A 82year old female with swelling,fever
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CASE REPORT
P.MANOGNA
2018
A 82 years old female came with the chief complaints of:
Swelling in both lower limbs since 25days
Pain in right knee since 25days
Fever since 10days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 25days 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 associated with redness,she was taken to hospital next day and was prescribed DEC(diethyl carbamazine) which she used to take till june 4th.
Later she came to our hospital with complaints of unable to walk and pain in the both knee joints more in right knee which was insidious in onset, pricking type of pain,continuous,non-radiating aggravted by walking and relieved by medication and rest.
FEVER which was high grade fever,continuous and relieved on medication
Not associated with chills and rigors.
SEQUENCE OF EVENTS:
On 26th may after she had swelling following which she was taken to the govt hospital the next day(27th) and was given DEC which she used till june 4th
her pain was relieved and was able to walk.
On june 5th she came to our hospital with
Swelling and pain which was reduced after medication
On june 16th she had fever which was high grade fever,continuous and relieved on medication
Not associated with chills and rigors
Following which she was admitted in our hospital with the complaints of swelling, pain in right knee for which she is being evaluated.
DAILY ROUTINE:
Before:
She wakes up at 5am, and does yoga and household works, drinks tea at 8Am,at 12pm she has her lunch and dinner at 9pm she takes milk before she sleeps.
She said that as the house is big she used to walk after getting up early in the morning and used to wash face and freshen up,
She used to sit for long hours to cut vegetables and write
After:
Due to the swelling and pain she is now unable to walk and do her yoga or things which she used to do before 25days
PAST HISTORY:
Known case of HTN since 10years and was on TELMESARTAN 40mg since then
Not a known case of DM,Asthma, TB,epilepsy,Thyroid disorders,CAD
She had a fracture in left hand wrist 10years ago
FAMILY HISTORY:
Not significant
PERSONAL HISTORY:
Diet: Vegetarian
Appetite: Adequate
Bowel and Bladder habits : regular
Sleep: Disturbed - due to which she takes ALPRAZOLAM
Addictions: none
GENERAL EXAMINATION:
Patient is conscious,coherent,co-operative and well oriented with time,place and person
Moderately built and nourished.
Pallor- Present
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Lymphadenopathy- Absent
Koilonychia- Absent
VITALS:
Temperature -98.6° F
Blood Pressure -130/70mmHg
Pulse Rate -80bpm
Respiratory Rate -16cpm
LOCAL EXAMINATION:
KNEE JOINT examination :
Inspection:
Swelling at and below the level of knee joint
Skin is normal over the knee joint
No scars,sinuses
Right knee joint- Fixed flexion deformity is seen
Palpation:
Right knee joint:
Local rise of temperature present
Pain on flexion of right knee joint
On palpation their is tenderness over lateral border of patella
Range of movement: limited, unable to perform complete flexion
Patellar tap- present
Left knee joint : normal
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM EXAMINATION:
Inspection:
Trachea-central
Chest appears b/L symmetrical and elliptical in shape
Palpation:
Trachea central in position
Apex beat felt at 5th ICS, 1cm medial to
mid-clavicular line
Tactile vocal Fremitus- normal on both sides
On percussion:resonant note on both the sides
On auscultation: Normal vesicular breath sounds heard
CVS:
Inspection:
There are no chest wall abnormalities
The position of the trachea is central.
Apical impulse is not observed.
There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses.
Palpation:
Apex beat was localised in the 5th intercostal space 1cm medial to the mid clavicular line
Position of trachea was central
There we no parasternal heave , thrills, tender points.
Auscultation:
S1 and S2 were heard
There were no added sounds / murmurs.
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
PER ABDOMEN:
Inspection:
Shape - Scaphoid, with no distention.
Umbilicus - Inverted
Equal symmetrical movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.
Palpation:
No lacal rise of temperature
Inspectory findings are confirmed
No hepatomegaly
Spleen not palpable
Percussion:
Normal liver span
Fluid thrill and shifting dullness absent
puddle sign absent
Auscultation:
Bowel sounds present.
PROVISIONAL DIAGNOSIS:
This is a case involving knee joint- ?inflammatory condition-?synovitis
Known case of HTN since 10years
Anemia(Nutritional- Iron deficiency anemia)
INVESTIGATIONS:
27th May:
5/6/23-7/6/23:
On 16/6/23:
Fever chart:
Chest X-Ray:
17/6/23:
USG B/L Knee:
20/6/23:
FINAL DIAGNOSIS:
This is a case involving knee joint- ?inflammatory condition-?synovitis
Known case of HTN since 10years
Anemia(Nutritional- Iron deficiency anemia)
COURSE IN HOSPITAL:
Ortho referral:
Rt knee aspiration done under aspectic condition, 40 ml of synovial fluid aspirated and dressing done.
Synovial fluid analysis-
TLC- 16,000 CELLS/cumm
DLC- 100% NEUTROPHILS
DIAGNOSIS-
SYNOVITIS OF RIGHT KNEE
Treatment
Tab.AUGUMENTIN 1.2GM IV/BD X 2 DAYS
Tab.ZERODOL SP X 3 DAYS
Tab.PAN 40 MG PO/OD/ BBF X 3 DAYS
SOAP NOTES:
21/06/2023
DOA : 16/06/2023
S :
82 year old female with C/O weakness of lower limb, Neck and shoulder pain since along with pedal oedema and fever since 10 days
O:
Patient is conscious coherent and cooperative
Pallor+
No icterus ,clubbing,cyanosis,lymphadenopathy ,pedal edema
K/c/o of HTN since 10 years(On medication- Telma 40mg)
Vitals :
BP- 130/70mmHg
PR -80bpm
RR-16cpm
Spo2-99% at room air
Temperature -98.6F
CVS: s1,s2 heard ,no Murmurs,
RS:BAE,no added sounds ,NVBS,
P/A: soft, non tender,No organomegaly
CNS:NFND
A:
Pyrexia under evaluation secondary to synovitis of Right knee
Iron deficiency anemia
No fever spikes
Pain in Right knee decreased
B/L pedal Edema increased
P:
1. Inj.NEOMOL 1 gm IV /SOS if Temp greater than 101 F
2.Tab OROFER -xt PO/OD
3.TAB.TELMA -AM(40/5) mg PO/OD
4. Tab DOLO 650mg PO/SOS
5.Tab ULTRACET (1/2) PO/QID
6.Tab.CHYMERAL FORTE PO/TID
7.Tab .SHELCAL -CT PO/OD
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