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History Investigation PowerPoint Presentation

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Published on : Dec 23, 2019 | Views : 2121 | Downloads : 1

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Case Presentation Prepared by: Supervised by:
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Outline The case History of present illness Physical exam Investigations Differential dx Management
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The case A 37 years old female presented to the clinic for a Knee pain in the left ,since 2 months
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History of presenting illness She was in her usual state of good health until 2 months ago when she start to complain about her knee which they become painful. Pain was localized to anterior aspect of knee With gradual onset and progressive course . Walking and climbing the stairs aggravated the pain . The pain was relieved by resting . Morning stiffness of knee less than 15 minutes , disappeared when she began activities Rated pain score 5/10 Not radiated to leg No history of trauma or surgery No other painful or swelling joint . No fever or weight loss
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Review of systems: CNS : no headache , dizziness or numbness GIT: no heartburn , N/V, change in appetite Cardio-pulmo: no chest pain , SOB or palpitation Urogenital : no hematuria , discharge Skin : no pigmentation , ulcers Hematology :no Anemia, petichiae , or gum bleeding “Unremarkable”
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Past Medical Hx (PMH) : Not significant Past Surgical Hx (PSH): Not significant Family Hx (FMHx): Not significant Medication Hx: Not taking any prescribed or over the counter medications Menstrual Hx: Menarche at 14 years, regular periods 5 days, normal flow Social history (SH): She is from Riyadh, living with her family at home and completed her college degree No known Allergies
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Summary A 37 years old female, medically and surgically free presented to the clinic for a painful left knee for 2 months
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Differential Diagnosis ? Trauma Osteoarthritis Patellofemoral knee pain (periarticular) Bakers cysts Degenrative Meniscus(Intra articular) Rhumatoid arthritis
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Physical exam The patient looks well , consciousness , alert oriented to time , place ,and person . Obese Body built . Vital signs : T:36.5 , RR:20 ,Bp:119/62 , WT:84,8 , BMI: 35,53 Gait: can not fully bear weight on left lower limb Hands: no clubbing , swelling or redness. Palm : no muscle wasting , erythema , or janeway lesions Eye : no Dryness, pain, redness, sensitivity to light or xanthelasma Neck : no LN Resp :symmetrical vesicular breathing Cvs :pulse is regular in rate &rhythm , no murmur .
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Lower limbs : Knee examination : Inspection: no erythema ,bruising of left knee. Also there is no swelling Musculature of both knees seems symmetric bilaterally There is no bone deformity On palpation:left knee joint is warm and tender mild crepitus sound while movement No effusion with the ballottement tap test weakness of quadriceps muscle ,No lower limb edema , no absent of LL pulse , no other joint swelling Restrict left knee flexions and extension
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Summary A 37 years old female, medically and surgically free presented to the clinic for a painful left knee for 2 months Exam:
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Investigations X-RAY knee Ap standing Labs screening : CBC ESR Free T4 Glucose fasting, Hb A1C Lipid panel Liver function test Renal function panel TSH Vit D 25 Hydroxy level
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صورة نورمل
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DIAGNOSIS Osteoarthritis
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plan Non pharmacotherapy: Full explanation of the condition via patient education: weight loss , which can reduce pain and slow progression of OA. Exercise each day. physical therapy & Muscle strengthening exercises. Medication: Paracetamole 1000 mg 2 tab orally / q6hr, prn . Voltarin topical (diclofenac) BID Referral to orthopedic
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Osteoarthritis محاضرة
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Epidemilogy: • OA is common in women and becomes more common with advancing age. The Framingham Osteoarthritis Study showed that the prevalence of radiographic OA increases with age from 27% in people younger than 60 years to 44% in those older than 70 years. Risk factors includs: • Older age (especially older than 50 years) • Female sex • Overweight or obesity • Previous joint injury • Job that requires bending or squatting • Family history • Participation in sports associated with repetitive impact (e.g., soccer, American football). BMJ AAFP
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