45/F with b/l knee pains

 NAME: Meghana.M

Roll no: 95

Batch: 2017

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A 45 year old female who is a daily wage labor by occupation

Came with the complaints of both leg pains since 1 year 

HOPI:

Patient was apparently a symptomatic one-year back then she developed bilateral lower limb pains, 

dragging type of pain insidious in onset gradually progressive radiating from hip to foot, accompanied with tingling sensation while walking since one year 

Bilateral knee pain, with crepitus dragging type of pain, non radiating insidious in Onset associated with morning stiffness no complaints of burning micturition urinary urgency or hesitancy history of usage of NSAIDs.

PAST HISTORY:

Not a known case of hypertension diabetes, thyroid disorders, CAD epilepsy 

PERSONAL HISTORY:

Married, daily wage laborer by occupation

diet mixed

 Appetite lost since 10 days.

Bowels regular difficulty in passing stools hard stools.

Bladder: normal

No known allergies.

Toddy drinker one glass per day 

Betel leaf chewing 4-5 per day.

MENSTRUAL HISTORY:

Age at menarche 11 years 

Menstrual cycle 3/ 30

LMP one year ago

Age at marriage 13 years 

Age at first childbirth 13 years 

FAMILY HISTORY:

Not significant

General examination.

Patient is conscious coherent, cooperative.

No pallor, icterus, cyanosis clubbing lymphadenopathy or edema of foot

Temperature afebrile.

Pulse rate 92 bpm.

Respiratory rate 16 cycles per minute

BP 130:80 mm hg 

GRBS 133 mg%

Systemic examination.

CVS S1S2 heard

RS bilateral air entry present, NVBS 

CNS: 

She is conscious, coherent, cooperative

GCS E4V5M6. 

Motor power:.    UL.         LL

   R                      5/5         5/5

   L                      5/5         5/5

Tone normal in all 4 limbs.

Reflexes:.     

           B     T     S     A    K     P

    R.   2+   2+   2+  2+   2+   Extensor

    L.   2+   2+   2+  2+   2+   Mute

 Cerebellar signs:

Finger nose in coordination: yes 

Knee heel in coordination: yes

Provisional diagnosis: 

?OSTEOARTHRITIS B/L KNEE

? LUMBAR RADICULOPATHY 

?DENOVO HTN

Treatment: 

(1)T. HIFENAC MR PO BO

(2) T. SHELCAL 500 mG y - 0

(3) T. ELIDEL CAMOTRYPTILLINE) 10mg Po/.   od 30 minutes before dinner

(4)T. A -z PO OD

(5)PHYSIOTHERAPY KNGE ROM SSE
     IFT- LOWER BACK

(6)T.TELMA 40mG Po/od