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Date posted: April 29, 2012

Dr Sreekumar A

Female 48 yrs came to our OPD on 23/5/05 with severe pain along her right lower limb.She could walk only with support.

Prescribed Bell 30 4 doses and was admitted in female ward Bed No : 62.
The Case was taken in detail and recorded as follows.

Presenting Complaints 
Pain Rt Hip
Stitching,burning.
Extending to Rt UL,LL.
< Walking,lying on sides.
> Lying on back.
Pain b/l Breast with heavy feeling.
Pain Chest.
Low abd. Pain.

History of presenting complaints
C/started as pain along Rt Lower Limb 1 month back.Later pain settled over Rt Hip.

History of past illness
R/c Mastitis more in Lt. since puberty.
Surgically treated 20 yrs back.

DUB
Hysterectomy done 2 years back.

Treatment History
Took Allopathic medicines,traction,and used lumbar corset.
FNAC showed features of Tr.Bursitis.
Surgery was adviced.

Family History
Father died 25 yrs back.Suffered from Ca.Stomach.
Mother is Hypertensive.
Patient has three children

First daughter – R/c Sinusitis
Second daughter – Renal Complaints
Third son – Nothing relevant.

Personal History
Born and brought up at Parapanangadi.
Muslim.
Studied upto Third Standard.
Married 26 yrs back.

Generals
Appetite : Satisfactory
Thirst : Good
Bowels : Regular
Urine : Normal
Sweat : Very Profuse and Offensive more in axilla
Sleep : Diminished
Prefers lying on sides.
Prefers Covering even in Summer.
Tendency to Suppuration.
Gets exhausted easily.
Menses – Hysterectomy done 2 yrs back
Menses was regular,profuse, with clots
Dysmenorhoea
With nausea,aversion to food.

Particulars
R/c acute Headache Rt sided
Impaired vision since 5 years
Teeth – Caries
R/c Dysuria

Examination
Physical Examination
General Survey- Conscious,alert,co-operative,supine,moderately built and nourished.No Pallor,cyanosis,icterus or clubbing.No lymphadenopathy.

PR 66/mt,rhythm and volume normal.
RR 24/mt,normal rhythm.
Temp 980F.
BP 120/80 mm Hg.
Height  5’5”.
Weight 60kg.

Local Examination
Inspection– Normal bone contours,Pelvis tilted up on Lt.Colour and texture normal,No Scars or sinuses.
Palpation – Skin temp ?,Normal bone and soft tissue contours.Local Tenderness +
Movements- All movements are painful esp. abduction.
Measurements – No discrepancy in limb length.

Systemic Examination
CVS –NAD
RS – NAD
G.I.System – NAD
Nervous System – NAD
Genito Urinary System – NAD

Provisional Diagnosis : ? TROCHANTERIC BURSTITIS
Investigations
23/4/05
Blood
TC9800,N58,L38,E04
Hb 12.5gm%,ESR 35
RBS 106mg/dl
X-Ray – Pelvis,Hip,LS Spine – NAD
USG – NAD
FNAC – Trochanteric Bursitis

Clinical Diagnosis :Trochanteric Bursitis : Why?
Painful Gait
Local Tenderness
Painful abduction
FNAC confirms

Evaluation of Symptoms
Following symptoms were taken for Evaluation –

Pain Rt. LL < Walking,Lying on sides
Pain Rt. Hip
Breast abscess
Increased,offensive perspiration
Desires covering
Aversion fanning
Tendency to suppuration
Gets exhausted easily
Dysmenorrhoea
Sleep – disturbed easily

Repertorisation
Complete Repertory.

Rubrics selected were –
Gen/Covers/Amel/and Desire for
Gen/Wounds/Heal/Slow
Combined Rubric – Profuse offensive sweat
Gen/Inflammation/Bursa of/Bursitis.

Medicine Selected
Hepar,Puls and Silicea covered all the four rubrics.

