A wound on left thigh since 19 years. Pain in both knees since 12 years. Pain in lower back since 12 years. Black discolouration on both feets since 6 months.

Name: XXXXXX.

Age/ Sex: 58 yrs/ M

Marital Status: Married since 34 years.

Religion: Hindu

Presenting Complaints

A wound on left thigh since 19 years.
Pain in both knees since 12 years.
Pain in lower back since 12 years.
Black discolouration on both feets since 6 months.

History of Presenting Complaint

Patient was apparently well 19 years back when he met with an accident and got fracture of both femur, both radius and right ulna and rupture of urinary bladder and was operated for all these and was hospitalised for 2 months, developed bed sores also which were taken care of in the hospital. But two fractures were mal- united:

Left radius: resulting in the restriction of supination of the forearm.
Left femur: resulting in formation of swelling and eventually the pus broke out from the surface of skin.

A sinus has formed from the lower 1/3 of the shaft of femur to the surface of skin on the lateral aspect of left thigh. Since then the patient has underwent drainage of the pus for 5 times. (1992, 1994, 1996, 1997, 1998). Since 13 years he taking care of the wound and presses the thigh himself to exude the pus daily.

Location: Lower 1/3 of the lateral aspect of left thigh.

Character of Discharge: Yellowish with tinge of blood.

Amount of Discharge: 2-3 drops daily. Discharge of pus, even a drop or two assures the patient that there is no collection inside.

Sensation: Dull aching pain persists throughout the day with occasional bouts of intense cutting pain.

Aggravation: In cold air, cold weather.

Amelioration: Nothing specific.

2. Pain in the lower back since 12 years.

According to the patient he developed this pain after getting repeated spinal anaesthesia (given for the drainage of pus.

Location: Lumbar region.
Sensation: Heaviness and tired feeling in the back.

Aggravation: Cold air, cold weather, prolong sitting.

Amelioration: Rest, allopathic medicine (?)

Pain in both knees since 12 years.

Location: Pain in both knees, more on the left knee.

Sensation: Burning pains, as if the coal is on fire inside the joint.

Aggravation: Cold air, cold weather (cannot tolerate fan), walking.
Amelioration: Rest (temporarily relieves), allopathic medicine (?)

4. Black discolouration of both feets since 6 months.
Patient used garlic and groundnut oil (Ayurvedic preparation) for the pain in knee joints 6 months back after which he developed intense itching and vesicular eruptions (exuding thick, sticky, straw coloured fluid). And then to relieve this he applied coconut oil and camphor that tend to give temporary relief of the itching.

Location: Dorsum of the foot, medial aspect of both the ankle, lower 1/3 of both the legs.

Sensation: Intense itching. Patient scratches the site.

No modalities as such.

Past History: Chickenpox in childhood; Accidents: Fracture of both femur, both radius and right ulna in Nov. 1992; Operation: Reduction of above fractures, rupture of urinary bladder, drainage of pus (5 times); Last exposure to X- Ray: 13.09.11, before that in 1998; Vaccination: Not known.

Family History: No history of TB, Diabetes mellitus, Hypertension, Asthma, etc.
Parents died of old age and siblings are apparently well.

Personal History: Developmental landmarks: on time; Habit/ addiction: Nil; Environment at home: Congenial; Diet: Veg; Occupation: Tea stall.

Physical Generals:

Thermal reaction: Chilly (+)
Appetite: Normal, 3 meals/ day.
Thirst: 2-3 L/ day.

Urine: D7-8N3-5, no associated complaints (even after trauma to the bladder).

Stool: D1N0, satisfactory.
Sleep: 3-4 hours, not refreshing, disturbed due to pain. At his home he used to take the allopathic medicine (pain killer) and sleep comfortably.

Dreams: NS

Desire: NS, prefers salty food.

Aversion: NS

Perspiration: Generalised, non- offensive, non- staining.

