82 years old female with joint pains

 A 82 year old female house maker who is  resident of Bidar came to OPD with chief complaints of 

Difficulty in walking since 26 days

Pain in the right knee since 26 days

Fever since 6 days 

History of presenting illness:

The patient was apparently asymptomatic for 25 days, starting on May 25th. Early in the morning when she woke up, she was unable to get up from the bed. Slowly with the help of her   family she tried to get up and noticed swelling and redness in her right ankle. The edema was sudden in onset and extended from her knee to her ankle. It was of the pitting type. She was taken to a local government hospital, where the doctor prescribed Diethyl carbamazine citrate tablets( parasitic infection tablet). She took the tablets three times a day and continued using them until June 5th and she got relived from symptoms so she stopped using the medication.

She has localized knee joint pain from past 26 days , which is sudden in onset and gradually progressed. The pain is described as pricking and is aggravated by walking and relieved by rest and medication. The pain is more severe in the morning.And present through out the day .

Since Past 6 days  she has been experiencing a continuous high grade  fever above 102°F with an insidious onset.

The fever is not associated with chills and rigors .

No agggirvating factors and relieved by medication.

Past history:

Know case of Hypertension since 10 years and is using medication telmesartan 

She takes calcium tablets everyday since more than 10 years .

No h/o of diabetes,thyroid disorder,cad,cvd

No similar complaints in the past

Family history:

No similar complaints in the family

Elder son has diabetes since 5 years

Personal history:

Diet:vegetarian

Appetite: normal

Sleep: decreased since 3 years and uses alprazolam benzodiazpam 

Bowel and bladder: regular

No addictions 

Daily routine:

Her daily routine starts at 5 am in the morning when she wakes up. After waking up, she engages in various household activities and chores. This may include tasks such as cleaning, cooking, laundry, and any other necessary tasks to maintain her home.

At 8 am, she takes a break to have a cup of tea. However, during this time, she doesn't have any tiffin or mid-morning snack.

Around 12 pm, she has her main meal of the day, which typically consists of roti (Indian bread) served with curry and accompanied by curd (yogurt). This provides her with the necessary nutrition and energy to sustain her throughout the day.

In the afternoon, she continues with her daily activities and responsibilities. If she feels the need for a refreshment, she may have another cup of tea at around 5 pm.

At 9 pm, she has her dinner, which usually consists of roti and curry. This serves as her final meal of the day, providing her with nourishment before she rests for the night.

Before going to sleep at 10 pm, she has a glass of milk. This is a common practice for many people, as milk is believed to have calming and soothing effects that can aid in a good night's sleep.

In addition to her daily tasks, she is an active individual who engages in activities like yoga and gardening. Yoga helps her maintain physical and mental well-being, while gardening allows her to connect with nature and enjoy the outdoors.

Overall, her daily routine involves a combination of household responsibilities, regular meals, breaks for tea, and engaging in activities that contribute to her overall well-being and enjoyment.

After that she was unable to walk and all works were restricted 

General examination:

Patient is conscious coherent cooperative

Moderately built and nourished

Pallor: present

Icterus: absent

Cyanosis: absent

Clubbing: absent

No lymphadenopathy

Pedal edema is present right leg

Vitals:

Temp: 99.2 F

Bp: 110/70 mmHg

PR: 102 bpm

RR: 17 cpm

SpO2: 98% on RA

Systemic examination:

Knee joint examination:

Inspection:

There is swelling in the right knee

No color changes,scars

Skin : normal

Palpation:

Local rise of temperature is present

Tenderness along medical joint line

Tenderness is present along the lateral border of patella 

Rom:painful

Freeflexion deformity:10_20°

Synovial fluid analysis- 

TLC- 16,000 CELLS/cumm

DLC- 100% NEUTROPHILS

RESPIRATORY SYSTEM:

Upper respiratory tract:

Nose is normal

No polyp,DNS,pharyngeal congestion

Trachea appears to be central 

Lower respiratory tract:

INSPECTION:

Chest is symmetrical

Movements of chest - symmetrical

Trachea appears to be central

No drooping of shoulders, intercostal fullness or retraction,crowding of ribs,winging of scapula

No visible sinuses,scars,dilated veins

PALPATION:

No local rise in temperature and no tenderness

All inspectory findings are confirmed.

Expansion of chest is bilaterally equal 

Trachea is central in position

Apex beat is felt in left 5th ICS half inch medial to mid claviclular line.

TVF-vibrations increased in right mammary,inframammary regions

PERCUSSION:

Direct-Resonant

Indirect- resonant

AUSCULTATION:

Breath sounds: normal 

Cardiovascular system:

On inspection chest appears to be normal

With no scars sinuses and dilated veins 

On palpation 

Apical impulse present

On ascultation

S1,s2 are heard 

Per abdomen examination:

On Inspection

Shape of abdomen :-flat 

Umbilicus is inverted.

No scars , engorged veins.

All parts of abdomen are moving equally with respiration 

On palpation:- all inspectory findings are confirmed.

abdomen is soft, non tender 

On percussion:- no shifting dullness and no fluid thrills.

On auscultation:- normal bowel sounds are heard

CNS:

HIGHER MENTAL FUNCTIONS:

Normal

Memory intact

 Orientation  normal 

Speech normal

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

Provisional diagnosis:

Anaemia under evaluation

Synovitis