Case Write Up Mark Sheet

Students name LEE CHUN SIAN

ID 1001335441
Year and Batch Year 4, Batch 2013/2018
Rotation 9
Group 3
Date 14th June 2017

No Contents Words Full Marks

1,500 marks awarded
+/_10%
1 A complete history 1
2 Full physical examination with detail of the local 1
problem
3 A list of problem faced by the patient and provisional 500 1
diagnosis
4 A summary of the history and physical examination to 1
support your provisional diagnosis
5 Differential diagnoses with discussion of points for and 1
against
6 Investigations you would ask for the patient with 1
reasons and expected results or findings and possible 500
complications
7 Principles of treatment and solution to patients 1
problem
8 Final discussion from literature search with correlation 3
to the patient problem and also related basic sciences. 500
The material should come from reference books and
medical journals
Total 1,500 10

Signature:
Assessor:
Date:
 History taking
Patient personal profile
Name: Hakimi Aminih Bin Mohd Fanazi
Age: 19 years old
Gender: Male
Race: Malay
Religion: Islam
Place of residence: Gombadak
Occupation: Professional football player
Marital status: Single
Registration Number: 980603115509
Date of Admission: 12th June 2017
Date of Clerking: 13th June 2017

Chief Complaint
Left knee joint pain due to sport injury for 3 months

History of Present Illness

He was well until 3 months ago, he had sudden onset of pain at his left knee when playing
football at about 6.30 p.m. He was running very fast chasing the football and suddenly his left
leg accidentally twisted outwards and he fell down due to pain and instability. The pain was
continuous and was throbbing in nature. It did not radiate to any part of the body. It was
exacerbated by left lower limb movement especially when he fully flexed his left knee. The pain
was not relieved by any mean but the pain killers prescribed by doctor in HSNZ later on. The
pain score was 6 out of 10. He was able to ambulate with the help of his friends. The pain did not
subside on the next day. He went to the emergency department in HSNZ. He was prescribed pain
killers and scheduled for physiotherapy for the following 3 months. He came to seek medical
attention in Hospital Kemaman as the pain did not fully subside. The pain score was maintained
at 2 out of 10 upon arrival to Hospital Kemaman.
During the injury, he was conscious all the time. He did not have bleeding, swelling of the left
knee joint, bruises and deformed joint.
Systemic review
There were no relevant symptoms and signs in cardiovascular, respiratory, gastrointestinal,
genitourinary and neurological system.

Past Medical & Surgical History

This is the first admission of the patient to orthopaedic ward. He has no underlying medical
illness. He has not had any surgical procedure previously. He has not been involved in any motor
vehicle accident before.

Drug history
He took pain killer (unidentified) from the doctor in HSNZ for his left knee joint pain for 3
months. He took it only when there was pain. Otherwise he did not take any other medicine. He
has no known drug allergy.

Family history
His father was 51 years old who is a freelancer. His mother was 38 years old who works as a
clerk in a police station. He is the 1st of 3 siblings in the family. They are all healthy.

Personal and Social history

The patient is a professional football player. He does not smoke and take alcohol. He is not a
drug abuser. His financial status is adequate.

Physical Examination
General survey
The patient was alert, conscious, cooperative, well-orientated to time, space and person. He was
moderately built and his nutrition and hydration status seemed to be fair. He was not having any
respiratory distress nor in pain.

Vital signs
Blood pressure: 119/71 mmHg
Pulse rate: 64 beats per min with regular and synchronized rhythm and normal volume
Respiratory rate: 16 breaths per min
Temperature: 37 degree Celsius
The patient is haemodynamically stable.

General Examination
Head and neck
There were no conjunctiva pallor and jaundice. There was no palpable cervical lymph node. He
had adequate oral hygiene and the tongue was moist.

Upper limbs
Both his hands were warm and pink. There were no pallor and finger clubbing. Capillary refill
time was less than 2 seconds.

Lower limbs
There was no pedal edema.

Local Examination (Knee Examination)

Upon inspection during stance and walking, the patient did not have any deformities such as
genu valgum, genu varum, hyperextended knee and fixed flexion deformity. For gait, the patient
has fully extended knee. There were no lateral or medial thrust. The knees moved freely when
walking.
Upon inspection during sitting, the knees had normal shape and were symmetrical. When flexed,
the patellas faced forwards. There were no patella alta and patella baja when extended. The Q
angle was about 15 degree.
When supine, on inspection, there were no scar, sinus, swelling, lumps, bruises and skin changes
on anterior, lateral and medial surface of the left and right knees. There was also no quadriceps
wasting of both the thigh. There was no sagging of both the legs. On palpation, the temperature
was equal on both sides. The maximal tenderness was felt at the anteromedial joint line of the
left knee. Otherwise, there was no tenderness on the contralateral knee. There were no tenderness
of anterior, medial, lateral and posterior surfaces of the patella bilaterally. The friction test were
negative on both the knees. The apprehension test were negative on both the knees. Patellar cross
fluctuation, tap and bulge test were all negative bilaterally. There were no synovial thickening on
both the knees. On varus stretch test, there was no tenderness in fully extended knee and 30-
degree flexed on both the knees. On valgus stretch test, there was no tenderness in fully extended
knee and 30-degree flexed on both the knees. The anterior drawer test was positive on the left
knee and was negative on the right knee. For both the knees, the posterior drawer test was
negative. The Lachman test was positive on the left knee. The pivot and reverse pivot shift test
were negative bilaterally. The McMurray test was negative for the lateral and medial sides of
both of the knees.
When prone, on inspection, there were no scar, sinus, swelling, lumps, bruises and skin changes
on the popliteal fossa of both the knees. The Apley grind test and Apley distraction test were
negative on both sides.
The patient had a fair neurovascular status. For motor component of the lower limbs, he had full
range of movement and power of grade 5 of the knee, ankle, metatarsophalangeal and
interphalangeal joints bilaterally. For sensory component, he had normal sensation of touch,
pain, vibration and proprioception. For vascular component, he had palpable pulses of popliteal
arteries, dorsalis pedis arteries and posterior tibial arteries bilaterally.

