20/M ANKLE TB
A 20/M came to general medicine opd with
Chief complaint: Pain in the right ankle causing difficulty in walking.
History of presenting illness: Patient was apparently asymptomatic 8 months ago.
8 months back he was working in the farm and suddenly started getting pain in the right ankle.
Pain was of low intensity and subsided on taking painkillers.
The pain was continuous and recurred everyday as the effect of the medication wore off.
For 5 months patient would take a painkiller tablet everyday and pain would subside
He went to an RMP where Xray and blood tests were done and everything was apparently normal. Patient continued taking painkillers.
Gradually the pain increased and swelling with pus developed over dorsum of the right foot.
He then again visited a doctor, MRI was done which showed infection and lytic lesions.
Patient got admitted on the 22nd of June 2022 for surgery(ANKLE ARTHROTOMY) under local anesthesia and pus was drained by excision.
Upon removal of sutures after 2 weeks biopsy was done which was suggestive of bone tuberculosis.
This was followed by an MRI which confirmed TB.
Treatment for TB started on the 18th of July 2022.
Patient is on ATT regimen and is regular with medication
Now patient also complains of pain over the left hip and lower back on lifting leg while sitting and also on walking after a long time of rest.
Previously, before the surgery patient's pain was over the swelling in dorsum and is now on over the lateral malleolus
History of past illness: Not a known case if Diabetes, hypertension, epilepsy, asthma
Diagnosed with Bone TB after biopsy report following surgical drainage of pus.
Drug history:
8 months back when pain was of low intensity and subsided on taking medication patient was taking one painkiller tablet everyday for 5 months
On first visit to RMP no other medication was given and patient continued use of painkillers
After surgery patient was prescribed the following medications, following which he reported swelling of the entire right lower limb:
1.Dalacin C
2. Limcee tab
3. Gemcal
4. Deksel nano syrup
Patient is currently on HRZE since 18th July 2022 and will commence HRE regimen from 13th September.
Personal history:
Mixed diet
Normal appetite
Bowel movement normal
Normal micturition
Patient does not report difficulty in sleeping
No addictions
Drug allergy?
Family history: No relevant family history
General examination:
Pallor: Present
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Koilonychia: Absent
Lymphadenopathy: Absent
Edema: Absent
Vitals:
Temperature:
Respiratory rate:
Pulse :
Blood pressure:
CVS examination:
Respiratory system examination:
CNS examination:
Higher functions: Patient is conscious and coherent, well oriented to time, place and person. He is able to recollect past events in orderly fashion and doesn't show any defecits.
Speech: Normal and coherent
Motor system examination:
Attitude and position: Normal
Bulk: Right lower limb shows wasting over the calf.
Tone: Normal
Power: 5
Reflexes : Normal
Gait: Limping due to pain in the right ankle
Demonstrated by the following videos:
Sensory System examination:
Normal
Signs of meningeal irritation are absent.
Cranial nerves: Intact and normal
IMAGING:
MRI : done previously before admitting into our ward
Before surgery:
After surgery:
XRAY on 9th September 2022:
Biopsy reports:( before admission into our hospital done at time of removal of sutures post arthrotomy)
Provisional Diagnosis: Tuberculous osteomyelitis?
Treatment:
Day1
Referral to orthopedic
Treatment suggested:
1. Continue ATT
2. Tab Hifenac BD
3. Tab Pantop 40 mg OF
4. Tab Benadone Forte 20mg OD
Updated on 13/9:
1. Ultracet 1/2 tab Qid for 3 days
2. Naproxicin 1 Tab OD for 3 days a week
3. Continue ATT regimen and Benadone Forte OD
On 12 -12 -22 he contacted us through wats app and updated that he has severe pain and ATT should be continued for 3 weeks.
HE COMPLETED ATT IN JANUARY 2023 AND TESTED NEGATIVE FOR TUBERCULOSIS.
HE IS COMPLAINING OF PAIN AND SWELLING OF ANKLE WHICH RELIEVED ON TAKING REST
OUTCOME - RECOVERED BUT STILL HAS PAIN AND SWELLING OF ANKLE WHICH RELIEVES ON TAKING REST
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