Mental Generals: As a child patient lived with his parents, had a good childhood, were 5 siblings. He studied up to 5^th standard, due to financial constraints he left studies and started working as a mechanic. He got married at the age of 24, has 4 children. Patient has cordial relations with his siblings, wife and children. Memory is good as he remembers the minute details of every event. After his accident in 1992 he left his job and again started working as a driver in 2006 but again met with an accident (as the brakes failed) resulting in the death of a person (who was drunk & does not responded to the horn and died not because of any injury causes by patient’s vehicle but because of the bottle of liquor that was tucked in his belt broke- off & entered abdomen after he fell down).he remained in jail for 3 days. Lower court cleared him of the charge but family of the victim took the case to High Court (case is still going on). He has no regrets for that event as he was not at the fault. After this event he left driving & opened his tea stall as he does not like to sit idle. He likes to be consoled when he is sick. He turned religious after his accident in 1992 as he survived such a major accident and is regularly doing puja 2-3 times a day since then.

General Physical Examination

Built: Endomorphic

Nutrition: Average

Decubitus: Sitting

Pallor: Absent

Icterus, cyanosis, clubbing, edema: Not present

Pigmentation: Hyperpigmented patched over legs and feets; at rest of the places: normal

Pulse: 80/ min

BP: 110/ 70 mmHg

RR: 20/ min

Tongue: Clean, moist
Temperature: 98.6 F

Local examination: Joint Examination

Left Knee: Redness: Not present, Temp.: Normal, Swelling: +, Tenderness: +, All movements are painful, flexion- 20 degrees only, Crepitations: +
Right knee: Redness, swelling: Not present, Temp.: Normal, Tenderness: +, All movements are painful, flexion- 30 degrees only, Crepitations: +
Right Hip: All movements are painful, flexion: 50, Abduction: 30 degrees
Left Hip: All movements are painful, flexion: 30, Abduction: 20 degrees
Right Elbow: Normal
Left Elbow: Supination restricted.
Lumbar Spine: Curvature (lordosis) maintained, Redness, swelling, tenderness: Not present, Temp.: Normal, All movements are possible but are painful. SLR: positive, Active- Left side: 30 & rt side 45 degrees.
Skin: Hyper-pigmented patches of variable size (2-5 cm) on the dorsum of the foot, medial aspect of both the ankle, lower 1/3 of both the legs with thickening and scaling of skin. No eruptions. All the senses are intact (touch, vibration, pain, pressure).
Systemic Examination: NAD

Investigations: X-Ray: B/l knee: Advanced OA changes; Left Femur: Chronic osteomyelitic Lesion. Urine: WBC: 0-2/ HPF, Ep. cells: 2-4/ HPF; Blood sugar (F): 81 mg/ dl, PP: 88 mg/ dl; CBC: Hb: 15 g%, TLC: 8100 /cumm, DLC: P63, L4, E2, M1, B1, ESR (Wintrobe’s): 51mm after 1 hr.

Prescription

12.9.11: Gun powder 3X/ QID x 1 day, G.C same.

1.9.11: Staphylococcinum 200/ QID x 1 day. Adv. Antiseptic dressing of the wound. At 7 pm, patient c/o intense pain in the wound, Bell 30/ 3 doses at 10 min interval.

14.9.11: Calc sulph 30/ QID x 1 day, Gun powder X/ QID x 1 day, Calendula ointment. Adv. Antiseptic dressing of the wound. G.C same.

15.9.11 and 16.9.11: Calc sulph 30/ QID x 1 day, Gun powder X/ QID x 1 day, Adv. Antiseptic dressing of the wound. G.C same.

17.9.11: Calc sulph 30/ QID x 2 day, Gun powder X/ QID x 2 day, Mag phos 6X/ 3 doses. Dressing of the wound not done as the wound is dry. G.C same.

18.9.11: Pain in knee joint is better, itching in the black lesion on dorsum of foot is better, wound on thigh is dry i.e, no discharge of pus since 2 days, G.C better.

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December 4, 2021

A wound on left thigh since 19 years. Pain in both knees since 12 years. Pain in lower back since 12 years. Black discolouration on both feets since 6 months.