Thesis collection

RIGHT OSTEOARTHRITIS KNEE

Case History and Clinical Findings

CHIEF COMPLAINTS

C/O PAIN IN B/L KNEE SINCE 5 YEARS, RIGHT >LEFT

HOPI-

PATIENT WAS APPARENTLY ASYMPTOMATIC 6 YEARS AGO, LATER DEVELOPED PAIN IN B/L

KNEE. PAIN IS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, AGGRAVATED ON

MOVEMENTS AND NOT RELEIVED WITH REST AND MEDICATION.

NO H/O TRAUMA, FEVER, MORNING STIFFNESS, INSTABILITY SYMPTOMS, WEIGHT LOSS

PAST HISTORY-

N/K/C/O TYPE 2 DM / HTN / HYPOTHYROIDSM/CVA/CAD/TB

NO PREVIOUS BLOOD TRANSFUSION

NO PAST SURGICAL HISTORY

O/E:

PATIENT IS C/C/C

AFEBRILE

PR- 86 / MIN

BP- 120/80 MMHG

L/E OF B/L KNEE

SKIN

RIGHT KNEE - NORMAL

LEFT KNEE - NORMAL

FFD

RIGHT KNEE -10 DEGREES

LEFT KNEE -10 DEGREES

SWELLING

LEFT KNEE - ABSENT

RIGHT KNEE - ABSENT

TENDERNESS

LEFT KNEE - ABSENT

RIGHT KNEE - PRESENT MJL

LOCAL RISE OF TEMPERATURE

LEFT KNEE - ABSENT

RIGHT KNEE - ABSENT

CREPITUS

LEFT KNEE - PRSENT

RIGHT KNEE - PRESENT

DISTAL PULSES -

LEFT KNEE - PRSENT

RIGHT KNEE - PRESENT

SENSATIONS

LEFT KNEE - INTACT

RIGHT KNEE - INTACT

Investigation

HBsAg-RAPID NEGATIVE

Anti HCV Antibodies - RAPID Non Reactive

RFTUREA 25 mg/dlCREATININE 1.10 mg/dlURIC ACID 2.60 mmol/LSODIUM 142

mmol/LPOTASSIUM 3.8 mmol/L.CHLORIDE 104 mmol/L

LIVER FUNCTION TEST (LFT)Total Bilurubin 0.60 mg/dlDirect Bilurubin 0.19 mg/dlSGOT(AST) 16

IU/LSGPT(ALT) 12 IU/LALKALINE PHOSPHATASE 239 IU/LTOTAL PROTEINS 6.8 gm/dlALBUMIN

4.1 gm/dlA/G RATIO 1.5

COMPLETE BLOOD PICTURE (CBP)HAEMOGLOBIN 9.8 Gm/dlTOTAL COUNT 6400

cells/cummNEUTROPHILS 63 %LYMPHOCYTES 29 %EOSINOPHILS 01%MONOCYTES 07

%BASOPHILS 00 %PLATELET COUNT 1.95SMEAR normocytic normochromic

COMPLETE URINE EXAMINATION (CUE)COLOUR Pale yellowAPPEARANCE ClearREACTION

AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS

2-3EPITHELIAL CELLS 1-2RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS

DEPOSITS AbsentOTHERS Nil

BT-2MIN 30 SEC

CT-4MIN

BG- O POSITIVE

PT - 16 SEC

APTT - 31 SEC

INR 1.11

RBS - 103 MG/DL

Treatment Given(Enter only Generic Name)

PATIENT WAS CLINICO RADIOLOGICALLY DIAGNOSED WITH GRADE 4 OA OF B/L KNEE

,REVIEWPAC DONE ON 15/10/25, RIGHT TOTAL KNEE REPLACEMENT DONE ON

16/10/25.IMPLANT USED: TIBIA (5 SIZE) ; 'F' RIGHT.UNEVENTFUL PROCEDURE, SHIFTED TO

POST OP UNDER HEMODYNAMICALLY STABLE CONDITION. ASEPTIC DRESSING DONE ON

POD 2,5 ,10.

ALTERNATE SUTURE REMOVAL DONE ON AND COMPLETE SUTURE REMOVAL DONE ON

PATIENT IS NOW BEING DISCHARGED UNDER HEMODYNAMICALLY STABLE CONDITION.

Advice at Discharge

TAB CEFTAS CL 200MG PO/BD X 5 DAYS

T XYKAA 1GM PO BD X 5 DAYS

TAB PAN 40 MG PO/OD X 5 DAYS

TAB LIMCEE 500MG PO/BD X 15 DAYS

TAB SHELCAL CT PO/OD X 15 DAYS

PHYSIO - TWICE A DAY

CPM - 0-110 DEGREE

QSE; KNEE ROM EXERCISE

VMO STRENGTHENING EXERCISE

MOBILISATION WITH OR WITHOUT WALKER

LUMBAR SPONDYLOSIS

Case History and Clinical Findings

C/O LOW BACK ACHE SINCE 6 MONTHS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 6 MONTHS AGO LATER SHE DEVELOPED PAIN

IN LOW BACK SUDDEN IN ONSET.DULL ACHING, RADIATING TO B/L LOWER LIMBS

ASSOCIATED WITHTINGLING AND NUMBNESS. PAIN AGGRAVATED ON MOVEMENTS AND

RELIEVED ON TAKING REST

H/O TRAUMA 6 MONTHS AGO

NO H/O FEVER

NO H/O BURNING MICTURITION

PAST HISTORY;

N/K/C/O T2DM/HTN/TB/EPILEPSY

NO PREVIOUS SURGICAL HISTORY

ON EXAMINATION

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY ,EDEMA

TEMP:AFEBRILE

PR:84 BPM

RR:18 CPM

BP:120/80MMHG

CVS- S1,S2 HEARD NO MURMURS

RS-BAE +NVBS

PA- SOFT ,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF SPINE

NO DEFORMITY

SKIN-NORMAL

NO LOCAL SWELLING

TENDERNESS PRESENT OVER L5 TO S1 LEVEL MILD TENDERNESS

DEFORMITY ABSENT

NO LOCAL RISE OF TEMPERATURE

CREPTUS ABSENT

MOVEMENTS-TERMINALLY PAINFULL

RIGHT LEFT

HIP:

FLEXION: 5/5 5/5

EXTENSION: 5/5 5/5

KNEE:

FLEXION: 5/5 5/5

EXTENSION: 5/5 5/5

ANKLE:

DORSIFLEXION: 5/5 5/5

PLANTARFLEXION: 5/5 5/5

EHL 5/5 5/5

FHL 5/5 5/5

SENSATIONS: INTACT DECREASED OVER MEDIAL ASPECT OF LEG AND MEDIAL AND

LATERAL ASPECT OF FOOT

DISTAL PULSES: PRESENT PRESENT

Investigation

X RAY LC SPINE

X RAY C SPINE

RFT UREA 20 mg/dlCREATININE 0.6 mg/dlURIC ACID 2.6 mmol/LCALCIUM 10.2

mg/dlPHOSPHOROUS 2.9 mg/dlSODIUM 133 mmol/LPOTASSIUM 4.0 mmol/L.CHLORIDE 97

mmol/L

LIVER FUNCTION TEST (LFT)

Total Bilurubin 0.49 mg/dlDirect Bilurubin 0.18 mg/dlSGOT(AST) 12 IU/LSGPT(ALT) 11

IU/LALKALINE PHOSPHATASE 195 IU/LTOTAL PROTEINS 6.9 gm/dlALBUMIN 3.84 gm/dlA/G

RATIO 1.25

COMPLETE BLOOD PICTURE (CBP)

HAEMOGLOBIN 12.5 gm/dlTOTAL COUNT 10600 cells/cummNEUTROPHILS 60

%LYMPHOCYTES 29 %EOSINOPHILS 04 %MONOCYTES 07 %BASOPHILS 00 %PLATELET

COUNT 3.88SMEAR Normocytic normochromic

COMPLETE URINE EXAMINATION (CUE)

COLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN

NilSUGAR +++BILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-4EPITHELIAL CELLS 2-3RED

BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS

Treatment Given(Enter only Generic Name)

1.TAB .XYKAA 1GM PO/BD

2.TAB PAN 40 MG PO/OD

3.TAB SHELCAL CTPO/OD

4.PHYSIO IFT TO B/L KNEE Q/E

Advice at Discharge

1.TAB .XYKAA 1GM PO/BD X 5DAYS

2.TAB PAN 40 MG PO/OD X5DAYS

3.TAB SHELCAL CTPO/OD X15 DAYS

4.PHYSIO IFT TO B/L KNEE Q/E

B/L OSTEOARTHRITIS OF KNEE

LUMBAR SPONDYLOSIS

Case History and Clinical Findings

CHIEF COMPLAINTS:

C/O NECK PAIN RADIATING TO B/L UPPERLIMB

LOWER BACK ACHE RADIATING TO BOTH LOWER LIMBS SINCE 1 YEAR

PATIENT CAME WITH CHIEF COMPLAINT OF B/L KNEE PAIN SINCE 1 YEAR

TINGLING +

NUMBNESS+

NO H/O TRAUMA

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 1 YEAR AGO THEN HE DEVELOPED

NECK PAIN, LOWER BACK ACHE,RADIATING TO BOTH LOWER LIMBS ASSOCIATED WITH

NUMBNESS AND TINGLING SENSATION ,WHICH IS INSIDIOUS IN ONSET GRADUALLY

PROGRESSIVE,AGGRAVATED ON MOVEMENT,NOT RELIEVED ON REST.

NOT ASSOCIATED WITH URINARY INCONTINENCE

NO H/O TRAUMA

NO H/O FEVER, VOMITINGS, LOOSE STOOLS,HEAD INJNURY,LOC,BURNING

MICTURITION,BLADDER AND BOWEL INCONTINENCE

PAST HISTORY:

K/C/O HTN SINCE 6 months

N/K/C/O DM, TB , ASTHMA,EPILEPSY

GENERAL EXAMINATION:

TEMP - 98.4F

PR 82 BPM

RR- 18CPM

BP-110/80 MMHG

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF RIGHT KNEE

SKIN- NORMAL

SWELLING -

NO LOCAL RISE OF TEMPERATURE

TENDERNESS +MTL

ROM- 0-100 DEGREE

CREPITUS -

SENSATIONS +

DISTAL PULSES +

LOCAL EXAMINATION OF LEFT KNEE

SKIN- NORMAL

SWELLING -

NO LOCAL RISE OF TEMPERATURE

TENDERNESS +MTL

ROM- 0-100 DEGREE

CREPITUS -

SENSATIONS +

DISTAL PULSES +

Treatment Given(Enter only Generic Name)

PATIENT WAS CLINICORADIOLOGICALLY DIAGNOSED AS BILATERAL OA KNEE TREATED

CONSERVATIVELY WITH ANALGESICS,CALCIUM SUPPLEMENTS AND PHYSIOTHERAPY.

