GM case -3
GM case - 3
45 year woman came with complaints of knee and lower limb pain since 1 year...
My self Anu Bandlagudem of 3rd BDS .This is an online E log book to discuss our patients de- identified health data shared after taking her guardian's signed informed consent.Here we discuss our individual patients problem through series'of inputs from available global online community of experts with aim to solve those patients clinical problems with collective current best evidence based inputs.
I have been given this case to slove in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history, findings, investigations, diagnosis and treatment plan.
Chief complaint:
45 yr old female who is a laborer came to hospital with complaints of lower limb and knee pain ..since 1 year
History of present illness,:
Patient was asymptomatic 1 yr back and she experienced dragging type of pain in both the legs(bilateral Lower limb) and radiating from hip to foot with tingling sensation while walking since 1 yr
Bilateral knee dragging type of pain with nonradiating associated with mrng stiffness
History of past illness:
Hypertension
Diabetes mellitus
CAD
Epilepsy
Family history:
No one in her family had Hypertension diabetes TB epilepsy asthama heart diseases strokes..
Personal history:
She is daily wage labourer who wake up in the mrng and goes to work after having breakfast, night she will return late in the evening she will have her dinner and sleep.She has 5 children. But from 10 days.she is unable to work becoz of pain in lower limbs.
Mixed diet
Appatite - lost
Micturation - normal
Sleep -lost from 10 days
Bowel - regular but hard stools from 10 days
Addictions: toddy and betel leaf
Relieving factor: in rest no pain
General examination:
Consicuous
Pallor - no
Icterus - no
Cyanosis - no
Clubbing - no
Lymphadenopathy - no
Edema - no
Vitals :
Temperature - afebrile
Bp - 130/80 mm hg
Pulse rate- 92/ min
Respiratory cycles:16 cycles/ min
Systemic examination:
Gait - normal
Reflexes - normal
Provisional diagnosis:
Lumbar spondylitis
Investigations:
Haemogram:
Hb-13.3 gm/dl
TLC-8100
PLC-1.93
RBS-108mg/dl
BGT-B postive
RFT:
Serum urea- 21
Serum creatinine -0.8
Uric acid-4.9
Na+ -141
K+ -3.7
Cl- -103
Ca+2-9.5
LFT:
TB-0.69
DB-0.19
AST-24
ALT-23
ALP- 169
JP-6.6
Albumin -4.01
A/G-1.58
ESR- 10
FBS- 86
Thyroid activity:
T3-0.88
T4-6.50
TSH-6.37
Definitive diagnosis:
Osteoarthritis
Lumbar radiculopathy
Denovo hypertension
Treatment:
Telma 40 mg
Eliwel ( aminotriphylline) 10 mg before dinner
Shelcal 500 mg
T .a .z OD
Physiotherapy knee and lower back
Questions:
Hw is Hypertension related to osteoarthritis???
According to my knowledge many told like osteoarthritis can't be treated permanently?? Is there any rate case thta...it treated like 90%???
