45 year old man with knee joint pain

 NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.

PAST HISTORY: The patient is a 48 yrs old male, who is a grocery shop owner by profession. 

He heard from his parents that at the age of less than 1 yr he had an allergic reaction due to an unknown etiology. Had rashes, and sneezing. They took him to a village quark and on his advice used to keep him wrapped in banana leaves and fed him some herbal medicine. He recovered within a few months. 

In 1992 at the age of 17 yrs, again allergic reaction due to an unknown etiology. Had severe rash, ?blisters, or lesions on hand and legs with an itchy sensation. Was given an injection in the gluteal region. after which the allergic symptoms went away. 

6-7 months later continuous sneezing and cough with sputum. Went to Vellore, where he was recommended to inhale saltwater through his nose. Diagnosis of asthma was made. He was recommended to use an inhaler only if he felt shortness of breath(for the past 18 yrs did not use an inhaler). His sneezing went away and he continued coughing with a lot of sputum. Clinician prescribed tab. Tryptomer 10mg OD before bed. The cough did not resolve. So, the dosage was increased to 25mg. Taking the same tab for the past 20 years. 

In between, 1.5 months ago tried to see what happens if the tab. is not taken on Clinician's advice. But the same allergic reaction happened. So, started the tab. again. 

12 years ago, felt a pain in lower back which gradually increased. An X-ray was done. Physiotherapy, a belt for back pain, and sleep on a hard mattress were recommended. The pain went away on following advice. Had to wear a belt for 2 months only. 

For the past 2-3 years suffered from gastric problems (acidity, sour breath, burning sensation in the epigastric region). So severe that he did not want to eat at all. In 2021.7, an endoscopy was done revealing a small hiatus hernia in the esophagus and clean based gastric ulcer in prepyloric area. HP kit (omeprazole + Tinidazole + Amoxycillin) tab. taken for 7 days. No gastric problem after that. 

4 to 5 years ago, started feeling a slight pain in lt. knee which aggravated with walking, climbing stairs, or straightening folded legs. Gradually pain increased and restricted his movements. Visited the Clinician and used to take medications. The pain got reduced temporarily with medications.

1 yr ago the pain became unbearable. Had difficulty in walking with restriction of movements. Most of the time at home or having to spend time sitting in a chair while in the shop. Also, started complaining of rt. knee jt pain that was comparatively less, but aggravating during walking and relieved during rest. Diagnosis made at that time i) Ch. monoarticular noninflammatory arthritis ii) Osteoarthritis iii) Medial meniscus tear of lt knee. Medicines and physiotherapy along with a knee cap recommended.

On 29.7.21 Arthroscopic partial meniscectomy was done on the left knee. Lt. knee pain reduced after Sx from the side from where the meniscus was partially removed(medial side). 

5 months ago went to KIMS for a checkup and to seek advice for his right knee pain. He was prescribed Paracetamol + Tramadol and told to follow a strict diabetic diet. His knee pain was reduced with medications.

Diabetes was detected when he came for Sx 1 yr back. Not on medication for diabetes. The patient does not have hypertension.

Pt started drinking alcohol at the age of 44 yrs and believes that because of alcohol his asthma got cured. Used to drink 90 ml/day and after Sx on 29.7.21 drinks 200 ml 1-2 times per wk. 

Pt chews tobacco 1-2 gms 3-4 times per day.

CHIEF COMPLAINT AND Pt REQ. :

For the past 1 wk c/o intense pain on standing still for even <1 min starting in the left buttocks and then traveling down to the gastrocnemius. The pain vanishes if he starts walking or sitting. While sitting on a hard surface pain reappears but of less intensity and pain is not there on lying down. The pain will reappear on walking for more than 15 feet. Did not reduce even on taking Nurokind Forte (Methylcobalamin, Zinc, Vitamin B6, Folic acid, Niacinamide, and Chromium) and Calbert-D3 as prescribed by Dr.

FAMILY HISTORY:

Father - prehypertensive at old age

Mother - no health issues reported

2 SISTERS - no health issues were reported

 REPORTS:

Blood sugar reports:

17.7.21 - Random - 231

18.7.21 - Fbs - 137, PP - 188

28.7.21 - Random - 105 PP - 152

29.7.21 - Random - 80, PP - 161

14.4.22 - Random - 198mg/dl

15.4.22 - Post dinner - 166mg/dl

16.4.22 - FBS - 155mg/dl

LFT:

Total bilirubin - 1.98mg/dl

Direct bilirubin - 0.80mg/dl

SGOT(AST) - 53 IU/L

SGPT(ALT) - 66 IU/L

Alk. phosphate - 153 IU/L

Albumin - 3.4gm/dl

BLOOD GROUP:

A+

BLEEDING TIME: 2min

CLOTTING TIME: 5min

CBP:

Normal

CUE:

Normal

PT:

Normal - 15sec

APTT:

30sec

Anti HCV Antibobies - RAPID

Non - reactive

HIV 1/2 Rapid Test:

Non-reactive

HBsAg Rapid:

-ve

RFT:

Phosphorus: 5.9mg/dl

Other values within the normal range

ARTHROSCOPIC FINDINGS(24.7.21):

Chondrocalcinosis observed on arthroscopy

-Denuded cartilage observed over medial femoral condyle and tibia(medial side)

-Central part of the menisci eroded

-Multiple micro-fractures done over medial femoral condyle to promote cartilage growth

                                                               

                                                          

                                                             Marks on hand after rashes healed