Medial meniscal tear of left knee
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This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 48 year old male resident of cooch Behar, came to the hospital on 17th July 2021 with the chief complaints of
Left knee pain since two years
History of presenting illness:
Patient was apparently assymptomatic two years back then he developed left lower knee joint pain which was insidious in onset, gradually progressive, aggrevated on sitting and walking with restriction of movements
Associated tingling and numbness of upper limb and lower limb with deep pain, crepitations
Past history
Similar complaints of backache was present 7years ago for which he took local medication and got cured
k/c/o asthma since 17years
Not a k/c/o HTN, DM
Family history
Not significant
Personal history
Diet mixed
Appetite normal
Bowel and bladder regular
Sleep adequate
No addictions
General examination
Patient is conscious coherent co operative
Oriented to time place and person
Moderately built well nourished
Temperature afebrile
Bp 120/90mm hg
Pulse rate 68bpm
Respiratory rate 16cpm
On examination of left knee
ROM 0-110°
Valgus stress test POSITIVE
Medial joint line tenderness PRESENT
ADT NEGATIVE
PDT NEGATIVE
CVS
S1 S2 heard
Respiratory examination
Normal VBS
BAE present
Per abdomen
INVESTIGATIONS
HEMOGRAM
treatment provided till now
TAB TRYPTOMER 25mg OD
Physiotherapy of QUADRICEPS TENDON
KNEE CAP
TAP JOINTACE C2
TAB TENDOFIRM
TAB ETOS 60mg
DIAGNOSIS
MEDIAL MENISCAL TEAR OF LEFT KNEE
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