Advice at Discharge

1. TAB. XYKAA 1GM PO/BD X 1WEEK

2. TAB. PAN 40 MG PO/OD X 1WEEK

3. TAB. SHELCAL-CT PO/OD PO/OD X 2WEEKS

4.TAB.TRIGABANTIN 100MG PO/HS X 1WEEK

B/L OA KNEE,LUMBAR SPONDYLOSIS

Case History and Clinical Findings

CHEIF COMPLAINTS:

PATIENT CAME WITH COMPLAINTS OF LOW BACK PAIN RADIATING TO B/L LOWER LIMBS

SINCE 3 YEARS

TINGLING AND NUMBNESS- ABSENT

NO H/O TRAUMA

C/O B/L KNEE PAIN SINCE 3 YEARS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YEARS BACK THEN DEVELOPED LOW BACK

PAIN RADIATING TO B/L LOWER LIMBS SINCE 3 YEARS WHICH IS INSIDIOUS IN ONSET

PROGRESSIVE IN NATURE.

PAST HISTORY:

K/C/O DM,AND HTN SINCE 2 YEARS AND IS ON MEDICATION

N/K/C/O EPILEPSY, ASTHMA, TB, CAD, CVA

GENERAL EXAMINATION:

TEMP - AFEBRILE

PR 84 BPM

RR- 18 CPM

BP-120/80 MMHG

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF B/L KNEE:

SKIN- NORMAL

SWELLING DIFFUSE PARAPATELLAR ON BOTH SIDES

NO LOCAL RISE OF TEMPERATURE

VARUS 5 DEGREES

CREPITUS-PRESENT ON BOTH SIDES

TENDERNESS + IN LJ

ROM 5-110 ON RIGHT SIDE

0-110 ON LEFT SIDE

DISTAL PULSES PRESENT

SENSATIONS INTACT

LOCAL EXAMINATION OF SPINE:

SKIN- NORMAL

SWELLING - ABSENT

NO LOCAL RISE OF TEMPERATURE

TENDERNESS - ABSENT

SLRT- 70 DEGREES

HIP FLEXION-5/5

EXTENSION-5/5

KNEE FLEXION-5/5

EXTENSION-5/5

ANKLE FLEXION-5/5

EXTENSION-5/5

SENSATIONS - INTACT

DISTAL PULSES +

Investigation

XRAY B/L KNEE AP LATERAL

XRAY LS SPINE AP LATERAL

Treatment Given(Enter only Generic Name)

TAB.XYKAA 1GM PO/BD

TAB.PAN 40MG PO/OD

TAB.TRIGABANTIN PO/HS

TAB.EVION LC PO/BD

PHYSIO IFT B/L KNEE

Advice at Discharge

TAB.XYKAA 1GM PO/BD

TAB.PAN 40MG PO/OD

TAB.TRIGABANTIN PO/HS

TAB.EVION LC PO/BD

PHYSIO IFT B/L KNEE

LUMBAR SPONDYLOSIS

Case History and Clinical Findings

C/O LOWER BACK ACHE SINCE 1 YEAR

NON RADIATING TYPE

HOPI

THE PATIENT WAS APPARTENTLY NORMAL 1 YEAR BACK THEN HE DEVELOPED LOWER

BACK ACHE WHICH IS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE THE PAIN IS

INTERMITTENT

THE PAIN IS AGGRAVATED ON MOVEMENTS AND RELIVED ON TAKING REST

NO H/O TRAUMA

NO H/O FEVER

NO CREPITUS

PAST HISTORY:

K/c/o HTN AND DM SINCE 2 YEARS

N/K/C/O, CVA, CAD, ASTHMA, EPILEPSY, TB, THYROID DISORDERS

GENERAL EXAMINATION:

TEMP. - AFEBRILE

BP - 110/80 MM/HG

PR - 82 BPM

RR - 18 CPM

SPO2 - 99%

GRBS - 110 MG/DL

SYSTEMIC EXAMINATION:

CVS - S1,S2 +

CNS - NFND

RS - BAE+

P/A - SOFT, NON TENDER

LOCAL EXAMINATION OF LS SPINE:

ATTITUDE- PATIENT IS IN SUPINE POSITION DISTAL LEFT TIBIA DORSALLY CURVED LEFT

FOOT LATERALLY ROTATED

SKIN - NORMAL

SWELLING - ABSENT

LOCAL RISE IN TEMP. - ABSENT

TENDERNESS - L4-L5

LT RT

SLRT 90 90

POWER 5/5 5/5

HIP 5/5 5/5

KNEE 5/5 5/5

ANKLE 5/5 5/5

FHL 5/5 5/5

EHL 5/5 5/5

SENSATIONS INTACT

DISTAL PULSES FELT

Investigation

COMPLETE BLOOD PICTURE (CBP) HAEMOGLOBIN 10.7 gm/dlTOTAL COUNT 9900

cells/cummNEUTROPHILS 54 %LYMPHOCYTES 36 %EOSINOPHILS 02 %MONOCYTES 08

%BASOPHILS 00 %PLATELET COUNT 2.47SMEAR Normocytic normochromic

COMPLETE URINE EXAMINATION (CUE) COLOUR Pale yellowAPPEARANCE ClearREACTION

AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS

2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS

DEPOSITS AbsentOTHERS Nil

RFTUREA 27 mg/dlCREATININE1.2 mg/dlURIC ACID4.9 mmol/LCALCIUM9.8

mg/dlPHOSPHOROUS2.0 mg/dlSODIUM135 mmol/LPOTASSIUM3.3 mmol/L.CHLORIDE98 mmol/L

Treatment Given(Enter only Generic Name)

PATIENT WAS CLINOCORADIOLOGICALLY DIAGNOSED AS DEGENERATIVE LUMBAR

SPONDYLOSIS MANAGED CONSERVATIVELY BY ANALGESICS,CALCIUM SUPPLEMENTSAND

PHYSIOTHERAPY.

1. TAB. XYKAA 1 GM PO/BD

2. TAB. PAN 40 MG PO/OD

3. TAB. SHELCAL CT PO/OD

4.PHYSIO IFT LOW BACK

5. PHYSIO BACK STRENGTHENING EXCERCISE

Advice at Discharge

1. TAB. XYKAA 1 GM PO/BD X 7 DAYS

2. TAB. PAN 40 MG PO/OD X 7 DAYS

3. TAB. SHELCAL CT PO/OD X 7 DAYS

4.PHYSIO IFT LOW BACK X 7 DAYS

5. PHYSIO BACK STRENGTHENING EXCERCISE

CERVICAL SPONDYLOSIS

Case History and Clinical Findings

C/O NECK PAIN RADIATING TO LEFT UPPER LIMB SINCE 2 DAYS

TINGLING -

NUMBNESS -

PATIENT WAS APPARENTLY ALRIGT 3 DAYS AGO THEN DEVELOPED NECK PAIN RADIATING

TO LEFT UPPER LIMBWHICH IS INSIDIOUS IN ONSET PROGESSIVE IN NATURE

AGGRAVATED ON MOVEMENTS RELIVED WITH MEDICATION

N/K/C/O HTN , DM , EPILEPSY , ASTHMA , TB , CAD ,CVA

GENERAL EXAMINATION

PT IS C/C/C

TEMP 98.2 F

PR 88 BPM

RR- 19 CPM

BP-120/70 MMHG

SPO2 98% RA

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

LOCAL EXAMINATION C SPINE

SKIN - NORMAL

SWELLING - ABSENT

TENDERNESS - ABSENT

LOCAL RISE OF TEMPERATURE- ABSENT

ROM FLEXION - 0-45

EXTENSION - 0-45

DISTAL PULSES- PRESENT

SENSATIONS INTACT

SPURLING TEST POSITIVE

Treatment Given(Enter only Generic Name)

TAB XYKAA 1 PO/BD

TAB PAN 40 MG PO/OD

TAB SHELCAL PO/OD

PHYSIO ICT NECK

Advice at Discharge

TAB XYKAA 1 PO/BD X 7 DAYS

TAB PAN 40 MG PO/OD X 7 DAYS

TAB SHELCAL PO/OD X 15 DAYS

PHYSIO ICT NECK

B/L OSTEOARTHRITIS OF KNEE

Case History and Clinical Findings

CHIEF COMPLAINTS:

PATIENT CAME WITH CHIEF COMPLAINT OF B/L KNEE PAIN SINCE 3 YEARS.

B/L ANKLE PAIN SINCE 2 YEARS.

NO H/O TRAUMA

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC3 YEARSAGO THEN HE DEVELOPED B/L

KNEE PAIN,WHICH IS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE,AGGRAVATED ON

MOVEMENT,NOT RELIEVED ON REST.

NOT ASSOCIATED WITH URINARY INCONTINENCE

NO H/O TRAUMA

NO H/O FEVER, VOMITINGS, LOOSE STOOLS,HEAD INJNURY,LOC,BURNING

MICTURITION,BLADDER AND BOWEL INCONTINENCE

PAST HISTORY:

K/C/O HTN AND DM SINCE 1 YEAR ON MEDICATION

N/K/C/O TB , ASTHMA,EPILEPSY

GENERAL EXAMINATION:

TEMP - 98.4F

PR 82 BPM

RR- 18CPM

BP-110/80 MMHG

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF RIGHT KNEE

SKIN- NORMAL

SWELLING SUPRAPATELLAR

NO LOCAL RISE OF TEMPERATURE

TENDERNESS DIFFUSE

ROM- 0-110 DEGREE

CREPITUS +

SENSATIONS - INTACT

DISTAL PULSES +

LOCAL EXAMINATION OF LEFT KNEE

SKIN- NORMAL

SWELLING SUPRAPATELLAR

NO LOCAL RISE OF TEMPERATURE

TENDERNESS DIFFUSE

ROM- 0-110 DEGREE

CREPITUS+

SENSATIONS - INTACT

DISTAL PULSES +

Treatment Given(Enter only Generic Name)

PATIENT WAS CLINICORADIOLOGICALLY DIAGNOSED AS BILATERAL OA KNEE TREATED

CONSERVATIVELY WITH ANALGESICS,CALCIUM SUPPLEMENTS AND PHYSIOTHERAPY.