Systemic examination
Cardiovascular examination
On examination of the cardiovascular system, apex beat was palpated with no displacement.
There were no tapping, thrills or heaving. On auscultation, normal first and second heart sounds
were audible with normal intensity. No murmur or added sounds were heard.

Respiratory examination
The chest is symmetrical without deformity and surgical scars. Anteroposterior diameter of the
chest was normal. The chest expanded symmetrically on both sides while breathing. Cricosternal
distance is three-fingered wide. There is no tracheal deviation. Tactile fremitus is normal and
equal on both sides of the lungs. Percussive notes are resonant at the whole lung field. Vesicular
sound and normal vocal resonance is heard all over the lung field.

Gastrointestinal examination
The abdomen is not distended, soft and non-tender. Visible pulsation and dilated veins were not
seen. There is no hepatosplenomegaly. The kidney is not ballotable. Renal punch test is negative.
There is no shifting dullness. Bowel sounds are normal. No bruits were heard.
 Case Summary
Hakimi, a 19 years old Malay professional football player, with no underlying medical illness
was admitted 2 weeks ago with chief complaint of left knee joint pain due to sport injury for 3
months.
Physical examination reveals tenderness over the anteromedial joint line of the left knee with
positive anterior drawer test and positive Lachman test.

Provisional Diagnosis
Left anterior cruciate ligament tear due to sport injury

Points for:
- Sudden onset of left knee joint pain following outward twisting action of leg.
- Sport injury
- Tenderness over the anteromedial joint line of left knee
- Positive anterior drawer test on left leg
- Positive Lachman test on left leg

Differential Diagnoses
1. Left medial meniscus tear
Points for:
- Sudden onset of left knee joint pain following outward twisting action of leg.
- Sport injury
- Tenderness over the anteromedial joint line of left knee

Points against:
- Negative Mcmurray test on left medial meniscus
- Negative Apley grind test on the left leg
- No swelling of the left knee joint, bruises and deformed joint.

2. Dislocation of left knee

Points for:
- Sudden onset of left knee joint pain following outward twisting action of leg.
 Points against:
- No deformed joint
- No swelling of the left knee joint

Investigation
Laboratory Investigation
1. Full blood count
To rule out infection through interpretation of white blood cells count
baseline study for preoperative assessment

2. ESR
markers of ongoing infection

3. CRP
markers of ongoing infection

4. Blood urea and serum electrolyte

baseline investigation for preoperative assessment

5. Coagulation profile
baseline investigation for preoperative assessment

Imaging Investigation
1. X-ray of the left knee joint at anteroposterior and lateral view
To check for clues of traumatic injury, fractures, joint dislocation or any skeletal
pathologies.
* The patient himself sought medical attention in Hospital Kemaman. He did not do X ray in
Kemaman when admitted as he was scheduled for diagnostic and therapeutic arthroscopy.

2. MRI of the left knee joint

MRI is best in investigating soft tissues.
To assess the extent of injury of anterior cruciate ligament
To rule out medial and lateral meniscus injury
To rule out other ligament injuries such as lateral and medial collateral ligament
Invasive Investigation
1. Diagnostic arthroscopy
Allow direct view of knee joint internal structures hence definitive diagnosis
Able to perform repair after definitive diagnosis.

Management
Provisional management
1. Bed rest
2. Avoidance of sport
3. Analgesic agent

Definitive management
Therapeutic arthroscopy under general anesthesia

Discussion
The cruciate ligaments provide both anteroposterior and rotary stability; they also help to resist
excessive valgus and varus angulation. Both cruciate ligaments have a double bundle structure
and some fibres of each bundle are taut in all positions of the knee. The anterior cruciate has
anteromedial and posterolateral bundles, whereas the posterior cruciate has anterolateral and
posteromedial bundles. Anterior displacement of the tibia (as in the anterior drawer test) is
resisted by the anteromedial bundle of the anterior cruciate ligament (ACL) whilst the
posterolateral part tightens as the knee extends. Posterior displacement is prevented by the
posterior cruciate ligament (PCL), specifically by the anterolateral bundle when the knee is in
near 90 degree flexion and by the posteromedial bundle when the knee is straight.

Most ligament injuries occur while the knee is bent. The damaging force may be a straight thrust
or, more commonly, a combined rotation and thrust as in a football tackle. The medial structures
are most often affected but if the injury involves a twist in addition to a valgus force, the ACL
also may be damaged. This twisting force in a weightbearing knee often tears the medial
meniscus, causing the well-recognized triad of MCL, ACL and medial meniscal injury. As with
medial injuries, the cruciate ligaments are at risk if there is a twisting component, and a clinically
detectable opening on varus stressing in an extended knee suggests that there is, in addition to a
rupture of the LCL, capsular and cruciate damage. Cruciate ligament injuries occur in isolation
or in combination with damage to other structures. The ACL is the more commonly affected.
Solitary cruciate ligament injuries result in instability in the sagittal plane. If there is
accompanying damage to a collateral ligament or the capsule, then the direction of instability is
often oblique and there may be a problem in controlling rotation.

If the knee with a partial ligament tear is not actively exercised, torn fibres stick to intact fibres
and to bone. Physiotherapy will resolve the problem. In addition, Ossification in the ligament
(PellegriniStiedas disease) will occur near the upper attachment of the medial ligament
following abduction injury. Sometimes, there is instability of the knee. It tends to get worse and
the repeated injury predisposes to osteoarthritis.