SHRUTHI ARUKONDA 02

GENERAL MEDICINE. 

7 July ,2021. 

Note: This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

   
                CASE SHEET 

This is an OPD  case of a 21 year old female (an animation student) with chief complaints of left shoulder joint pain and pain of the right TMJ.

CHEIF COMPLAINTS: 
  • pain in the left shoulder joint 
  • Pain of the TMJ(temperomandibular joint) 

HISTORY OF PRESENT ILLNESS :

LEFT SHOULDER PAIN:
  • Site: left shoulder to the left scapula 
  • Time of onset : since past 2 months 
  • Radiation: towards the left side of the neck. 
  • Alleviating factors : looking straight. 
  • Exacerbating factor: while turning towards the right side 
  • Severity: pain is manageable but since past one week but there are sudden episodes of aggravated pain in a day.  

TMJ DISLOCATION:
  • Site: TMJ 
  • no history of trauma 
  • No unilateral chewing habits 
  • No deteriorating habits 
  • No specific pattern of pain 
  • Pain has started an year ago.  Since the past 6 months it has aggregated slightly.  
  • Abnormal postural habits while at work.  
  • Pre auricular pain associated with ipsilateral headache 
  • The pain is experienced over the right side of the face. 
  • When weights are carried with the right hand, pain is observed in the right hand followed by the right jaw on gradual increase of the weights. 

PAST MEDICAL HITORY : 
  • Not a k/c/o diabetes, jaundice, TB, MI, hypertension
  • Has been affected by the COVID virus in the month of June and has taken Ayurvedic medicine and vitamin supplements and also the medicines prescribed by the local clinician after which the symptoms have subsided. 


PERSONAL HISTORY : 
  • Diet : easily chewable soft foods to prevent excess pain of the jaw 
  • Sleep: adequate. But sometimes can’t fall asleep due to the aggravating pain 
  • No known allergies 
  • Addictions: none 


FAMILY HISTORY: 
Nothing specific 


GENERAL EXAMINATION:
  • Patient is conscious, coherent and co-operative 
  • No icterus,pallor, cyanosis, clubbing,koilonychia, generalized lymadenopathy,edema. 
VITALS:  stable 


CLINICAL FEATURES : 

Clicking sound on opening the mouth and lateral movements 
No deviation 


INVESTIGATIONS: 

1. X-ray reports. 






2. Advised to get a right USG TMJ
3. Advised to get a MRI c spine. MRI dl spine 


PROVISIONAL DIAGNOSIS : 

Doctor 1: Internal de-arrangement of right TMJ. 
  • The wisdom tooth appears to be in a slant order which seems to be one of the causative factors for pain,  which can be corrected by wisdom tooth extraction immediately. 


Doctor 2: The wisdom tooth appears to be pressing on a nerve which seems to be the causative factor for the pain. And the extraction of the tooth might be slightly complicated as there’s a risk of the nerve being damaged during the procedure and the patient might lose senses over the right side of the lip. There is no guarantee of the time line (can vary from 6 months -12 months or more) of when the senses might be properly functioning provided they reappear. 
  • Advised to use braces only for the lower jaw. 


TREATMENT: 

For left shoulder joint pain: 
  • Tab. Myoril 4mg twice a day 
  • Tab. Zerodal sp twice a day for 5 days. 

For TMJ dislocation: 
  • Tab. Rutoheal D twice a day for 5 days 
  • Tab. Predmet 8mg twice a day for 5 days 
  • Splints for the upper jaw were advised.  (Which she stopped using after a while as there was no improvement) 
 

PATIENT QUERIES: 

1. Ever since the pain of the right jaw begun, I am unable to sleep on the right side as the pressing of my jaw against the pillow is proving to be really painful. In order to avoid this I have been sleeping on my left side. However , after few days I started observing pain in my left shoulder and hand. How do I manage the sleeping postures?

2. When will my pain of the left shoulder subside ?

3. Will engaging in Physio therapy help subsidising my pain  in any way?

4. Should I go for the tooth extraction or no ? Can it help my condition or will it worsen any more .? What all risk factors am I to consider here ? 


















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