Advice at Discharge

1. TAB. XYKAA 1GM PO/BD X 1WEEK

2. TAB. PAN 40 MG PO/OD X 1WEEK

3. TAB. SHELCAL-CT PO/OD PO/OD X 2WEEKS

RHEMATOID ARTHRITIS

Case History and Clinical Findings

C/O POLYARTHALGIA PRESENT SINCE 7 YEARS (NECK PAIN ,ELBOW ,FINGER

JOINTS,KNEE,ANKLE AND FIST METACARPAL JOINT)

HISTORY OF PRESENT ILLNESS:-

PATIENT WAS APPARENTLY ALRIGHT 1 YEAR AGO,THENHE DEVELOPED POLYARTHALGIA

WHICH IS INSIDUOUS IN ONSET,GRADUALLY PROGRESSIVE FROM NECK-B/L SHOULDERS-

B/L ELBOWS-WRIST-MCP JOINT- ANKLE.

ASSOCIATED WITH MORNING STUFFNESS,FEVER ON AND OFF, SWELLING AT WRIST

AGGREVATED BY WALKING,EATING MEAT

RELIEVED BY REST AND PAIN MEDICATIONS.

PAST HISTORY:-

K/C/O HYPERTENSION ON TAB.TELMA 40 MG SINCE 5 YEARS

EULAR CRITERIA:-

JOINT INVOLVEMENT- MORE THAN 10 JOINTS - 5

SEROLOGY - LOW POSTIVE RA FACTOR -2

ACUTE PHASE REACTANTS-O

DURATION OF SYMPTOMS- MORE THAN 6 WEEKS - 1

TOTAL 8/10--DEFINITE RHEUMATOID ARTHRITIS

Investigation

COMPLETE BLOOD PICTURE (CBP) 28-02-2025HAEMOGLOBIN 10.6 gm/dlTOTAL COUNT 8100

cells/cummNEUTROPHILS 49 %LYMPHOCYTES 40 %EOSINOPHILS 02 %MONOCYTES 09

%BASOPHILS 00 %PLATELET COUNT 2.59SMEAR Normocytic normochromic Anemia

COMPLETE URINE EXAMINATION (CUE) 28-02-2025COLOUR Pale yellowAPPEARANCE

ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS

NilPUS CELLS 2-3EPITHELIAL CELLS 2-4RED BLOOD CELLS NilCRYSTALS NilCASTS

NilAMORPHOUS DEPOSITS AbsentOTHERS NilRFT 28-02-2025 06:15:PMUREA 20

mg/dlCREATININE 1.2 mg/dlURIC ACID 5.0 mmol/LCALCIUM 9.9 mg/dlPHOSPHOROUS 3.5

mg/dlSODIUM 136 mmol/LPOTASSIUM 5.2 mmol/L.CHLORIDE 99 mmol/L

LIVER FUNCTION TEST (LFT) 28-02-2025Total Bilurubin 0.88 mg/dlDirect Bilurubin 0.20

mg/dlSGOT(AST) 22 IU/LSGPT(ALT) 15 IU/LALKALINE PHOSPHATASE 225 IU/LTOTAL

PROTEINS 6.4 gm/dlALBUMIN 3.63 gm/dlA/G RATIO 1.31

Treatment Given(Enter only Generic Name)

PATIENT WAS CLINICALLY DIAGNOSED AS RHEUMATOID ARTHRIRTIS,TREATED

CONSERVATIVELY WITH ANALGESICS,ANTI RHEUMATOID MEDICATIONS AND CALCIUM

SUPPLEMENTS

T HIFENAC P PO BD

T PAN 40MG PO BD

T SHELCAL CT PO OD

T TELMA 40 MG PO OD

Advice at Discharge

T HIFENAC P PO BD FOR 1 WEEK

T PAN 40MG PO BDFOR 1 WEEK

T SHELCAL CT PO ODFOR 1 WEEK

T TELMA 40 MG PO ODFOR 1 WEEK

T HCQ 200 MG PO BD FOR 14 DAYS

Follow Up

REVIEW AFTER 2 WEEKS OR SOS ON TUESDAY OT FRIDAY

B/L OSTEO ARTHRITIS OF KNEE

Case History and Clinical Findings

COMPLAINS OF BILTERAL KNEE PAIN SINCE 6 MONTHS

NO H/O TRAUMA

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 6MONTHS AGO THEN HE DEVELOPED

PAIN OVER BOTH KNEE PAIN WHICH WAS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE

IN NATURE NOT ASSOCIATED WITH ANY SWELLING AGGRAVATED ON MOVEMENTS

UNABLE TO SQUATT

NO H/O TRAUMA

NO H/O FEVER, VOMITINGS, LOOSE STOOLS,HEAD INJNURY,LOC,BURNING

MICTURITION,BLADDER AND BOWEL INCONTINENCE

PAST HISTORY:

N/K/C/O HTN DM, TB , ASTHMA,EPILEPSY

GENERAL EXAMINATION:

TEMP - 98.4F

PR 82 BPM

RR- 18CPM

BP-110/80 MMHG

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF RIGHT KNEE

FFD -10

SKIN- NORMAL

SWELLING MILD PARAPATELLAR

NO LOCAL RISE OF TEMPERATURE

TENDERNESS + IN MJL

ROM- 0-130 DEGREE

VARUS- 5 DEGREE

CREPITUS- PRESENT

SENSATIONS - INTACT

DISTAL PULSES +

FFD 10 DEGREE

LOCAL EXAMINATION OF LEFT KNEE

FFD -10

SKIN- NORMAL

SWELLING MILD PARAPATELLAR

NO LOCAL RISE OF TEMPERATURE

TENDERNESS + IN MJL

ROM- 0-130 DEGREE

VARUS- 5 DEGREE

CREPITUS- PRESENT

SENSATIONS - INTACT

DISTAL PULSES +

FFD 10 DEGREE

Investigation

COMPLETE BLOOD PICTURE (CBP)HAEMOGLOBIN 10.5 gm/dlTOTAL COUNT

7400cells/cummNEUTROPHILS 64 %LYMPHOCYTES 26 %EOSINOPHILS 03%MONOCYTES

07%BASOPHILS 00 %PLATELET COUNT 1.9SMEAR Normocytic normochromic

COMPLETE URINE EXAMINATION (CUE)COLOUR Pale yellowAPPEARANCE ClearREACTION

AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR TRACEBILE SALTS NilBILE PIGMENTS NilPUS

CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS

DEPOSITS AbsentOTHERS Nil

RBS

130 MG/DL

ESR

45MM/1ST HR

RFTUREA 50 mg/dlCREATININE 4.2 mg/dlURIC ACID 4.8mmol/LCALCIUM 9.8

mg/dlPHOSPHOROUS 35 mg/dlSODIUM 137 mmol/LPOTASSIUM 3.6 mmol/L.CHLORIDE

105mmol/L

LIVER FUNCTION TEST (LFT)Total Bilurubin 0.68 mg/dlDirect Bilurubin 0.17 mg/dlSGOT(AST) 16

IU/LSGPT(ALT) 11IU/LALKALINE PHOSPHATASE 356 IU/LTOTAL PROTEINS 6.5 gm/dlALBUMIN

4.305 gm/dlA/G RATIO 1.65

Treatment Given(Enter only Generic Name)

PT WAS CLINICORADIOLOGICALLY DIAGNOSED WITHB/L OSTEOARTHRITIS KNEE AND

CONSERVATIVE TREATED WITH

1.TAB ULTRACET PO/BD

2.TAB PAN 40MG PO/BD

3.TAB NUROKIND

4.PHYSIO IFT B/L KNEE

Advice at Discharge

1.TAB ULTRACET PO/BD X 5 DAYS

2.TAB PAN 40MG PO/BDX 5 DAYS

3.TAB NEUROKIND PO/ODX 10 DAYS

4.TAB SHELCAL CT PO/ODX 10 DAYS

GRADE II L4-L5 SPONDYLOLISTHESIS

BILATERAL OA KNEE

Case History and Clinical Findings

C/O LOW BACK ACHE SINCE 6 MONTHS

B/L KNEE PAIN SINCE 3 MONTHS

PATIENT WAS APPARENTLY ALRIGHT 6 MONTHS AGO THE SHE DEVELOPED BACK ACHE

WHICH IS INCIDIOUS IN ONSET GRADUALLY PROGESSIVE , AGGRAVATED ON WALKING

RELIVED BY REST AND MEDICATION , RADIATING TO BOTH LOWER LIMBS

NO URINARY INCONTENCE

TINGLING AND NUMBNESS OVER MEDIAL HALF OF LEFT FOOT

BILATERAL KNEE PAIN WHICH IS INCIDIOUS IN ONSET GRADUALLY PROGESSIVE

AGGRAVATED ON MOVEMENTS AND RELIVED ON REST AND MEDICATIONS

NO H/O TRAUMA

PAST HISTORY -K/C/O HTN AND SINCE 2 YEARS

?H/O LEFT SIDE HEMIPLEGIA

ON EXAMINATION

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY ,EDEMA

TEMP:AFEBRILE

PR:82BPM

RR:20CPM

BP:110/90MMHG

CVS- S1,S2 HEARD NO MURMURS

RS-BAE +NVBS

PA- SOFT ,NON TENDER

CNS-NFND

GAIT STABLE

SKIN- NOREMAL

NO DEFORMITY SEEN

NO LOCAL RISE OF TEMPERATURE

TENDERNESS L5

HIP:

FLEXION: 5/5 5/5

EXTENSION: 5/5 5/5

KNEE:

FLEXION: 5/5 4/5

EXTENSION: 5/5 4/5

ANKLE:

