60 YR OLD FEMALE WITH RT KNEE PAINS

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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.

 Case taken by R.Akhil Chowdary, P.Manogna 

A 60 yr old female resident of Narketpalli , agriculture labourer by occupation came to with 

Chief complaints:

Pain during walking since 3 years. 

HOPI: 

Patient was apparently asymptomatic 3 yrs back then she develop pain in right knee which was insidious in onset gradually progressive ,pricking type of pain , non radiating, aggravated on climbing stairs, relieved after taking ayurvedic medication and resting for short time  which she is taking from 2 yrs as suggested by her neighbours in Nalgonda and then reappears and unable to walk to properly due to her pain and due to which she stopped go to work but she managed to maintain her daily chores and work like cleaning washing utensils etc. She also had complaint of walking with limp 

H/o  early morning stiffness since 2 yrs. Duration of stiffness was less than 1 hr and disappeared slowly after starting her activities. 

No h/o Other large joint involvements like hip,elbow,shoulder joints.

No h/o trauma.

DAILY ROUTINE:

She wakes up at 5 am then she does her daily routine and household hold work( preparing breakfast and washing utensils,cleaning house and after having her breakfast at 8 am , she will go to field for agriculture work ( Naru poyadam) and works there upto 1 pm and there have her lunch at the field at that time and start working just after the lunch at 1:30 pm and works upto 5:30 pm and then have her house hold work and preparing dinner and have her dinner at 8:30 pm and then goes for sleep at 9 pm. 

After getting the right knee pain she stopped going to her work and just handling the daily house hold work. 

PAST HISTORY:

HTN since 2 yrs on medication ? 

No h/o Dm, asthma,Tb,epilepsy,Cad,thyroid abnormalities.

No h/o surgeries in past. 

No h/o similar complaints in the past.

FAMILY HISTORY :

No relevant family history 

TREATMENT HISTORY:

On ayurvedic medication for knee pain since 2 yrs 

On medication ? For Htn since 2 yrs

PERSONAL HISTORY:

Diet:Mixed 

Appetite: Normal 

Sleep: Adequate

B&b : Regular 

No h/o any addictions. 

GENERAL EXAMINATION:

Patient was Conscious coherent co operative mod built mod nourished 

No signs of pallor, icterus,cyanosis, clubbing, lymphadenopathy,pedal edema.

Vitals: 

Temp: afebrile 

RR: 18 cpm 

Bp: 130/90

Pulse : 78 bpm 

LOCAL EXAMINATION:

Inspection: 

Slight Swellings seen around medial and lateral end of Rt knee.

No bruising or discolouration seen

No redness.

Palpation: 

No local rise of Temperature.

Joint line Tenderness present on Medial ,Anterior,lateral aspects of knee.

Range of movement reduced 

Fluctuation test positive 

Patellar tap seen.

SYSTEMIC EXAMINATION: 

Cvs: S1s2 heard no murmurs.

Respiratory: B/L air entry present , NVBS heard 

Abdomen: Soft non tender, no organomegally 

CNS: No focal neurological deficits 

PROVISIONAL DIAGNOSIS:

This is a case involving Large joint knee , it is a degenerative conditions probably Osteoarthritis?