67 year old male with B/L KNEE AND JOINT PAINS since 5 years

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Patient came with chief complaints of pain in both knee joints since 5 years 

Pain in both upper limbs since 3 years 

Patient was apparently asymptomatic 5 years back , gradually he developed pain in both knee joints , dragging type of pain in both upper limbs Since 3 years.  extending from fingers to shoulder  , aggravated on doing work 

No  h/o tingling and numbness .

 no other joint involvement .

no early morning stiffnes of joints 

no redness, swelling and local rise of temperature involving joints . 

No h/o fever, chills, weight loss 

No h/o vomiting, loose stools, constipation 

No h/O eye redness, pain, photosensitivity 

No H/o chest pain , palpitations, dyspnea 

Past history : no H/o DM,HTN,ASTHMA, EPILEPSY, HTN 

personal history :patient works in steel shop 

 appetite normal 

Diet mixed 

Bowel and bladder regular 

Addictions none 

Family history: not significant

General physical examination 

Patient is conscious, coherent, cooperative well. Oriented to time ,place person 

No signs of pallor, icterus ,cyanosis,

clubbing lymphadenopathy edema 

Vitals : 

Temp  98.6 F 

PR. 80 bpm

RR  20 com

BP  140/90 MM hg 

Systemic examination

CVS- S1,S2 heard,no murmurs

RS - BLAE, NVBS  

Per abdomen - soft , non tender 

CNS -  patient is conscious coherent and cooperative. 

No neck stiffness 

NORMAL

MOTOR SYSTEM-      

TONE    UL  LL         

RT    N   N

LT     N    N

SENSORY SYTEM - NORMAL

GLASGOW SCALE- 15/15

REFLEXES  

BICEPS   TRICEPS  SUPINATOR  

RT 2+        2+             2+

LT  2+        2+             2+

KNEE ANKLE

RT     2+     2+

LT      2+     2+

 

  

 

Hba1c : 

C 4 ,c5 symmetrical disc bulge with  osteophyte complex causing neural foraminal narrowing and indentation over nerve root bilaterally 

C5 c6 disc osteophyte  herniation  causing narrowing of the spinal cord  with B/L  neural foraminal narrowing and abutment of exiting nerve root 

Decrease in intervertebral disc space noted

Lumbar spine screening 

Investigations done on 21/11/23: 

Provisional diagnosis:  iron deficiency anemia with upper limb myalgia? Arthritis 

Treatment given : 

Tab ultracet po /BD 

TAB PAN  40 MG PO/OD 

TAB LIVOGEN 120 MG PO/OD 

SOAP NOTES DAY 1 

S : pain in both upper limbs 

B/l knee joint pains 

O : pt is c/c/c

      Bp  : 140/90 mm hg

       Pr  : 82v bpm 

       Cvs : s1 and s2 heard 

        Rs  BAE + ,NVBS 

       P/A : soft, non tender 

A:

P: TAB ULTRACET PO /BD 

    TAB. PAN PO OD BBF 

 SOAP NOTES 

DAY 2 : 

 

S : PAIN IN BOTH UPPER LIMBS 

      B/ L KNEE JOINT PAINS

O: 

PT C/C/C 

BP 130/80 MM HG 

PR : 75 BPM 

CVS S1 and s2 heard 

Rs : B/L AE ,NVBS 

 

A : ANEMIA UNDER EVALUATION 

P: TAB ULTRACET PO/ BD 

     TAB PAN PO OD BBF 

  Day 3 : 

S : PAIN IN BOTH UPPER LIMBS 

      B/ L KNEE JOINT PAINS 

  O :   PT C/C/C 

BP 130/90 MM HG 

PR : 72 BPM 

CVS S1 and s2 heard 

Rs : B/L AE ,NVBS 

 

A : iron deficiency anemia with upper limb myalgia , ? Arthritis  

P: TAB ULTRACET PO/ BD 

     TAB PAN PO OD BBF 

      Tab LIVOGEN 120 mg PO OD