DORSIFLEXION: 5/5 3/5

PLANTARFLEXION: 5/5 3/5

EHL 5/5 3/5

FHL 5/5 3/5

SENSATIONS: INTACT INTACT

DISTAL PULSES: PRESENT REDUCED

LOCAL EXAMINATION OF KNEE

PATIENT IS IN SUPINE POSITION WITH BOTH KNEE PATELLA AND MEDIAL MALLEOUS ARE

AT SAME POSITION CALCALEUM TOUCHING HAND COUCH

SKIN- NORMAL NORMAL

SWELLING DIFFUSE DIFFUSE

LOCAL RISE - -

OF TEMPERATURE

TENDERNES: MJL, LJL MJL, LJL

CREPITUS PRESENT PRESENT

FFD 10 10

ROM 0-90 0-70

SENSATIONS:INTACT INTACT

DISTAL PULSES : FELT FELT

Treatment Given(Enter only Generic Name)

TAB HIFENAC P PO/BD

TAB PAN 40MG PO/OD

TAB SHELCAL CT PO/OD

PHYSIO BILATERAL KNEE

Advice at Discharge

TAB HIFENAC P PO/BD X 7 DAYS

TAB PAN 40MG PO/OD X 7 DAYS

TAB SHELCAL CT PO/OD X 15 DAYS

PHYSIO BILATERAL KNEE

L4-L5 SPONDYLOLISTHESIS

Case History and Clinical Findings

C/O LOWER BACK PAIN, RADIATING TO LOWER LIMBS SINCE 2 YEARS

NUMBNESS +

TINGLING+

HISTORY OF PRESENT ILLNESS:

THE PATIENT WAS APPARTENTLY NORMAL 2 YEARS BACK THEN SHE DEVELOPED LOWER

BACK PAIN RADIATING TO LOWER LIMBS ASSOCIATED WITH NUMBNESS +,TINGLING+,

INSIDIOUSIN ONSET, SLOWLY PROGRESSIVE , AGGRAVATED ON MOVEMENTS AND

RELIVED ON TAKING REST

PAST HISTORY:

K/C/O DM SINCE 3 YEARS

N/K/C/O HTN, CVA, CAD, ASTHMA, EPILEPSY, TB, THYROID DISORDERS

GENERAL EXAMINATION:

TEMP. - AFEBRILE

BP - 110/80 MM/HG

PR - 82 BPM

RR - 18 CPM

SPO2 - 99%

SYSTEMIC EXAMINATION:

CVS - S1,S2 +

CNS - NFND

RS - BAE+

P/A - SOFT, NON TENDER

LOCAL EXAMINATION OF LS SPINE:

SKIN - NORMAL

SWELLING - ABSENT

LOCAL RISE IN TEMP. - ABSENT

TENDERNESS- PRESENT L4-L5 PARASPINAL REGION

LT RT

SLRT 90 90

POWER 5/5 5/5

HIP 5/5 5/5

KNEE 5/5 5/5

ANKLE 5/5 5/5

FHL 5/5 5/5

EHL 5/5 5/5

SENSATIONS INTACT INTACT

DISTAL PULSES FELT FELT

Investigation

COMPLETE BLOOD PICTURE (CBP)HAEMOGLOBIN 10.7 gm/dlTOTAL COUNT 9900

cells/cummNEUTROPHILS 54 %LYMPHOCYTES 36 %EOSINOPHILS 02 %MONOCYTES 08

%BASOPHILS 00 %PLATELET COUNT 2.47SMEAR Normocytic normochromic

COMPLETE URINE EXAMINATION (CUE)COLOUR Pale yellowAPPEARANCE ClearREACTION

AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS

2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS

DEPOSITS AbsentOTHERS Nil

SERUM ELECTROLYTESSODIUM 141 mmol/LPOTASSIUM 3.9 mmol/LCHLORIDE 103 mmol/L

RANDOM BLOOD SUGAR: 94 mg/dL

THYROID PROFILE T3 1.2 ng/ml, T4 11.7 µg/ml, TSH 2.24 µIU/ml

APTT 32.00 Seconds ESR20 mm/1st hr

CRP: NEGATIVE

BLEEDING TIME 2:30 MINUTES

CLOTTING TIME 4:30MINUTES

PT 16.0 Seconds, INR 1.11

BLOOD GROUPING AND RH TYPING: O POSITIVE

LIVER FUNCTION TEST

TOTAL BILIRUBIN 0.60 mg/dL

DIRECT BILIRUBIN 0.19 mg/dL

SGOT (AST) 24 IU/L

SGPT (ALT) 27 IU/L

ALKALINE PHOSPHATASE 174 IU/L

TOTAL PROTEINS 7.6 g/dL

ALBUMIN4.5 g/dL

GLOBULIN 3.10 gm/dL

A/G 1.45

RENAL FUNCTION TEST

UREA 20.00 mg/dL

CREATININE 1.10 mg/dL

URIC ACID 4.50 mg/dL

CALCIUM 9.6 mg/dL

PHOSPHORUS 4.0 mg/dL

SODIUM 135 mmol/L

POTASSIUM 3.7 mmol/L

CHLORIDE 99 mmol/L

HBsAg-RAPID Negative

Anti HCV Antibodies - RAPID Non Reactive

HIV - RAPID - NON REACTIVE

Treatment Given(Enter only Generic Name)

PATIENT CLINICORADIOLOGICALLY DIAGNOSED AS L4-L5 SPONDYLOLISTHESIS AND

PLANNED FOR L4-L5 PSF + L4 LAMINECTOMY + PLIF UNDER GA

ORDERS FOLLOWED

SURGERY DONE ON 23/10/25

T. XYKAA 1GM PO/BD

T. GABAPENTIN 100MG PO/HS

T. PAN 40MG PO/OD

T. SHELCAL CT PO/OD

T. EVION LC PO/BD

T. CEFTAS CL 200MG PO/BD

T. EVTOV ER 40MG PO/BD

T. DEFCORT 6MG PO/OD

T. TRIGABANTIN 300MG PO/HS

PHYSIO HAMSTRING EXERCISES

Advice at Discharge

T. PAN 40MG PO/OD X 10 DAYS

T. EVION LC PO/BDX 10 DAYS

T. CEFTAS CL 200MG PO/BD X 5 DAYS

T. EVTOV ER 40MG PO/BDX 10 DAYS

T. TRIGABANTIN 300MG PO/HS X10 DAYS

PHYSIO HAMSTRING EXERCISES

B/L OA KNEE WITH HYPERTENSION

Case History and Clinical Findings

CHIEF COMPLAINTS-

PATIENT CAME WITH CHIEF COMPLAINT OF B/L KNEE PAIN SINCE 8 YEARS

NO H/O TRAUMA

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 8 YEAR AGO THEN SHE DEVELOPED

PAIN OVER BOTH KNEE PAIN WHICH WAS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE

IN NATURE AGGRAVATED ON MOVEMENTS AND NOT RELIEVED ON REST AND MEDICATION

NO H/O FEVER, VOMITINGS, LOOSE STOOLS,HEAD INJNURY,LOC,BURNING

MICTURITION,BLADDER AND BOWEL INCONTINENCE

PAST HISTORY:

K/C/O HTN AND SINCE 5 YEARS

N/K/C/O DM, TB , ASTHMA,EPILEPSY

GENERAL EXAMINATION:

TEMP - 98F

PR 74 BPM

RR- 16CPM

BP-110/70 MMHG

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF RIGHT KNEE

FFD -10

SKIN- NORMAL

SWELLING MILD PARAPATELLAR

NO LOCAL RISE OF TEMPERATURE

TENDERNESS PRESENT OVER MJL

ROM- 0-100 DEGREE

VARUS- 5 DEGREE

CREPITUS- PRESENT

SENSATIONS - INTACT

DISTAL PULSES +

FFD 10 DEGREE

LOCAL EXAMINATION OF LEFT KNEE

FFD -10

SKIN- NORMAL

SWELLING MILD PARAPATELLAR

NO LOCAL RISE OF TEMPERATURE

TENDERNESS PRESENT

ROM-10-100 DEGREE

VARUS- 5 DEGREE

CREPITUS- PRESENT

SENSATIONS - INTACT

DISTAL PULSES +

FFD 10 DEGREE

Investigation

RFT 17-06-2025 06:32:PMUREA 26 mg/dlCREATININE 0.7 mg/dlURIC ACID 3.1 mmol/LCALCIUM

10.0 mg/dlPHOSPHOROUS 3.7 mg/dlSODIUM 139 mmol/LPOTASSIUM 3.7 mmol/L.CHLORIDE 102

mmol/L

LIVER FUNCTION TEST (LFT) 17-06-2025 06:32:PMTotal Bilurubin 0.51 mg/dlDirect Bilurubin 0.14

mg/dlSGOT(AST) 15 IU/LSGPT(ALT) 11 IU/LALKALINE PHOSPHATASE 194 IU/LTOTAL

PROTEINS 7.0 gm/dlALBUMIN 4.27 gm/dlA/G RATIO 1.56COMPLETE BLOOD PICTURE (CBP) 17-

06-2025 06:34:PMHAEMOGLOBIN 11.4 gm/dlTOTAL COUNT 7700 cells/cummNEUTROPHILS 51

%LYMPHOCYTES 37 %EOSINOPHILS 02 %MONOCYTES 10 %BASOPHILS 00 %PLATELET

COUNT 3.2SMEAR Normocytic normochromic

COMPLETE URINE EXAMINATION (CUE) 17-06-2025 06:34:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN TraceSUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilInvestigationsName

Value

Name ValueRFT 17-06-2025 06:32:PMUREA 26 mg/dlCREATININE 0.7 mg/dlURIC ACID 3.1

mmol/LCALCIUM 10.0 mg/dlPHOSPHOROUS 3.7 mg/dlSODIUM 139 mmol/LPOTASSIUM 3.7

mmol/L.CHLORIDE 102 mmol/L

LIVER FUNCTION TEST (LFT) 17-06-2025 06:32:PMTotal Bilurubin 0.51 mg/dlDirect Bilurubin 0.14

mg/dlSGOT(AST) 15 IU/LSGPT(ALT) 11 IU/LALKALINE PHOSPHATASE 194 IU/LTOTAL

PROTEINS 7.0 gm/dlALBUMIN 4.27 gm/dlA/G RATIO 1.56COMPLETE BLOOD PICTURE (CBP) 17-

06-2025 06:34:PMHAEMOGLOBIN 11.4 gm/dlTOTAL COUNT 7700 cells/cummNEUTROPHILS 51

%LYMPHOCYTES 37 %EOSINOPHILS 02 %MONOCYTES 10 %BASOPHILS 00 %PLATELET

COUNT 3.2SMEAR Normocytic normochromic

COMPLETE URINE EXAMINATION (CUE) 17-06-2025 06:34:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN TraceSUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

