82yr female with fever and pain in B/L knee joint since 1 day

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Pt presented with complaints of

Fever since 1 day

Pain in left knee joint since 1 day

HISTORY OF PRESENTING ILLNESS:

Pt was apparently asymptomatic 1 day back, then she developed fever-high grade,not associated with chills and rigors,no diurnal variation, relieved on medication

Pain in B/L knee joint since 1 day 

No H/o cough,cold,shortness of breath 

No h/o burning micturition,vomitings,loose stool,pain abdomen,giddiness 

H/o similar complaints 20 days ago and was admitted to our hospital   Diagnosed to have synovitis of right knee (resolved),with right lower lobe pneumonia(resolved)with bilateral knee osteoarthritis with IDA

And was discharged 1 week ago

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 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:

K/c/o hypertension since 10 years on tab.Telma, 40 MG

N/k/c/o DM,CAD,CVA,asthma,thyroid disorders

PERSONAL HISTORY:

Diet-veg

Appetite:normal 

Bowel and Bladder movements -regular 

Addictions-nil

Sleep -adequate

GENERAL EXAMINATION:

Patient was consious, coherrent and co-operative. Well oriented to time place and person.moderately built and nourished 

pallor -present 

No icterus 

No clubbing

No cynosis

No generalized lymphadenopathy 

No b/L pedal edema

Vitals: 

Temp: 100F

Bp: 120/60 mmHg

PR: 92 bpm

RR: 20 cpm

SpO2: 98% on RA

LOCAL EXAMINATION OF KNEE JOINT:

Inspection: 

Swelling at and below the level of knee joint

Skin is normal over the knee joint

No scars,sinuses

 Fixed flexion deformity is seen

Palpation: 

Local rise of temperature present 

Pain on flexion of knee joint(lt>Rt)

On palpation their is tenderness over lateral border of patella

Range of movement: limited, unable to perform complete flexion

Patellar tap- present 

Systemic Examination -

CVS : 

S1 S2 + ,No murmurs

RESPIRATORY SYSTEM;

B/l symmetrical chest

Trachea - Central

B/l air entry present

NVBS heard

ABDOMEN:

Shape of abdomen: Scaphoid

Soft, non tender.

No rigidity or guarding.

BS+

CENTRAL NERVOUS SYSTEM EXAMINATION- 

GCS- 15/15 

Higher mental functions

- Conscious

- Oriented to time,place and person

- Memory - Intact

- Speech - no deficit

Cranial nerve examination -intact and normal 

1 - olfactory sense - normal

2- Direct and indirect light reflex present

3,4,6 - no ptosis and nystagmus

All eye movements were normal

5- Touch - 

Sensory -by cotton and pin felt

 Motor - chewing movements seen             

7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present

8- Hearing normal 

9,10- position of uvula is central

No regurgitation after drinking water

11- looked for trapezius muscle - contraction present

12- no deviation of tongue on protrusion

Motor system 

Attitude - left and right lower limb slightly flexed at knee joint in lying down posture

Reflexes 

b                     Right         Left            

Biceps                  2+      2+

Triceps                 2+      2+

Supinator               1+     1+ 

 Knee. .                   -        -

Ankle.                     -         -

Babinski            B/L flexor 

Power

Upper limb -4+/5            Could not be elicited

Lower limb -4-/5                4-/5 

                                

TONE            Lt. Rt

 Upper limbs N N                

 Lower limbs N N         

        

No involuntary movements

CORTICAL:

Two point discrimination- ++

Stereognosis ++

Graphesthesia ++

Cerebellum:

Finger nose Coordination -past pointing present 

Dysdisdokokinesia +

Knee heel coordination present 

Intentional tremors present 

Ataxic Gait?

         

COURSE IN HOSPITAL:

A 82 year old female had H/o similar complaints 20 days ago and was admitted to our hospital   Diagnosed to have synovitis of right knee (resolved),with right lower lobe pneumonia(resolved)with bilateral knee osteoarthritis with IDA

When she was admitted previously -20 days ago-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

She was admitted again in our hospital on 28/6/23 with c/o left knee pain

Monitoring of temperature was done for any fever spikes

ORTHO REFERRAL:(done on 28/6/23):

Diagnosis:grade 4 B/L OA knee

Impression:

Degenerative changes noted in B/L knee 

Mild joint effusion in Rt knee

Mild to moderate effusion in lt knee

B/L synovium thickened in both knees

Advice:

INJ.antibiotics as per physician 

T.ultracet PO/BD

T.pan 40mg PO/OD

Quadriceps strengthening exercises

We adviced her for monitoring and investigations for further management but the patient is not willing and want to get discharged .

