A 82 year old female with pain in right knee

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan


Case taken by Shivang sharma 

 A 82 year old female resident of Bidar came to OPD with chief complaints of 


Difficulty in walking since 25 days


Pain in the right knee since 25 days. 


HOPI -Patient was apparently asymptomatic 1month back on getting up in the early morning she was unable to get up and she noticed a swelling which was sudden in onset extending from knee to ankle she was taken to hospital next day and was prescribed DEC which she used to take till june 4th on june 5th she came to our hospital with complaints of unable to walk and pain in the right knee which was insidious in onset, pricking type of pain,continuous aggravted by walking and relieved by medication and rest.

She has knee localised joint pain .sudden onset gradually progressive pricking type of pain.Pain aggregated by walking relieved by rest and medication.pain is more in the morning

From 16 June she is suffering from fever which is 104° F insidious onset continuous not associated with chills and rigors .fever was relieved by medication.

.10 years ago she had left wrist joint fracture which appears as malunited.


Past history - hypertension since 10 yrs using telma 40 mg 

Calcium tablets everyday since 12 years

No h/o of diabetes,thyroid disorder,cad,


Family history:-

No similar complaints in the family 


Personal history - 

Diet:vegetarian

Appetite: normal

Sleep: decreased since uses alprazolam

Bowel and bladder: regular

No addictions 


General examination:

Patient is conscious coherent cooperative

Moderately built and nourished


Pallor: present

Icterus: absent

Cyanosis: absent

Clubbing: absent

No lymphadenopathy 


Vitals:

Temp: 98.2 F

Bp: 100/60 mmHg

PR: 102 bpm

RR: 18 cpm

SpO2: 98% on RA 


Systemic examination:


RESPIRATORY SYSTEM- 



INSPECTION:

Chest is symmetrical

Movements of chest - symmetrical

Trachea appears to be central

No drooping of shoulders, intercostal fullness or retraction,crowding of ribs,winging of scapula

No visible sinuses,scars,dilated veins

PALPATION:

No local rise in temperature and no tenderness

All inspectory findings are confirmed.

Expansion of chest is equal on both sides in anterior,posterior and apical areas.

Trachea is central in position
 
Apex beat is felt in left 5th ICS half inch medial to mid claviclular line.
 

 PERCUSSION:

Direct-Resonant

Indirect- resonant

AUSCULTATION:

Breath sounds: normal 


Cardiovascular system:

Apical impulse present


S1,s2 are heard 


Per abdomen:



On Inspection

Shape of abdomen :-flat 

Umbilicus is inverted.

No scars , engorged veins.

All parts of abdomen are moving equally with respiration 

On palpation:- all inspectory findings are confirmed.

abdomen is soft, non tender 

On percussion:- no shifting dullness and no fluid thrills.

On auscultation:- normal bowel sounds are heard
CNS:

HIGHER MENTAL FUNCTIONS:

Normal

Memory intact



CRANIAL NERVES :Normal



SENSORY EXAMINATION

Normal sensations felt in all dermatomes



MOTOR EXAMINATION



Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait



REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited



CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited


Knee joint examination:


Inspection:
There is swelling in the right knee
No color changes,scars
Skin : normal

Palpation:
Local rise of temperature is present
Tenderness along medical joint line
Tenderness is present along the lateral border of patella 
Rom:painful

Provisional diagnosis - microcytic hypochromic anemia 
Synovitis




























https://youtube.com/shorts/Q1bsI1HDYTw?feature=share4

Comments

Post a Comment

Popular posts from this blog

2015 neuro cases blog

Done by shivang sharma 2018 batch  1.      https://nairaditya97.blogspot.com/2020/11/40-yr-old-male-with-bl-lower-limb.html?m=1 2. https://agnoormourya.blogspot.com/2021/01/a-70-year-old-patient-with-co-of.html?m=1 3. https://kalyansumanalladi.blogspot.com/2021/01/26-year-old-woman-with-co-seizures.html?m=1 4. https://vamshigoudmamidi.blogspot.com/2021/05/altered-sensorium.html?m=1     5.  https://sruthi995.blogspot.com/2021/04/60-year-old-male-came-with-co.html?m=1 6.  https://rashmipeddapalli.blogspot.com/2021/05/cerebellar-ataxia-acute-cerebellar.html?m=1 7. https://vaish7.blogspot.com/2020/05/stroke-case.html?m=1 8.  https://mekalasiddhu.blogspot.com/2021/03/23-year-old-with-weakness.html?m=1 9. https://yaminimandava4114.blogspot.com/2021/02/45-year-old-male-with-co-seizures.html?m=1 10.  https://supriyareddy2396.blogspot.com/2021/02/this-is-online-e-log-book-to-discuss.html?m=1 11.  https://amulyamamidifml.blogspot.com/2021/02/a-68-year-old-female-came-to-hospital.html?m=1 12. htt
Read more

A 37year old male with lower back ache

Image
  This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan .  Case taken by -- shivang sharma and manogna  CASE REPORT A 37 year old male came with the chief complaint of: Lower back ache since 10months HOPI: Patient is a resident of Coochbehar
Read more

pancytopenia secondary to vitamin B12 deficiency.

Image
27 years old male patient who is preparing for govt. job is also an agriculture worker , came to the opd on 15.9.22  with the complaints of  •fever since 15 days  •generalized weakness since 1 month. HOPI. patient was apparently asymptomatic 1 month back,then he developed generalized weakness and dizziness. He visited some MBBS doctor for the same complaints,was given some medications and was advised to visit a hospital. • h/o fever since 15 days. On and off.  Low grade. Not a/w chills, rigor. No h/o muscle pain. H/o loss of weight of 10 kgs in 6 months  He does agricultural work for 6 hours in a day and then he prepares for govt. job at night. H/o decreased intake of food and inadequate sleep since 1 month. No h/o abdominal problem. No h/o  cold and cough. No h/o   burning micturition. No h/o numbness,tingling sensation • past history. No similar complaints in past. Not a k/c/o TB,asthma,htn,DM,CAD,epilepsy. Personal history: Appetite : less Sleep: inadequate Diet: mixed B/b : regular
Read more