Silicea  was selected.
0/3 was given inorder to repeat frequently.
Follow up
24/5 – Silicea 0/3 1D
Pain < ,with mental well being and good sleep
27/5 – Silicea 0/3 1D
Pain lower and upper limbs >
30/5 – Silicea 0/3 2D
Gen>. Pain Hip persisting
1/6 – Silicea 0/6 2D
Gen>, Can walk easily
C/o Low abd pain
Blood TC 6,000 N 54%,L 46%,ESR 15
Hb 12.1 gm%RBS 94,Uric Acid 7.2
Urine Pus 3-5,EPI 2-4.

Trochanteric Bursitis.
Is the inflammation of the Bursae of Gluteus Medius muscle.

Anatomy
Bursae are synovial lined sacs over bony prominences.
Fibres of Gluteus Medius converge into a flattened tendon and gets inserted to lateral surface of greater trochanter.
Trochanteric Bursae separates this tendon from the anterosuperior area of lateral surface of the trochanter over which it glides.

Etiology
Trochanteric Bursitis follow mechanical trauma – single or repeated injuries.
Infections – eg. TB.

Pathogenesis
Psora

Mild inflammatory reaction in the wall of bursae.
Effusion of clear fluid within the sac.

Sycosis
Bursal wall gets infiltrated by lymphocytes, plasma cells, macrophages and may show focal calcium deposits.

Syphilis
If the inflammation become chronic abscess formation takes place within the walls of bursae.This may burst through the skin to form sinus.
Later the surface of the greater trochanter gets eroded.
Even collapse of head of Femur can occur.

Clinical Presentation
Pain over the lateral aspect of  Hip and Thigh.
Local  tenderness.
Crepitus on flexing and extending Hip.

Investigation
Routine blood examination
Raised ESR.

X-ray
May show evidence of previous fractures, protruding metal implant.
Calcification or shadows suggesting soft tissue swelling.
FNAC

Differential Diagnosis
Stress fractures in athlets,elderly.
Slipped epiphysis in adolescents.
Bone infection.
Gout.
RA.
Infections like TB should be ruled out.

Management 
Medicinal management.
Rest is very important.

Therapeutics

  • Pulsatilla – Smarting, itching, relieved by cold.
  • Silicea – Chronic bursitis; pain as if sticking or itching.
  • Sticta – Very efficacious in bursitis; with swelling and darting pains.
  • Sulphur – Inflamed bursa, with a feeling of formication.

Herings Guiding Symptoms : Bry
Lower Limbs.  Inflammation of psoas muscles.  Pains  in  right trochanteric and gluteal region, of  an  aching, cramplike and  bruised kind; (>) at every motion.

A Cyclopedia of Drug pathogenesy vol.1 by Hughes R
Aching,  cramp-like, and bruised pains in right trochanteric  and gluteal  region, worse at every motion; stools dry, large,  hard, and  very dark.

Ruta  graveolens
A manual of Homoeopathic therapeutics by Neatby E
Pathogenesis – RUTA  is a drug with a limited but well-defined sphere.   It appears to affect both injuriously and curatively the fibrous and bony  tissues,  especially  in the  vicinity  of  joints.   Taken experimentally,  it causes distress of pain such as would  result from traumatism or over-exertion of the part affected, or of  the body as a whole.
Chronic  synovitis  and  bursitis  are   often benefited  by rue,even when given by routine, as  in  housemaid’s knee,”  or in ganglion about the wrist tendons

Repertory
CompleteRepertory/Generalities/Infla-mmation/Bursae of/Bursitis – 6
3 Silicea.
2 Bellis ,Lycopersicum ,Sticta ,Sulphur.
1 Anti.crud,Apis,Graph,Hep,Iod,Puls.

CompleteRepertory/Extremity Pain/Lower Limb/Hips/Trochanteric major/Right – Cicuta 1.

CompleteRepertory/Extremity Pain/Lower Limb/Thigh/Trochanter -Asterias,Verat-vir.

Allen’s Rep/Hip;Trochanter major, region of; Trochanter, under, pain, right - Arum Trip

Dr.Sreekumar.A.
Email : hmctirur@gmail.com

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