Treatment Given(Enter only Generic Name)

PT WAS CLINICORADIOLOGICALLY DIAGNOSED AS B/L OA KNEE AND CONSERVATIVE

TREATMENT IS GIVEN

1.TAB. XYKAA 1GM PO/OD

2.T PAN 40MG PO OD

3.TAB SHELCAL PO/OD

4.PHYSIO IFT B/L KNEE

5. TAB . TELMISARTAN 40 MG PO/OD

Advice at Discharge

1.TAB. XYKAA 1GM PO/OD X 5 DAYS

2.T PAN 40MG PO ODX 5 DAYS

3.TAB SHELCAL PO/ODX 5 DAYS

4.PHYSIO IFT B/L KNEE

5. TAB . TELMISARTAN 40 MG PO/OD

BILATERALOSTEOARTHRITIS WITH HTNWITH TYPE 2 DM

Case History and Clinical Findings

C/O PAIN IN B/L KNEE SINCE 2 YEARS

C/O LT HIP PAIN SINCE 1 YEARS

NO H/O TRAUMA

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 YEARS AGO LATER SHE DEVELOPED PAIN

OVER BOTH KNEES. PAIN INSIDIOUS IN ONSET, PROGRESSIVE NATURE. PAIN

AGGRAVATED ON REGULAR ACTIVITIES AND RELIEVED ON TAKING REST AND MEDICATION

C/O LT HIP PAIN SINCE 1 YEARS

NO H/O TRAUMA

NO H/O FEVER

NO H/O BOWEL AND BLADDER INCONTINENCE

PAST HISTORY;

K/C/O HTN AND DM SINCE 3 YEARS

N/K/C/O TB/EPILEPSY / ASTHAMA/ CAD

NO PREVIOUS SURGICAL HISTORY

ON EXAMINATION

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY ,EDEMA

TEMP:98.6 F

PR:82 BPM

RR:20CPM

BP:130/90MMHG

SYSTEMIC EXAMINATION

CVS- S1,S2 HEARD NO MURMURS

RS-BAE +NVBS

PA- SOFT ,NON TENDER

CNS-NFND

L/E OF B/L KNEE:

PT IS IN SUPINE POSITION ON HARD COUCH AT BOTH ASIS AT SAME LEVEL

RIGHT LEFT

SKIN NORMAL NORMAL

SWELLING MILD PREPATELLAR MILD PREPATELLAR

TENDERNESS PRESENT ON MEDIAL ASPECT PRESENT ON MEDIAL ASPECT

PATELLAR TAP PRESENT PRESENT

VARUS 5 5

FFD 10 10

ROM 0-90 10-90

CREPITUS PRESENT PRESENT

SENSATIONS:INTACT INTACT

DISTAL PULSES : FELT FELT

Investigation

COMPLETE BLOOD PICTURE (CBP) 23-07-2025 09:30:PMHAEMOGLOBIN 11.4 gm/dlTOTAL

COUNT 9500 cells/cummNEUTROPHILS 56 %LYMPHOCYTES 32 %EOSINOPHILS 04

%MONOCYTES 08 %BASOPHILS 00 %PLATELET COUNT 2.40SMEAR Normocytic

normochromicCOMPLETE URINE EXAMINATION (CUE) 23-07-2025 09:30:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR +BILE

SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilRFT 23-07-2025

09:30:PMUREA 39 mg/dlCREATININE 1.1 mg/dlURIC ACID 4.1 mmol/LCALCIUM 9.9

mg/dlPHOSPHOROUS 3.8 mg/dlSODIUM 138 mmol/LPOTASSIUM 3.6 mmol/L.CHLORIDE 101

mmol/LLIVER FUNCTION TEST (LFT) 23-07-2025 09:30:PMTotal Bilurubin 0.65 mg/dlDirect

Bilurubin 0.17 mg/dlSGOT(AST) 11 IU/LSGPT(ALT) 10 IU/LALKALINE PHOSPHATASE 181

IU/LTOTAL PROTEINS 6.7 gm/dlALBUMIN 4.18 gm/dlA/G RATIO 1.66

Treatment Given(Enter only Generic Name) PATIENT WAS CLINICORADIOLOGICALLY DIAGNOSED ASBILATERALOSTEOARTHRITIS KNEE

AND CONSERVATIVELY TREATED WITH BELOW MEDICATION. NOW PATIENT IS BEING

DISCHARGED IN STABLE CONDITION WITH BELOW MEDICATIONS

1.T XYKA 1GM PO/BD

2.T PAN 40MG PO/OD

3. T.SHELCAL CT PO/OD

4. IFT B/L KNEE ,B/L KNEE ROM EXERCISE

Advice at Discharge

1.T XYKA 1GM PO/BD X 5 DAYS

2.T PAN 40MG PO/ODX 5 DAYS

3. T.SHELCAL CT PO/ODX 15 DAYS

4. B/L KNEE ROM EXERCISE

CKD STAGE IIIb

CERVICAL SPONDYLOSIS

LUMBAR SPONDYLOSIS

B/L OSTEOARTHRITIS OF KNEE

Case History and Clinical Findings

C/O GENERALISED WEAKNESS SINCE 1 MONTH

C/O B/L KNEE PAIN SINCE 1 YEAR

C/O BACKPAIN SINCE 1 YEAR

HOPI PATIENT WAS APPARENTLY ASYMPTOMATIC 1 YEAR AGO ,AND THEN DEVELOPED

KNEE PAIN SINCE 1 YEAR NO AGGREVATING AND RELIVING FACTORS ,IT IS A/W

RESTRICTION OF MOVEMENTS ,NIN RADIATING ,NOT ASSOCIATED WITH TINGLING AND

NUMBNESS

PATIENT DEVELOPED BACK PAIN SINCE 1 YEAR AND A/W RESTRICTION OF MOVEMENTS

,NON RADIATING ,N/H/O TINGLING ,NUMBNESS, PARESTHESIAS

PATIENT DEVELOPED GENERALISED WEAKNESS SINCE 1 MONTH ,NOT A/W

SOB,PALPITATIONS, PEDAL EDEMA, SWEATING

PAST HISTORY-

N/H/O SIMILAR COMPLAINTS

N/K/C/O DM ,HTN,EPILEPSY , ASTHMA, CAD, THYRIOD, TB

PERSONAL HISTORY

APPETITE NORMAL

SLEEP ADEQUATE

BOWEL MOVEMENTS REGULAR

BLADDER MOVEMENTS REGULAR

ADDICTIONS :NO

FAMILY HISTORY NOT SIGNIFICANT

GENERAL EXAMINATION

PT IS CONSCIOUS COHERENT COOPERATIVE

NO PALLOR ICTERUS CYANOSIS CLUBBINGLYMPHADENOPATHY,PEDAL EDEMA

VITALS

TEMPERATURE 98F

BP 120/70MMHG

PR 76BPM

RR 18CPM

SPO2 98%AT RA

SYSTEMIC EXAMINATION

CVS - S1S2 HEARD NO MURMURS

PA - SOFT , TENDER

CNS - NO FOCAL NEUROLOGICAL DEFICIT

RS - BAE+ NVBS

USG ABDOMEN AND PELVIS

FINDINGS : E/O FEW CYSTS NOTED IN UPPER POLE OF RIGHT KIDNEY LARGEST

MEASURING 12X 14MM, IN LEFT KIDNEY MEASURING 16X 16 MM IN UPPER POLE.

IMPRESSION : B/L GRADE II RPD CHANGES WITH B/L RENAL CORTICAL CYSTS

Investigation

HBsAg-RAPID 03-03-2025 05:25:PM Negative

Anti HCV Antibodies - RAPID 03-03-2025 05:25:PM Non ReactiveRFT 03-03-2025 05:25:PMUREA

48 mg/dl 50-17 mg/dlCREATININE 2.3 mg/dl 1.3-0.8 mg/dlURIC ACID 5.4 mmol/L 7.2-3.5

mmol/LCALCIUM 9.3 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.7 mg/dl 4.5-2.5 mg/dlSODIUM 136mmol/L 145-136 mmol/LPOTASSIUM 5.0 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 101 mmol/L 98-107mmol/LLIVER FUNCTION TEST (LFT) 03-03-2025 05:25:PMTotal Bilurubin 0.50 mg/dl 1-0 mg/dlDirect Bilurubin 0.17 mg/dl 0.2-0.0 mg/dlSGOT(AST) 19 IU/L 35-0 IU/LSGPT(ALT) 10 IU/L 45-0

IU/LALKALINE PHOSPHATASE 242 IU/L 128-56 IU/LTOTAL PROTEINS 6.2 gm/dl 8.3-6.4

gm/dlALBUMIN 4.17 gm/dl 4.6-3.2 gm/dlA/G RATIO 2.05COMPLETE URINE EXAMINATION (CUE)

03-03-2025 05:25:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY

1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL

CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS

AbsentOTHERS Nil

HEMOGRAM ProvisionalTest Result Units Normal Range MethodHAEMOGLOBIN 9.1 gm/dl 13.0 -

17.0 Colorimetric LOX -PAPTOTAL COUNT 7,400 cells/cumm 4000 - 10000

ImpedenceNEUTROPHILS 55 % 40 - 80 Light MicroscopyLYMPHOCYTES 29 % 20 - 40 Light

MicroscopyEOSINOPHILS 10 % 01 - 06 Light MicroscopyMONOCYTES 06 % 02 - 10 Light

MicroscopyBASOPHILS 00 % 0 - 2 Light MicroscopyPCV 26.5 vol % 40 - 50 CalculationM C V 88.6 fl

83 - 101 CalculationM C H 30.4 pg 27 - 32 CalculationM C H C 34.3 % 31.5 - 34.5 CalculationRDW-

