A case of 75 yr old male with B/L osteoarthritis

 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. 


A 75 yr old male resident of suryapet came with

CHEIF COMPLAINTS 

Bilateral knee joint pains since 1yr

History of presenting illness 

Patient was apparently asymptomatic 2 yrs back then he developed knee pain for which he went to a local hospital where they given medication for pain , pain relives on medication temporarily
pain in  both knee joints which is insidious onset and gradually progressive and pricking in nature which aggravates on walking and climbing stairs and relieved by rest. Pain is not associated with fever. 

No H/O sob , cough, cold. 

Daily routine

Wakes up at 5am 

breakfast - 7:00

11am - lunch

4.00pm- tea

8pm - dinner 

9pm - sleep 





Past history 

Not a k/c/o hypertension, dm, Tb , epilepsy, asthma

Surgical history - 

undergone appendicitis 4 yr back and 

right eye cataract surgery 1yr back.

Personal history

He used to work in farm for 40 years, but stopped working from past 2yrs due to knee pain . 

Diet - mixed

Appetite - normal

Sleep - adequate

Bowel and bladder - normal

Addictions - Drinks  toddy occasionally 


Family history

No similar complaints in the family

GENERAL PHYSICAL EXAMINATION

Patient is conscious, coherent and cooperative 
Well built and moderately nourished. 


Pallor :- Absent 

Clubbing: Absent 

Icterus :- Absent 

Cyanosis :- Absent 

Lymphadenopathy :-Absent

Pedal Edema :-Absent 


VITALS:.

Temperature :- Afebrile

Respiratory Rate :- 24 cycles per minute.

Pulse Rate :-74 beats per minute 
       
Blood pressure :-  100/80 mmHg taken from Left arm ,measured in sitting position.
.
SYSTEMIC EXAMINATION 

The patient was examined in a well lit room after taking a valid informed consent after adequate exposure.

Cardio vascular system

S1S2+

RESPIRATORY SYSTEM:

BAE+

PER ABDOMINAL EXAMINATION :- 

Soft and no tenderness.

NO HEPATOSPLENOMEGALY

CENTRAL NERVOUS SYSTEM 

Higher mental functions are normal 

Sensory and motor examinations are normal

No signs of meningeal irritation.

.
Local Examination

Inspection - 

swelling on both knee , 
No scars , 

Palpation - 

No local rise in temperature 

tenderness present in both ( right more than left) 

crepitus is felt upon moving the knee joint. 

Movement - 

Flexion  
right - 0-120
Left  - 0-120

Extention
right - 0
Left - 0 












Investigation 











Provisional diagnosis 

B/L knee joint primary osteoarthritis  

Treatment 

T. Ultracet 
T.MVT




































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