32 Y/M with right knee pain

This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

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 a diagnosis and treatment plan.

32 yr old male patient came to the casulaty with the cheif complaint of right  knee pain since 1 month 

History of present illnesses:

Patient had h/o trauma 2 months back with Metatarsophalangeal joint pain for which he sustained k wire insitu on right first toe region 

Patient had normal routine after implant with no difficulty later after a month he had pain in his right knee region

Pain is insiduous in onset , gradually progressive , aggravated on movement associated with diffuse swelling of knee joint

History of past illnesses:

Patient is not a known case of diabetes, Astama, tuberculosis , hypertension , epilepsy

Personal history : 

Married

Occupation: Village sarpanch

Appetite:normal 

Diet:mixed 

Bowel and bladder:regular

No known allergies

Alcohol history

-intake of whisky twice a week

-180ml

FAMILY HISTORY 

Not significant 

PHYSICAL EXAMINATION:

No pallor,icterus,cyanosis,clubbing, lymphedenopathy

Oedema of feet - present  

Temperature:98F

PR:78 bpm

BP:120/90mmhg

RR:22cpm

Spo2:99%

On examination :

Skin - normal 

Swelling - present 

Patellar tap - present

Local rise in temperature - present

No neurological defects

Distal pulses - present 

USG - right knee 

Mild knee joint effusion noted 

E/O small Baker's cyst measuring 1.7×1.2cm with septations - likely superadded infection 

No supra patellar or prepatellar bursa 

Impression- small Baker's cyst with super added infection 

Mild knee joint effusion

Systemic observation- 

CVS :

No murmur 

No thrills 

S1 and S2 heart sounds heard

Rhythm - normal 

Volume - normal 

CNS:

- patient is conscious

- speech is present

- reflexes are normal

Respiratory :BAE+ , NCBS heard 

Per abdomen : soft , not tender 

Provisional diagnosis :

Infection bursitis of knee 

Investigations :

Day -1 

Bp : 130 / 90 mmhg 

PR: 78 bpm 

Temperature : afebrile 

T Hifenac-P - po bd 

T PAN 40 - po od 

Day -2 

Bp : 120/80 mmHg 

PR : 78 bpm 

Temperature : afebrile

T Hifenac-P - po bd 

T PAN 40 - po od 

T febuxostat 80 - po bd 

T Goutil 0.25 mg - po od