INVESTIGATIONS:

XRAY KNEE JOINT:

USG B/L KNEE JOINT

CHEST X-RAY

On 28/6/23:

CBP:

Haemoglobin 8.9gm/dl

TLC, 19,900cells/cu mm

Neutrophils 84 %

lymphocytes 9%

Eosinophils 1

PCV 27.9 vol%

MCV 72.7fl

MCH 23.2pg

RBC count:3.84million/cumm

Platelets 3.87 lakhs/cumm 

ESR: 35 mm/1st hr

CUE:

Albumin-nil

Sugars-nil

Pus cells - 1-2/HPF

CRP- positive (2.4mg/dl)

30/6/23:

Hemogram:

Hb: 8.4gm/dl

TLC:12,300

PCV :25.8 vol%

MCV:71.3fl

MCH:23.2pg

Platelets:3.90 lakh/cumm 

FINAL DIAGNOSIS:

Pyrexia(resolved) with polyarthralgia 

B/L Non inflammatory synovitis secondary to OA 

B/l(left>right)cerebellar?atrophic lesion under evaluation 

B/L symmetric sensory,motor peripheral neuropathy (L1-S1)

With iron deficiency anaemia with K/c/o HTN since 10yrs

TREATMENT:

IVF NS,RL @50ml/hr

INJ NEOMOL 1g/IV/sos(if temp more than 102 F)

Tab.Dolo 650 MG PO/SOS(if temp more than 100F)

Tab.TELMA-AM 40/5 PO/OD

Tab.OROFER-XT PO/OD

TAB.SHELCAL -CT 500mg PO/OD

ADVICE AT DISCHARGE:

Tab.TELMA-AM 40/5 PO/OD

Tab.OROFER-XT PO/OD

Tab.ECOSPRIN 75mg PO/HS

Tab.PAN 40mg PO/OD BBF

Tab.HIFENAC 

Tab.DOLO 650mg PO/SOS

Tab.CHYMEROL FORTE PO/TID for 15days

Tab.SHELCAL PO/OD

FOLLOW UP:

Review to general medicine OPD with Hemogram reports after 2 weeks 

Review to orthopedics OPD after 1 week 

Refer to neurology OPD on Thursday

30/6/23:

S:

2 fever spikes present (100.2F and 100.8F)

C/o generalised weakness 

O:

Patient is c/c/c 

Temp: 100.2F

PR- 88 bpm

RR-18 cpm 

BP-130/80 mm of Hg

Spo2 -98% 

GRBS:129mg/dl

I/O -2600ml/1300ml 

RS-B/L air entry present, NVBS

CVS- S1S2present, no murmurs heard

PA- soft,non tender 

CNS- soft,non tender 

A:

  Pyrexia with polyarthralgia under evaluation 

Non inflammatory synovitis secondary to OA 

With iron deficiency anaemia 

with K/c/o HTN since 10yrs

P:

1.inj.neomol 1g IV/sos (if temp >102F)

2.tab.dolo 650mg PO/sos (if temp>100F)

3.tab.TELMA-AM 40/5 po/od 

4.tab.OROFER-XT PO/OD 

5.tab.ULTRACET 1/2tab PO/TID

6.tab.SHELCAL-CT 500mg PO/OD 

7.monitor vitals and inform sos 

8.strict I/O charting

1/06/23:

S:

Patient mainly complaints of generalised weakness of lower limbs due to which she is unable to walk 

B/L knee pain on movement 

O:

Patient is c/c/c 

Temp: 98.7F

PR- 92bpm

RR-22cpm 

BP-130/70 mm of Hg

Spo2 -98% 

GRBS:135mg/dl

I/O -2200ml/1050ml 

RS-B/L air entry present, NVBS

CVS- S1S2present, no murmurs heard

PA- soft,non tender 

CNS- NAD

A:

  Pyrexia with polyarthralgia under evaluation 

Non inflammatory synovitis secondary to OA 

With iron deficiency anaemia 

with K/c/o HTN since 10yrs

P:

1.inj.neomol 1g IV/sos (if temp >102F)

2.tab.dolo 650mg PO/sos (if temp>100F)

3.tab.TELMA-AM 40/5 po/od at 9am

4.tab.OROFER-XT PO/OD at 2 pm 

5.tab.ULTRACET 1/2tab PO/TID

6.tab.SHELCAL-CT 500mg PO/OD 

7.monitor vitals and inform sos 

8.strict I/O charting