A 63 yrs old male with bilateral knee pains since 2 yrs and lower back pain since 1 year.

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 centered online learning portfolio and your valuable comments on comment box is welcome.

I have 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 diagnosis and treatment plan.
B.Pavithra (intern)
Roll no:9
Presenting complaints:
1.Bilateral knee pains since 2 years
2.Lower back pain since 1 year
HOPI:
Patient is apparently asymptomatic 2 years ago and then he developed bilateral knee pains which are insidious in onset gradually progressive,dull aching type of pain aggrevates on walking he is not able stand up from sitting position,walking with the knees flexed and with help of a stick.Pain is associated with early morning stiffness.
Patient complaints of dragging type of pain in hamstring muscles and calf muscles while walking since 1 yr
No c/o any other joint pains.
C/o lower back ache and right flank pain which is insidious in onset gradually progressive,dragging type of pain,non radiating with no aggrevating and relieving factors.
C/o sob on walking since 1 week
H/o buring micturation on and off since 1 yr,
H/o nocturia(3 to 4 times) and terminal dribbling of urine on and off since 1 yr.
No h/o hematuria ,decreased or incresed urine output
No h/o cough,chest pain and palpitaions.
No h/o fever,headache,nausea and vomiting.

Past history:
C/o loin pain 3 years ago daignosed with kidney stones and treated with medication and got cured
N/k/c/o dm,htn,tb,asthma,epilepsy,thyroid disorders,cva and cad.
No h/o any surgeries and blood transfusions.

Personal history:
Diet:mixed
Apetite: normal
Sleep:adequate
Bowel:regular
Bladder: burning micturition occasionally.
Addiction: smoker(2 beedis/day)for 20 years stopped since 3 years.
Drinks alcohol occasionally for 35 years.

Family history:not significant
Treatment history: Not significant.

General examination:
Patient  is conscious, coherent, cooperative.
Gait:walking with the stickp with knee flexed.
Vitals:
Bp:140/100
Pr:72bpm
Rr:20 cpm
Temp:afebrile
Spo2:99%
Grbs:110mg/dl
No signs of pallor,icterus, cyanosis,clubbing,generalised lymphadenopathy and bilateral pedal edema.

Examination of knee joint:
On/I: there is swelling around both the knees,
 And there is a flexon deformity of both the knees. No redness.No scars,sinus and discharge.





On/p: no local raise of temperature.Joint line tenderness is present in both the kness. Fluctuation is present in both the kness.
Movements:not able to flex and extend the knees completely.Tenderness is present on movement.
All other joints are normal.
Systemic examination:

Respiratory system:
Shape of the chest is scaphoid.
Moving symetrically with respiration
Trachea is in central.
Bilateral air entry is present 
Normal vesicular breath sounds are heard.

 Cardiovascular system:s1 and s2 heard no murmurs.
P/A:  obese,umbilicus inverted and centrally located.





soft ,non tender and no oraganomegaly
No fluid thrills and shifting dullness 
Normal bowel sounds are heard.

INVESTIGATIONS:
















Comments

Post a Comment

Popular posts from this blog

A 36 Year old male with bilateral upper and lower limb weakness.

Image
  This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.  Date of admission: 21/06/22 CHIEF COMPLAINT:  A male patient aged 36 years came to the opd with chief complaints of Fever since 15 days  Weakness of b/l upper and lower limbs since 3 days  HISTORY OF PRESENT ILLNESS:  Patient came to the casuality with altered sensorium and quadriparesis.  Patient was apparently asymptomatic 15 days back, then he presented with fever which was intermittent and relieved on medication.  Patient had complaints of weakness of b/l upper limb and lower limb with decrease in tone and power since 3 days.  Patient also had developmental delay of milestones in his childhood ( he walked at 6 yea
Read more

A 42 years old female with SOB on exertion and generalised weakness.

Image
July,7 2022  This is an online E log to discuss our patients de-identified health data shared after taking his/her/guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based inputs. This E log book also reflects my patients-centered  online learning portfolio and your valuable inputs on the comment box is welcome. CASE: A 42 yrs old female resident of chityal,hotel worker by occupation came with the cheif complaints of SOB on exertion and generalised weakness since 1 month. HISTORY OF PRESENTING ILLNESS:  Patient was apparently asymptomatic 1 month back and then she noticed SOB on exertion(while doing work) since 1 month and stopped her work 20 days back,ggeneralised weakness since 1 month. No h/o fever,cough ,PND, orthopnea and wheez. SEQUENCE OF EVENTS: 5 years back(in 2017) patient had che
Read more