82 year female with knee pain and fever

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A 82 years old female patient who is home maker came with complaints of

 fever since 2 days

 knee joint pain since 2 days

 swelling in both legs below knee joint since 2 days 

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 3 weeks ago, when in the morning after waking up ,the patient was unable to lift both her legs from the bed due to weakness and felt the heaviness of the legs. She recalls dragging herself to the bathroom.

3 days later, the patient developed swelling and pain in both lower limbs at and below the knee joint, right more than left. The pain was sudden in onset, pricking in nature, continuous, aggravated with walking, relieved on taking rest, and did not radiate to any other site. It was associated with redness and increased warmth of the overlying skin. The patient also complained of high-grade fever, that was continuous and not associated with chills and rigor, associated with generalized body pain.

The patient visited a doctor and was prescribed medication, after which her symptoms were reduced. 

1 week ago the patient presented to our Hospital as her fever, swelling, and pain aggravated, medication was given and symptoms were reduced.

2  days ago, the patient presented back to the hospital with fever, bilateral knee joint pain, and swelling, more in the right leg than the left.

The patient also complains of pain in the joints of both hands since 15 days.

The patient also complains of bilateral knee joint pain while climbing stairs , that is relieved on rest . 

HISTORY OF PAST ILLNESS

Known case of HTN since 13 years.

Not a known case of DM, asthma, TB, Thyroid condition, CVD, or Epilepsy.

History of trauma 10 years ago, resulting in fracture of the left ulnar bone 

History of syncopal attack 8 months ago.

No history of blood transfusion 

DRUG HISTORY

Telmisartan and amlodipine since 13 years

Ecosprin since 8 months

Diethylcarbamazine since 15 days.

Amoxycillin since 7 days .

PERSONAL HISTORY

DIET- Vegetarian

APPETITE- Normal

SLEEP- Disturbed. Consuming alprazolam since 4 months

BOWEL AND BLADDER MOVEMENTS - 

Micturition - 4-5 months ago complained of low urinary output. Currently increased frequency of urination at night and reduced control in the bladder.

Bowel movements- Regular 

ADDICTIONS- none

ALLERGIES-none

EXAMINATION

PR- 94 bpm

BP- 120/70mmHg

AFEBRILE

GENERAL EXAMINATION

The patient is conscious, coherent and cooperative.

She is moderately built and nourished

Pallor- Present

Icterus- Absent

Cyanosis- Absent

Clubbing-  Absent

Lymphadenopathy- Absent

Koilonychia- Absent

Pedal oedema- present

Peripheral pulse felt.

MUSCULOSKELETAL SYSTEM 

Inspection

Bilateral swelling of the lower limbs, at and below the level of the knee joint. More prominent on the right than the left. 

Right, Limb Fixed flexion deformity seen at the knee joint. 

Left lower limb, ability to flex knee present. 

No scars, sinus, erythema or rashes

Palpation 

Local rise of temperature present bilaterally on the knee joint

Palpable swelling is present on the right and left knee, and ankle with mild oedema in her lower limbs , associated with tenderness, in the suprapatellar bursa

Patellar tap is positive bilaterally.

Join Line tenderness observed.

absence of lower limb shortening. 

Range of motion 

Inability to flex the left lower limb. 

Investigations