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This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the 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.
A 48 year old male, Resident of Cooch Bihar, Came to the hospital on 11th of April,2022 with the cheif compliants of
Left knee pain since 2 years
Right knee pain since 2 years
History of presenting illness:
Patient was apparently asymptomatic 2years back then he developed Left knee pain since 2years which is insidious in onset, gradually progressive,aggravated on standing and walking.
Pain is associated with Restriction of movements
Past history
Similar complaints of left knee pain associated with tingling and numbness of upper limb and lower limb with deep pain, crepitations were present for which he got admitted on 17th July, 2021
Arthroscopic partial menisectomy was done on 26th July, 2022.
On Examination of Left knee:
ROM 0-110°
Valgus stress test POSITIVE
Medial joint line tenderness PRESENT
ADT NEGATIVE
PDT NEGATIVE
Similar complaints of backache was present 7years ago for which he took local medication and got cured
k/c/o asthma since 17years
K/c/o Diabetes (but not on medication)
Not a k/c/o HTN,Tb
ARTHROSCOPIC FINDINGS :(24th July,2021)
Chondrocalcinosis observed on arthroscopy
-Denuded cartilage observed over medial femoral condyle and tibia(medial side)
-Central part of menisci eroded
-Multiple micro fractures done over medial femoral condyle to promote cartilage growth
Family history
Not significant
Personal history
Diet -mixed
Appetite -normal
Bowel and bladder regular
Sleep -adequate
No addictions
General examination
Patient is conscious, coherent, co operative
Oriented to time, place and person
Moderately built well nourished
Temperature afebrile
Bp 120/90mm hg
Pulse rate 68bpm
Respiratory rate 16cpm
LOCAL EXAMINATION OF LEFT KNEE :
Tenderness present over medial aspect of knee joint
No swelling
Distal pulses - felt
Valgus stress test - Negative
Varus stress test -Negative
Mc Murray test - Positive
CVS
S1 S2 heard
No murmurs
Respiratory examination
Normal VBS
BAE present
Per abdomen
Soft, non tender in all quadrants
No guarding, No rigidity
Bowel sounds present
Central Nervous System
No abnormality detected
INVESTIGATIONS:
Complete blood picture
Haemoglobin - 14.1gm/dL
Total count -7,900
N/L/E/M/B - 63/27/03/07/00
CUE
Colour -Pale yellow
Reaction-Acidic
Specific gravity - 1.010
Albumin -Nil
Sugars -
Pus cells -2-4
Liver function test
Total bilirubin-1.98mg/dL
Direct bilirubin-0.80mg/dL
SGOT -53IU/L
SGPT -66IU/L
Alkaline phosphatase -153 IU/L
Total proteins-7.8gm/dL
Albumin-3.4
A/G ration - 1.0
Renal function test
Urea -27mg/dL
Creatinine-1mg/dL
Uric acid - 7mg/dL
Calcium -9.3 mg/dL
Phosphorus- 5.9 mg/dL
Sodium -140 mEq/L
Potassium-140mEq/L
Chloride - 98 mEq/L
Blood sugar -Random
198mg/dL
Blood grouping and RH type
A POSITIVE
BLEEDING TIME 2min 00sec
CLOTTING TIME 5mij 00sec
PT
15sec
APTT
30sec
INR -1.11
DIAGNOSIS:
?Monoarticular non inflammatory arthritis
?Osteoarthritis
?Degenerative Joint disease of Left knee with mild synovitis