CV 13.2 % 11.6 - 14.0 HistogramRDW-SD 43.8 fl 39.0-46.0 HistogramRBC COUNT 2.99

millions/cumm 4.5 - 5.5 ImpedencePLATELET COUNT 2.57 lakhs/cu.mm 1.5-4.1

ImpedenceSMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits with

increasedeosinophilsLight MicroscopyPLATELETS Adeqaute Light MicroscopyHEMOPARASITES

No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic anemiawith

eosinophili

SERUM ELECTROLYTES (Na, K, C l)Test Result Units Normal Range MethodSODIUM 136 mmol/L

136 - 145 Ion SelectivePOTASSIUM 5.1 mmol/L 3.5 - 5.1 Ion SelectiveCHLORIDE 103 mmol/L 98 -

107 Ion SelectiveCALCIUM IONIZED 1.11 mmol/L Cord Blood : 1.30 - 1.60

Treatment Given(Enter only Generic Name)

T ULTRACET PO/QID

T SHELCAL PO/OD

T MVT PO/OD

T VERTIN 10 MG PO/TID

T OROFER XT PO/BD/BEFORE BREAKFAST

T NODOSIS 500MG PO /OD

K BINDER SACHETS IN 1 LITER WATER PO/TID

SOFT CERVICAL COLLAR

NEB WITH SALBUTAMOL 2 RESP/STAT

Advice at Discharge

T ULTRACET PO/QID FOR 5 DAYS

T MVT PO/OD FOR 15DAYS

T VERTIN 10 MG PO/TID FOR 7 DAYS

T OROFER XT PO/OD/BEFORE BREAKFAST FOR 15 DAYS

T NODOSIS 500MG PO /OD FOR 15 DAYS

K BINDER SACHETS IN 1 LITER WATER PO/TID FOR 1 WEEK

SOFT CERVICAL COLLAR

TYPE 2 DIABETES MELLITUS WITH SENSORY PERIPHERAL NEUROPATHY

LUMAR SPONDYLOSIS

LIPOMA IN LUMBAR REGION

Case History and Clinical Findings

C/O BACK PAIN SINCE 1 MONTH

C/O LEG PAIN SINCE 1 MONYTH

C/O BURNING SENSATION OF EYES SINCE 1 MONTH

HOPI

PATEINT WAS APPARENTLY ASYMPTOMATIC 1 MONTH AGO THE DEVELOPED BACK PAIN

DRAGGING TYPE ,AGGREVATED ON DOING WORK, RELIVED ON REST

H/O LEG PAIN PRICKING TYPE

BURNING SENSATION OS EYE AND SWEELLING OVER THE EYE

N/H/O SOB,CHEST APIN, PAPLPITATIONS, FEVER,COUGH, HEADCHE, VOMITINGS

PAST HISTORY-

N/H/O SIMILAR COMPLAINTS

K/C/O DM II SINCE 3 MONTHS

N/K/C/O HTN,EPILEPSY , ASTHMA, CAD, THYRIOD, TB

PERSONAL HISTORY

APPETITE NORMAL

SLEEP ADEQUATE

BOWEL MOVEMENTS REGULAR

BLADDER MOVEMENTS REGULAR

ADDICTIONS :ALCOHOL OCCASIONALLY,SMOKING DAILY 4

FAMILY HISTORY NOT SIGNIFICANT

GENERAL EXAMINATION

PT IS CONSCIOUS COHERENT COOPERATIVE

NO PALLOR ICTERUS CYANOSIS CLUBBINGLYMPHADENOPATHY,PEDAL EDEMA

VITALS

TEMPERATURE 98F

BP 120/80MMHG

PR 76BPM

RR 18CPM

SPO2 98%AT RA

SYSTEMIC EXAMINATION

CVS - S1S2 HEARD NO MURMURS

PA - SOFT , TENDER

CNS - NO FOCAL NEUROLOGICAL DEFICIT

RS - BAE+ NVBS

Investigation

Name Value Range

Name Value RangeHBsAg-RAPID 22-03-2025 04:42:PM Negative

Anti HCV Antibodies - RAPID 22-03-2025 04:42:PM Non ReactiveCOMPLETE BLOOD PICTURE

(CBP) 22-03-2025 04:42:PMHAEMOGLOBIN 11.3 gm/dl 17.0-13.0 gm/dlTOTAL COUNT 9500

cells/cumm 10000-4000 cells/cummNEUTROPHILS 72 % 80-40 %LYMPHOCYTES 16 % 40-20

%EOSINOPHILS 02 % 6-1 %MONOCYTES 10 % 10-2 %BASOPHILS 00 % 2-0 %PLATELET

COUNT 2.51SMEAR Normocytic normochromic

COMPLETE URINE EXAMINATION (CUE) 22-03-2025 04:42:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilRFT 22-03-2025

04:43:PMUREA 18 mg/dl 42-12 mg/dlCREATININE 1.0 mg/dl 1.3-0.9 mg/dlURIC ACID 5.7 mmol/L

7.2-3.5 mmol/LCALCIUM 10.1 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.8 mg/dl 4.5-2.5

mg/dlSODIUM 140 mmol/L 145-136 mmol/LPOTASSIUM 3.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

105 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 22-03-2025 04:43:PMTotal Bilurubin 0.68 mg/dl 1-0 mg/dlDirect

Bilurubin 0.18 mg/dl 0.2-0.0 mg/dlSGOT(AST) 17 IU/L 35-0 IU/LSGPT(ALT) 23 IU/L 45-0

IU/LALKALINE PHOSPHATASE 146 IU/L 280-53 IU/LTOTAL PROTEINS 6.0 gm/dl 8.3-6.4

gm/dlALBUMIN 4.0 gm/dl 5.2-3.5 gm/dlA/G RATIO 2.05Treatment Given(Enter only Generic Name)

Treatment Given(Enter only Generic Name)

SRICT DIABETIC DIET

T ISTAMET 50/500 PO/BD

T ULTRACET PO/BD

T REJUNEX CD3 PO/OD

Advice at Discharge

SRICT DIABETIC DIET

TAB ISTAMET 50/500 PO/BD TO CONTINUE

TAB ULTRACET PO/BD FOR 5 DAYS

TAB PREGABA-NT 75/10 PO/HS FOR 15 DAYS

TAB REJUNEX CD3 PO/OD FOR 15 DAYS

BILATERAL OSTEOARTHRITIS KNEE

Case History and Clinical Findings

PATIENT CAME WITH COMPLAIINTS OF BL HIP PAIN SINCE 2 YEAR

C/O B/L KNEE PAIN

NO H/O TRAUMA,FEVER

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 YEARS AGO, THEN SHE STARTED

DEVELOPING B/L HIP PAIN WHICH IS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE AND

AGGRAVATED ON MOVEMENTS, RELEIVED ON MEDICATIONS AND REST.

NO H/O TRAUAMA, BURNING MICTURITION,BOWEL AND BLADDER INCONTINENCE

PAST HISTORY:

NOT A KNOWN CASE OF DM, HYPERTENSION, CAD, CVA AND THYROID DISORDERS

GENERAL EXAMINATION:

PT IS C/C/C

TEMP 98.2 F

PR 88 BPM

RR- 20CPM

BP-120/60 MMHG

SPO2 98% RA

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF SPINE : ATTITUDE: PATIENT LYING IN SUPINE POSITION AND BOTH

ASIS AT SAME LEVEL

GAIT :WADDLING

SWELLING : ABSENT

SKIN: NORMAL

LOCAL RISE IN TEMPERATURE : ABSENT

TENDERNESS : PRESENT

LEFT RIGHT

FLEXION 60 DEGREE 60DEGREE

EXTENSION 45 DEGREE 45 DEGREE

ABDUCTION 45 DEGREE 45 DEGREE

ADDUCTION 30 DEGREE 30 DEGREE

INTERNAL ROTATION 30 DEGREE 30 DEGREE

EXTERNAL ROTATION 40 DEGREE 45 DEGREE

SENSATIONS INTACT INTACT

DISTAL PULSES FELT FELT

L/E OF B/L KNEE:

ATTITUDE:PATIENT IS IN SUPINE POSITION,RIGHT HIP IN SLIGHTLY FLEXED

POSITION,RIGHT FOOT EXTERNAL ROTATED,LATERAL BORDER TOUCHING COUCH

RIGHT LEFT

SKIN- NORMAL NORMAL

SWELLING DIFFUSE SWELLING

LOCAL RISE ABSENT ABSENT

OF TEMPERATURE

TENDERNES: MJL, MJL,

CREPITUS PRESENT PRESENT

FFD 5 5

ROM 10-110 5-110

SENSATIONS:INTACT INTACT

DISTAL PULSES : FELT FELT

Investigation

COMPLETE BLOOD PICTURE (CBP) HAEMOGLOBIN 10.5 gm/dlTOTAL COUNT 8300

cells/cummNEUTROPHILS 64 %LYMPHOCYTES 27 %EOSINOPHILS 02 %MONOCYTES 07

%BASOPHILS 00 %PLATELET COUNT 2.26SMEAR Normocytic normochromic anemia

COMPLETE URINE EXAMINATION (CUE) COLOUR Pale yellowAPPEARANCE ClearREACTION

AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS

2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS

DEPOSITS AbsentOTHERS NilRFT UREA 45 mg/dlCREATININE 0.9 mg/dlURIC ACID 2.6

mmol/LCALCIUM 9.3 mg/dlPHOSPHOROUS 3.0 mg/dlSODIUM 143 mmol/LPOTASSIUM 4.1

mmol/L.CHLORIDE 104 mmol/L

LIVER FUNCTION TEST (LFT) Total Bilurubin 0.46 mg/dlDirect Bilurubin 0.19 mg/dlSGOT(AST) 29

IU/LSGPT(ALT) 25 IU/LALKALINE PHOSPHATASE 159 IU/LTOTAL PROTEINS 6.0 gm/dlALBUMIN

3.76 gm/dlA/G RATIO 1.68

Treatment Given(Enter only Generic Name)

