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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
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