CASE OF A 65 YEAR OLD FEMALE WITH HIP PAIN

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This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

January 30, 2022

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CASE:

A 60 year old female ,presented to the OPD with chief complaints of 

1) Back Pain on the right side since 13 days

2) Nausea and vomiting since 9 days 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 13days back ,then she developed pain in the lower back on right side which was dull aching type which is non-radiating, aggravated by movement of right leg and relieved on resting.

Then she consulted a local doctor who prescribed medication(unknown) 10 days back. After taking the medication her pain has relieved partially, but she developed severe nausea and vomiting 9 days back.

Then she had two episodes of seizures 2 days back.

     First episode in the afternoon 2 days back.

     Second episode at night 2 days back.

Then she developed swelling over the  right shoulder which is associated with pain which was dull aching type , non radiating and aggravated by movement of right shoulder joint.

PAST HISTORY:

Not a known case of 

DIABETES 

HYPERTENSION

TUBERCULOSIS
ASTHMA

EPILEPSY

PERSONAL HISTORY:

Diet - MIXED

Appetite - Decreased since 9 days

Sleep - Inadequate due to pain

Bowel moments - Constipated since 10 days

Addictions - Alcohol occasionally

Treatment history:

She had a history of treatment for Pain at a local clinician (medication unknown) 10 days back.

GENERAL PHYSICAL EXAMINATION:

Patient is conscious , coherent and cooperative.

No Pallor ,Icterus ,Cyanosis ,Lymphadenopathy.

Edema is seen over the Right shoulder.

                                                                                                                                                                    RIGHT SHOULDER

                                                                                                                                                                     LEFT SHOULDER

VITALS-

 Temperature - Afebrile

 Blood Pressure - 

 Pulse rate - 

 Respiratory rate - 

 

SYSTEMIC EXAMINATION:

RS - BAE + , NVBS

CVS - S1 S2 +

Per Abdomen - soft , Non tender.

CNS - 

  Level of consciousness - Drowsy 1 , arousable

  Speech - No response

  Signs of meningial irritation - None

  Cranial nerves - Normal

  Motor system - Normal

  Sensory system - Normal

  Glasgow scale - 10/15 

        Eye response - 3 Eye opening to verbal command

        Motor response - 6 obeys command

        Verbal response - 1 No verbal response

                                                                                                                                                                  ULTRASOUND

DIAGNOSIS:

Fracture in Right Hip Joint secondary to post menopausal Osteoporosis due to elderly age.

Dislocation in Right Shoulder ?