRESENT ILLNESS:
according to t&e statement of t&e patient &is rig&t patella displaces e(ery time '&en &e flexes &is knee and it relocates automatically since &is c&ild&ood% )e &as no definite &istory of trauma. *&ere is no pain '&en &e flexes &is knee%
HISTORY OF PAST ILLNESS: TREATMENT HISTORY:
not&ing significant
not&ing significant
none of &is family member suffered from t&is type of illness% FAMILY HISTORY:
PERSONAL HISTORY: nonsmoker+
non alco&olic%
ON EXAMINATION: General examination
Bo!y bilt; ae"age.
nae(ia;
Decbits on choice t"itional stats; ae"age
%yanosis
Plse;&2 beat0(in D
an!ice;
BP;12/0)/ (( of g
'e!e(a;
Te(p;no"(al ea"t0lng;D
Local examination:
Ly(ph o!e; Dehy!"ation;
9t 6nee
Loo.: Patella is late"ally place!. $en "ec"at(;absent $en algs;absent a!"iceps +asting;p"esent $ait;no"(al SAat;possible7 in this position patella is !isplace! (o"e late"ally
3eel: Local te(p;no"(al Ten!e"ness;absent Patellofe(o"al oint;no"(al pp"ehension test;negatie.
angle;&/ Patella" t"ac6ing test;Ce Patella" g"in!ing test;negatie Patella" tilt test;negatie. >eat"es of liga(ent la=ity;absent a!"iceps +asting;p"esent & c( at 1) c( aboe oint line on "ight si!e %ont"act"e of Aa!"iceps;absent Tibial to"sion;absent.
o'e: 9t 6nee; >le=ion;14// *=tension;// Lt 6nee;no"(al
Ot%er systemic examination;D SALIENT 3EAT"$E
b!l alil73/ y"s of age e! sst7 f"o( et"o6ona a!(itte! in ito" +ith the co(plaints of !isplacement of rig&t knee cap '&en &e flexes &is knee and it relocates automatically since &is c&ild&ood% )e &as no definite &istory of trauma. *&ere is no pain '&en &e flexes &is rig&t knee% ,atella is laterally displaced% % *&ere is no genu (algus% angle is .0% ,atellar tracking test is positi(e% ,atellar grinding test is positi(e% *ibial torsion is absent% /igamentous laxity is absent% nee mo(ement is normal%
Pro'isional )ia&nosis*
Ha/it(al )islocation of Patella Di4erential )ia&nosis %ongenital !islocation of patella 9ec""ent !islocation of patella
In'esti&ation
J "ay both 6nee oint;P. Late"al an! S6yline ie+ 'the" "otine inestigation
An.ylosin& spon)ylitis PARTICULARS OF THE PATIENT
Name-Sumon Age- 0 yrs Sex-male Occupation-unemployed Address-J&alokat&i Date of admission-0.-0$-"# Date of examination-0!-0$-"#
CHIEF COMPLAINTS:
a% ,ain in bot& &ip for 0" yr and difficulty in 'alking for t&e same duration% b% 1nability to stand straig&t for last 0! mont&s%
HISTORY OF PRESENT ILLNESS:
according to t&e statement of t&e patient+ &e 'as reasonably 'ell 0" yr back% *&en &e de(eloped pain at &is bot& &ip more in t&e rig&t for last 0" yr% ,ain is constant dull ac&ing+ aggra(ated by 'alking and relie(ed by taking rest% )e also complains of inability to stand straig&t for last 0! mont&s% Moreo(er+ &e complains of anorexia+ 'eig&t loss and occasional rise of temperature for last 0" yr% )e &as no &istory of coug&+ &aemoptysis or contact 'it& a *2 patient% HISTORY OF PAST ILLNESS:
not&ing significant
&e took anti *2 for 0 mont&s '&ic& 'as stopped 03 mont&s back% No' &e is taking sala4ine for last 03 mont&s and &is condition impro(ed% TREATMENT HISTORY:
none of &is family member suffered from t&is type of illness% FAMILY HISTORY:
PERSONAL HISTORY: &e
'as smoker but stopped after t&e disease+ non alco&olic% IMMUNI!ATION HISTORY: immuni4ed
sc&edule%
as per 5,1
ON EXAMINATION: General examination
Bo!y bilt; ae"age.
nae(ia;(il!
t"itional stats; poo"
%yanosis
Plse;&2 beat0(in D
an!ice;
BP;12/0)/ (( of g
'e!e(a;
Te(p;no"(al
Ly(ph o!e;
ea"t0lng;D
Dehy!"ation;
Local examination: Loo.: Patient can,t stan! st"aight. Spine is bo+e!. e can,t +al6 +ithot sppo"t. Easting of both glteal (scles an! both thigh (scles e can,t sAat
3eel: Local te(p;no"(al at both hip "egion Ten!e"ness;absent Tho(as test;bil >>D 3//7 f"the" Fe=ion pto &// LLD;nil L(be" spine e=c"sion;3 c( Eall test;positie %eiling test;negatie %hest e=pansion;2 c(
o'e: >le=ion !!ction b!ction *=te"nal "otation
9ight hip 3//;&// // // //
Left hip 3//;&// // // 5/
Inte"nal "otation
//
5/
P(p han!le test;positie bilate"ally
Ot%er systemic examination;D SALIENT 3EAT"$E S(on 72/ y"s of age f"o( halo6athi a!(itte! in ito" on /&./-.15 +ith the co(plaints of pain in both hip fo" /1 y" % ,ain is dull ac&ing+ aggra(ated by 'alking and relie(ed after taking rest% Occasionally pain is associated 'it& mild rise of temperature% Moreo(er+ &e complains of inability to stand straig&t for last 0! mont&s% )e 'as treated 'it& antitubercular for 0 mont&s but &e 'as not impro(ed% No' &e is taking sala4in for last 0 mont&s and &is pain decreased but deformity persisted% )e &as anorexia and 'eig&t loss but no &istory of coug&+ &aemoptysis or nig&t s'eat% None of &is family member suffered from t&is sort of illness% )e is of poor nutritional status% )is (ital parameters are 'it&in normal limit% )e can6t stand straig&t% *&ere is kyp&osis% )e can6t 'alk 'it&out support% )is t&ig& and gluteal muscles are 'asted% )e can6t s7uat% *&omas test is positi(e and bil 88D is 30 0%
8urt&er flexion is upto .00% All ot&er mo(ements are se(erely restricted% //D is nil% 9&est expansion is cm% lumber excursion is restricted% :all test is positi(e% ,ump &andle test is positi(e%
Pro'isional )ia&nosis*
An.ylosin& spon)ylitis in'ol'in& /ot% %ip5 spine an) SI 6oint Di4erential )ia&nosis TB hip 9he(atoi! a"th"itis
In'esti&ation %B% %9P *S9 LB2& 9 test T
%J9 Spt( fo" >B J "ay pelis 0P ie+ incl!ing both hip oint J "ay l(bo sac"al spine 0P an! late"al ie+ J"ay !o"sol(ba" spine 0P an! late"al ie+