PATIENT WAS CLINICO RADIOLOGICALLY DIAGNOSED AS BILATERAL OSTEOARTHRITIS

KNEE.PATIENT MANAGED CONSERVATIVELY.NOW PATIET IS BEING DISCHARGED IN

STABLE CONDITION WITH BELOW MEDICATIONS`

1.TAB .XYKAA 1GM PO/BD

2.TAB PAN 40 MG PO/OD

3.TAB SHELCAL CTPO/OD

4.TAB LIMCEE 500MG PO/BD

5.PHYSIO IFT TO B/L KNEE Q/E

Advice at Discharge

1.TAB .XYKAA 1GM PO/BD X 5DAYS

2.TAB PAN 40 MG PO/OD X 5DAYS

3.TAB SHELCAL CTPO/OD X 15 DAYS

4.PHYSIO B/L KNEE ROM EXRERCISES

5.TAB LIMCEE 500 MG PO/BD

Diagnosis

LUMBAR SPONDYLOSIS

Case History and Clinical Findings

C/O LOWER BACK ACHE RADIATING TO RT LOWER LIMB SINCE 3 MONTHS

TINGLING + NUBNESS +

NO HISTORY OF TRAUMA

HOPI :

THE PATIENT WAS APPARTENTLY NORMAL 3 MONTHS BACK THEN SHE DEVELOPED

LOWER BACK ACHE WHICH WAS GRADUAL IN ONSET, PROGRESSIVE IN NATURE

ASSOCIATED WITH TINGLING AND NUMBNESS .AGGREVATED ON MOVEMENTS AND

RELIEVED ON REST AND MEDICATION

PT C/O KNEE PAIN GRADUAL IN ONSET ,PROGRESSIVE IN NATURE .AGGREVATED ON

MOVEMENTS AND RELIEVES ON REST AND MEDICATION

THE PAIN IS AGGRAVATED ON MOVEMENTS AND RELIVED ON TAKING REST

NO H/O TRAUMA

K/C/O HTN,DM SINCE 2 YEARS

N/C/O CVA, CAD, ASTHMA, EPILEPSY, TB, THYROID DISORDERS

GENERAL EXAMINATION:

TEMP. - AFEBRILE

BP - 110/80 MM/HG

PR - 82 BPM

RR - 18 CPM

SYSTEMIC EXAMINATION:

CVS - S1,S2 +

CNS - NFND

RS - BAE+

P/A - SOFT, NON TENDER

LOCAL EXAMINATION OF LS SPINE:

PT IS IN SUPINE POSITION ON HARD COUCH WITH BOTH ASIS AT SAME LEVEL

DEFORMITY :ABSENT

SKIN - NORMAL

SWELLING - ABSENT

TENDERNESS - ABSENT

RT LT

HIP 5/5 5/5

KNEE 5/5 5/5

ANKLE 5/5 5/5

FHL 5/5 5/5

EHL 5/5 5/5

SENSATIONS INTACT INTACT

DISTAL PULSES FELT FELT

Investigation

COMPLETE BLOOD PICTURE (CBP) 30-06-2025 07:41:PMHAEMOGLOBIN11.4 gm/dlTOTAL

COUNT6400 cells/cummNEUTROPHILS47 %LYMPHOCYTES43 %EOSINOPHILS03

%MONOCYTES07 %BASOPHILS00 %PLATELET COUNT1.96SMEARNormocytic

normochromicInvestigation

Treatment Given(Enter only Generic Name)

PATIENT WAS CLINICO-RADIOLOGICALLY DIAGNOSED WITH LUMBAR SPONDYLSIS

.TREATED CONSERVATIVELY WITH MEDICATION AND PHYSIOTHERAPY.NOW PATIENT IS

BEING DISCHARGED IN STABLE CONDITION WITH BELOW MEDICATION

1.TAB XYKAA 1GM PO/BD

2)TAB PAN 40 MG PO/OD

3)TAB TRIGABAPENTIN 100 MG PO/OD

4)TAB EVION PO/OD

5)TAB SHELCAL CT PO/OD

6)PHYSIO IFT LOW BACK, BILATERAL KNEES

QSE

BACK STRENTHENING EXERCISES

BILATERAL KNEE ROM EXERCISES

Advice at Discharge

1.TAB XYKAA 1GM PO/BD X 5 DAYS

2)TAB PAN 40 MG PO/OD X 5 DAYS

3)TAB TRIGABAPENTIN 100 MG PO/OD X 15 DAYS

4)TAB EVION PO/OD X 15 DAYS

5)TAB SHELCAL CT PO/OD

6)BACK STRENTHENING EXERCISES

BILATERAL KNEE ROM EXERCISES

Diagnosis

CERVICAL SPONDYLOSIS

ALCOHOL AND TOBACCO HARMFUL USE

MIXED ANXIETY AND DEPRESSION

Case History and Clinical Findings

PATIENT CAME WITH C/O LEFT NECK PAIN SINCE 10 DAYS

HOPI:

PATIENT WAS APPAEANTLY ASYMPTOMATIC 10 DAYS AGO AFTER WHICH HE DEVELOPED

NECK PAIN WHICH IS INSIDIOUS IN ONSET,GRADUALLY PROGRESSIVE,AGGREVATED ON

MOVEMENTS,RELIEVED ON REST,RADIATING TO LEFT UPPERLIMB ASSOCIATED WITH

TINGLING OF LEFT HAND FINGERS.

H/O LOW MOOD AND FEARFULNESS TOWARDS LIFE A/W PALPITATIONS OCCASIONALLY

NO H/O HEADACHE,GIDDINESS

NO C/O SIB,PAIN ABDOMEN,NAUSEA,VOMITINGS

NO C/O FEVER,CIUGH,COLD

NO C/O PEDAL EDEMA,FACIAL PUFFINESS

H/O HEAVY WEIGHT LIFTING PRESENT

NO H/O CHEST PAIN ,SOB,PALPITATIONS

PAST HISTORY:

K/C/O HTN,DM SINCE 3 YEARS

N/C/O CVA, CAD, ASTHMA, EPILEPSY,

PATIENT IS C/C/C

NO PALLOR,ICTERUS, CYANOSIS, CLUBBING, LYMPHEDENOPATHY, PEDAL EDEMA

BP: 130/70 MMHG

PR: 88 BPM

RR: 18 CPM

SPO2: 97%

APPETITE- NORMAL

BOWELS- REGULAR

MICTURITION- NORMAL

ADDICITIONS- ALCOHOL (90-180ML/DAY) AND TOBACCO CHEWING SINCE 3 YEARS

SYSTEMIC EXAMINATION :

CVS: S1S2+, NO MURMURS

NO JVP RAISED

RS: BAE+, NVBS +,NO ADDED SOUNDS

CNS:

TONE RIGHT LEFT

UL NORMAL NORMAL

LL NORMAL NORMAL

POWER RIGHT LEFT

UL 5/5 5/5

LL 5/5 5/5

REFLEXES B +2 +2

T +2 +2

S + +

K +2 +2

A + +

P FLEXION FLEXION

P/A: SOFT, NON TENDER, NO ORGANOMEGALY

PSYCHIATRY REFERRAL WAS DONE ON 25/1/25 I/V/O CHRONIC ALCOHOLISM

IMPRESSION:

1.ALCOHOL HARMFUL USE

2. TOBACCO HARMFUL USE

3.MIXED ANXIETY AND DEPRESSION

ADVICE:

1.PATIENT COUNSELLED AND BRIEF PSYCHOTHERAPY GIVEN

2.T.LORAZEPAM 2MG X-X-1

3.T.ESCITALOPRAM 5MG X-X-1

4.T.CLONAZEPAM 0.25MG PO/SOS(WHEN ANXIOUS AND RESTLESS)

Investigation

COMPLETE URINE EXAMINATION (CUE) 24-01-2025 04:20:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

RFT 24-01-2025 04:20:PMUREA 21 mg/dl 42-12 mg/dlCREATININE 0.8 mg/dl 1.3-0.9 mg/dlURIC

ACID 4.4 mmol/L 7.2-3.5 mmol/LCALCIUM 9.5 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 3.7 mg/dl 4.5-

2.5 mg/dlSODIUM 134 mmol/L 145-136 mmol/LPOTASSIUM 4.2 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

102 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 24-01-2025 04:20:PMTotal Bilurubin 0.99 mg/dl 1-0 mg/dlDirect

Bilurubin 0.20 mg/dl 0.2-0.0 mg/dlSGOT(AST) 34 IU/L 35-0 IU/LSGPT(ALT) 26 IU/L 45-0

IU/LALKALINE PHOSPHATASE 146 IU/L 128-53 IU/LTOTAL PROTEINS 6.9 gm/dl 8.3-6.4

gm/dlALBUMIN 4.13 gm/dl 5.2-3.5 gm/dlA/G RATIO 1.49

RBS- 103 MG/DL

HBsAg-RAPID 24-01-2025 04:20:PM Negative

HIV 1/2 RAPID TEST - NON REACTIVEAnti HCV Antibodies - RAPID 24-01-2025 04:20:PM Non

ReactiveHEMOGRAM:HAEMOGLOBIN14.4gm/dl13.0 - 17.0ColorimetricTOTAL

COUNT6,700cells/cumm4000 - 10000ImpedenceNEUTROPHILS54%40 - 80Light

MicroscopyLYMPHOCYTES33%20 - 40Light MicroscopyEOSINOPHILS05%01 - 06Light

MicroscopyMONOCYTES08%02 - 10Light MicroscopyBASOPHILS00%0 - 2Light

MicroscopyPCV39.5vol %40 - 50CalculationM C V94.3fl83 - 101CalculationM C H34.4pg27 -

32CalculationM C H C36.5%31.5 - 34.5CalculationRDW-CV11.7%11.6 - 14.0HistogramRDWSD41.4fl39.0-46.0HistogramRBC COUNT4.19millions/cumm4.5 - 5.5ImpedencePLATELET

COUNT2.90lakhs/cu.mm1.5-4.1ImpedenceSMEARRBCNormocytic normochromicLight

MicroscopyWBCWith in normal limitsLight MicroscopyPLATELETSAdeqauteLight

MicroscopyHEMOPARASITESNo hemoparasites seenLight MicroscopyIMPRESSIONNormocytic

normochromic bloodpicture

Treatment Given(Enter only Generic Name)

