# data[].attributes.body
1. Anatomy of the lower limb (big bones, group of muscles + general movement, main nerve from the thigh, route of the nerve, where it is associated, can relate to referred pain, main arteries)

2. MSK PE (lower limb examination, achilles tendon reflex etc)

3. How to differentiate normal infection inflammation w/ tumour

4. Types of fractures (classify and describe, closed/open)

5. Pathophysio 3

6. How to differentiate the top 3 differentials (symptoms, complications & prognosis)

7. Imaging 3

8. Lab investigation 3

9. conventional management 3

10. Non-invasive management 3

# data[].attributes.body
LAB INVESTIGATIONS

1. Pus drainage (pus C&S)

2. AFB C&S (ZN stain)

3. FBC (hemoglobin, differentiate viral, bacterial infections, platelet count i.e coagulapathies)

4. ESR (chronic conditions & non-specific)

5. CRP (acute conditions, to monitor disease progression e.g. antibiotics effectiveness, 7-14 days)

6. Blood glucose level (capillary test, to detect for DM, delayed wound healing)

Imaging

1. MRI (more detailed for soft tissues compared to CT)

2. Right thigh XRAY

3. Bone biopsy

# data[].attributes.body
1. Temp - elevated, fever

1. Suggests an infection

2. HR - borderline elevated

3. RR - elevated, tachypnea

1. Systemic response to infection

4. BP - Borderline elevated

5. flexion deformity of 20 degrees at the right knee.

1. Patient cannot fully extend his right knee

2. Can exclude cellulitis

6. sinus discharging pus mixed with serosanguineous fluid at the lateral aspect of the right thigh.

1. Hallmark sign of chronic osteomyelitis

2. Sinus tract neovascularisation which are fragile and lead to rupture which leaks to the sinus, thus, mixing with pus.

7. There was redness of the skin around the sinus.

8. localised tenderness in the projection of the incision line

1. Localized inflammation

2. Commonly seen in infections

9. patient was observed to be limping on the right side

10. There was no evidence of regional lymphadenopathy

1. No dissemination

# data[].attributes.body
1. serosanguineous fluid

1. Light pink, presence of blood, contain both serous fluid and blood

2. Release during inflammation

# data[].attributes.body
PE

Vital signs

1. Temp

2. BP

3. PP

4. RP

General examination

1. Cachexic (body habitus)

2. Alert, comfortable

3. Require any supporting apparatus

Inspection

1. Size and depth of sinus

2. Inflammation, swelling, discolouration

3. The pus (foul smelling, colour)

4. Bursting of stitches

5. Malunion

6. Gait (Active & passive range of motion)

Palpation

1. Warmth (redness)

2. Tenderness (indicates osteomyelitis, sakit)

3. Swelling (consistency, soft or firm)

4. Any palpable masses

5. Pulses

6. Lymph node assesment

7. tendon reflex

8. Checking depth of sinus (probe to bone test)

# data[].attributes.body
closed fracture of the right femoral shaft two months before and was operated three days after the accident.

Decreased risk of infection, but increased when there is surgical intervention which causes distruption in the blood flow which is a foreign body which serves as a surface for bacterial growth.

The fracture was fixed with an intramedullary nail in a private clinic

kenot trust huaaaa :(

predispose to infection, unsanitary and under equipped for orthopedic surgery.

Before and during operation, his vital signs were normal.

Developed symptoms after surgery

No initial systemic complications

patient gradually developed persistent pain

Slowly developed

2 months

redness around the incision line and fever.

Cardinal sign of inflammation

patient was treated with antibiotics without achieving the intended response.

Low compliance

MRSA

Antibiotic x kene ngan bacteria (empirical given)

Developed resistance

Past medical history was unremarkable.

The patient had neither surgery in the past nor known allergies.

No history of HIV / TB infection.

Immunocompetent, less likely immunocompromised

Family history.

He also disclosed that he had no family history of diabetes mellitus or tuberculosis.

Medications.

The patient took aspirin for his fever.

Can cause hematoma

Social history.

No history of alcohol or drug abuse

# data[].attributes.body
1. Closed fracture

The bone is fractured and the skin is still intact

2. Incision line

Cut made in the skin that is made during surgery or procedure aka surgical wound

3. Intramedullary nail

Nail to support structure of bone

# data[].attributes.body
Site

Where does the patient feel the pain

Onset

When did the symptoms start

Gradual, sudden

Characteristics

Type of pain (throbbing, localised, burning)

Smell and colour of the pus

Discharge continuous and intermittent

Characteristics of the swelling, how does the patient walk?

Does the limping require a supporting apparatus.

Weakness? lethargy?

Superficial or deep

Radiation

Does the pain spread around the right thigh

Assoc. symptoms

Fever

Range of motion?

Weight loss (appetite, unintentional weight loss, time since difference in weight)

Night sweats

Loss of sensation (light touch, pinprick), any numbness?

Joint stiffness

Time

Worsening at night

How long has the patient been feeling pain

How long has been limping, swelling, sinus discharge

Exacerbating/allev fact

Bearing weight worsens the pain

Does the pain worsens with movement

Any analgesics that relieve the pain (aspirin)

Resting or sitting relieves the pain

Severity

Effects lifestyle

Pain scale 1-10

PMH

Trauma

Recent surgeries

Any comorbidities

Allergies

PDH

Medications (immunosuppressive mediations, analgesics e.g. NSAIDs, OTC medications? How long? Compliant on prescribed drug? Dosage? i.e overdosage)

Family history

Any history of cancer/tumour

TB

Comorbidities? (HT, diabetes)

Genetic predisposition to bone or joint diseases e.g. rheumatoid athritis, osteosarcomma)

Social hx

Activity, occupation

Smoking/ alcohol, predisposes to infection

Drug abuse

Living conditions (crowded, unsanitary)

Occupation

Trauma

Travel history

To an area with high incidence of TB

# data[].attributes.body
1. Infection

1. Bone

1. osteomyelitis (PO osteomyelitis)

2. arthritis (septic athritis)

3. TB

2. Muscle

1. Pyomyositis

3. Skin

1. Cellulitis

1. Trauma

2. Tumour

3. Soft tissue abscess (formation of immune response due to bacterial infection, pressure will increase and sinus tract will penetrate thru the surface, releasing pus)

4. Hematoma

# data[].attributes.body
1. 23-year-old man

Young adult

Assumed active lifestyle

Predisposed to infection and trauma

Assumed immunocompetent

2. complaining of limping

Trauma

Muscle strain/cramp

4 types of limping

Antalgic (infection, osteomyelitis)

Trendelenburg gait (weakness of muscle at hip, stand at weak leg, pelvic senget (abnormal walking))

Lympho structure abnormalities (congenital abnormalities, abnormal in leg length)

Neurological damage

3. severe persistent pain

Chronic condition

3 conditions

Bone involvement

Soft tissue

Nerve compression/irritation

Focus on the origin of the pain to understand the limping

4. swelling

Tumour, infection(primary cause)

Or could just be a symptom of an underlying condition

5. sinus discharge in the right thigh.

Various factors

Infection

trauma

underlying medical condition

Sinus tract, abnormal channel from the deep skin to the surface (

yellow-greenish discharge, bacterial infection with foul odour, suggest anaerobic infection

chronic inflammatory causes (persistent and chronic pain)

Sinus is the channel, pus is the fluid

# data[].attributes.body
1. Limping - Difficulty in walking