1T.BENFOTIAMINE 100 MG PO/BD

2.T.ULTRACET PO/BD

3.T.PAN 40MG PO/OD BBF

4.T.REJUNEX CD3 PO/OD

5.T.PREGABA 75MG PO/HS

6.T.LORAZEPAM 1MG X-X-1

7.T.ESCITALOPRAM 5MG X-X-1

8.T.CLONAZEPAM 0.25MG PO/SOS(WHEN ANXIOUS AND RESTLESS)

Advice at Discharge

1T.BENFOTIAMINE 100 MG PO/BD X 2 WEEKS

2.T.ULTRACET PO/BD X 1 WEEK

3.T.PAN 40MG PO/OD BBFX 1 WEEK

4.T.REJUNEX CD3 PO/ODX 2 WEEKS

5.T.PREGABA 75MG PO/HSX 2 WEEKS

6.T.LORAZEPAM 1MG X-X-1 X5 DAYS

7.T.ESCITALOPRAM 5MG X-X-1 X 2 MONTHS

8.T.CLONAZEPAM 0.25MG PO/SOS(WHEN ANXIOUS AND RESTLESS)

Diagnosis

GRADE 3 B/L OSTEOARTHRITIS KNEE WITH VARUS DEFORMITY WITH DEGENERATIVE

LUMBAR SPONDYLOSIS

HBS AG POSITIVE

Case History and Clinical Findings

CAME WITH C/O BILATERAL KNEE PAIN SINCE 5 YEARS , LOW BACK PAIN SINCE 5 YEARS

HOPI:

PATIENT WAS APPARENTLY ASSYMPTOMATIC 5 YEARS BACK THEN DEVELOPED

BILATERAL KNEE PAIN, INSIDIOUS ONSET GRADUALLY PROGRESSIVE A/W TINGLING

SENSATION OF BOTH LEGS. AGGREVATED ON PROLONGED WORKING AND RELIEVED ON

MEDICATION

C/O LOW BACK ACHE, INSIDIOUS ONSET GRADUALLY PROGRESSIVE AGGREVATED ON

WORK , BENDING DOWN

C/O OCCCASIONAL COPUGH WITH SPUTUM SINCE 2 DAYS

NO H/O COLD, FEVER

NO H/O PAIN ABDOMEN, VOMITINGS, LOOSE STOOLS

NO H/O PEDAL EDEMA, DECREASED URINE OUTPUT, PROFUSE SWEATING

NO H/O POLYPHAGIA, POLYIURIA, POLYDYPSIA

PAST HISTORY;

K/C/O HTN,DM SINCE 5 YEARS

N/C/O CVA, CAD, ASTHMA, EPILEPSY,

PERSONAL HISTORY

APPETITE NORMAL

SLEEP ADEQUATE

BOWEL MOVEMENTS REGULAR

BLADDER MOVEMENTS REGULAR

ADDICTIONS : ALCOHOL- OCCASIONAL SINCE 40 YERS , SMOKING - 4-5 CIGARRETES PER

DAY SINCE 40 YEARS

FAMILY HISTORY NOT SIGNIFICANT

GENERAL EXAMINATION

PT IS CONSCIOUS COHERENT COOPERATIVE

PALLOR NO ICTERUS CYANOSIS CLUBBINGLYMPHADENOPATHY PEDAL EDEMA

VITALS

TEMPERATURE 98F

BP 130/70MMHG

PR 80BPM

RR 18CPM

SPO2 98%AT RA

SYSTEMIC EXAMINATION

CVS - S1S2 HEARD NO MURMURS

PA - SOFT NON TENDER

CNS - NO FOCAL NEUROLOGICAL DEFICIT

RS - BAE+

ORTHO REFERRAL DONE ON 18/2/25 I/V/O B/L KNEE PAIN AND LOW BACK ACHE

DIAGNOSED AS GRADE 3 B/L OSTEOARTHRITIS KNEE WITH VARUS DEFORMITY WITH

DEGENERATIVE LUMBAR SPONDYLOSIS

ADVICED: TAB XYKAA 1GM PO/BD X 7 DAYS

TAB SHELCAL CT PO/OD X 10 DAYS

PHYSIOTHERAPY IFT TO RIGHT AND LEFT KNEE AND LOW BACK

Investigation

NameValueRangeNameValueRangeCOMPLETE URINE EXAMINATION (CUE) 17-02-2025

06:24:PM COLOURPale

yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINNilSUGARNilBILE

SALTSNilBILE PIGMENTSNilPUS CELLS2-3EPITHELIAL CELLS2-3RED BLOOD

CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilRFT 17-02-2025

07:47:PM UREA30 mg/dl50-17 mg/dlCREATININE1.3 mg/dl1.3-0.8 mg/dlURIC ACID3.7 mmol/L7.2-

3.5 mmol/LCALCIUM9.5 mg/dl10.2-8.6 mg/dlPHOSPHOROUS2.6 mg/dl4.5-2.5 mg/dlSODIUM137

mmol/L145-136 mmol/LPOTASSIUM3.5 mmol/L.5.1-3.5 mmol/L.CHLORIDE106 mmol/L98-107

mmol/LLIVER FUNCTION TEST (LFT) 17-02-2025 07:47:PM Total Bilurubin0.66 mg/dl1-0

mg/dlDirect Bilurubin0.18 mg/dl0.2-0.0 mg/dlSGOT(AST)12 IU/L35-0 IU/LSGPT(ALT)11 IU/L45-0

IU/LALKALINE PHOSPHATASE119 IU/L128-56 IU/LTOTAL PROTEINS5.9 gm/dl8.3-6.4

gm/dlALBUMIN3.6 gm/dl4.6-3.2 gm/dlA/G RATIO1.62

Name Value Range

COMPLETE URINE EXAMINATION (CUE) 17-02-2025 06:24:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

RFT 17-02-2025 07:47:PMUREA 30 mg/dl 50-17 mg/dlCREATININE 1.3 mg/dl 1.3-0.8 mg/dlURIC

ACID 3.7 mmol/L 7.2-3.5 mmol/LCALCIUM 9.5 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 2.6 mg/dl 4.5-

2.5 mg/dlSODIUM 137 mmol/L 145-136 mmol/LPOTASSIUM 3.5 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

106 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 17-02-2025 07:47:PMTotal Bilurubin 0.66 mg/dl 1-0 mg/dlDirect

Bilurubin 0.18 mg/dl 0.2-0.0 mg/dlSGOT(AST) 12 IU/L 35-0 IU/LSGPT(ALT) 11 IU/L 45-0

IU/LALKALINE PHOSPHATASE 119 IU/L 128-56 IU/LTOTAL PROTEINS 5.9 gm/dl 8.3-6.4

gm/dlALBUMIN 3.6 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.62

SEROLOGY HBSAG POSITIVE

Treatment Given(Enter only Generic Name)

TAB XYKAA 1GM PO/BD

TAB SHELCAL CT PO/OD 0-1-0

TAB PAN 40MG PO/OD 1-0-0

TAB PREGABA M PO/HS 0-0-1

SYP ASCORYL D 10ML PO 0-0-1

MONITOR VITALS

Advice at Discharge

TAB XYKAA 1GM PO/BD X 7 DAYS

TAB SHELCAL CT PO/OD X 10 DAYS

TAB PAN 40MG PO/OD 1-0-0 X 5 DAYS

TAB PREGABA M PO/HS 0-0-1 X7 DAYS

SYP ASCORYL D 10ML PO 0-0-1 X 7 DAYS

PHYSIOTHERAPY IFT TO RIGHT AND LEFT KNEE AND LOW BACK

Diagnosis

GRADE 1 L3-L4 SPONDYLOLISTHESIS WITH GRADE 4 B/L OA KNEE

CERVICAL SPONDYLOSIS

CHRONIC KIDNEY DISEAS STAGE 3A

K/C/O TYPE 2 DIABETES MELLITUS

DIABETIC NEUROPATHY

Case History and Clinical Findings

C/O CHEST PAIN SINCE 10 DAYS

BACK ACHE SINCE 1 MONTH

KNEE PAIN SINCE 5 YEARS

NECK PAIN SINCE 15 DAYS

TINGLING AND NUMBNESS OF B/L LOWER LIMBS SINCE 6 MONTHS

LOSS OF APPETITE SINCE 10 DAYS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS BACK THEN HE DEVELOPED CHEST

PAIN WHICH WAS INSIDIOUS IN ONSET AND GRADUALLY PROGRESSIVE AND NOT

ASSOCIATED WITH SOB, RADIATING TO ARM AND SHOULDERS, PALPITATIONS.PATIENT

DEVELOPED NECK PAIN NOT ASSOCIATED HEADACHE ,NAUSEA,VOMITING,RESTRICTION

OF MOVEMENTS.

H/O GIDDINESS PRESENT AGGRAVATED WITH NECK PAIN.

PATIENT DEVELOPED KNEE PAIN WHICH WAS INSIDIOUS IN ONSET GRADUALLY

PROGRESSIVE NOT ASSOCIATED WITH RESTRICTION OF MOVEMENMTS, SWELLING .

PATIENT DEVELOPED BACK ACHE ASSOCIATED WITH TINGLING AND NUMBESS TO B/L

LOWER LIMBS

NO H/O COUGH,FEVER ,COLD

NO H/O NAUSEA, VOMITING

NO H/O ABDOMINAL DISCOMFORT, CONSTIPATION,BURNING MICTURITION

PAST HISTORY:

K/C/O HTN SINCE 3 MONTHS NOT ON MEDICATION

K/C/O TYPE 2 DM SINCE 1 1/2YEAR ON TAB.METFORMIN HYDROCHLORIDE 500MG PO/BD

ON TAB.SITAGLIPTIN 50MG PO/BD

PERSONAL HISTORY

MARRIED, MIXED DIET, APPETITE LOST, REGULAR BOWEL AND BLADDER MOVEMENTS,

NO KNOWN ALLERGIES, ADDICTION- STOPPED ALCHOHOL 5 YEARS AGO.

FAMILY H/O - NIL

O/E:

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA.

PRESENTATION VITALS:-TEMPERATURE- AFEBRILEBP - 120/80 MMHGPR- 80 BPMRR-18

CPMSPO2- 98% ON ROOM AIRGRBS 180MG/DLSYSTEMIC EXAMINATION:-CVS-S1,S2

PRESENT, NO MURMURSRS- B/L AE PRESENT. NVBSP/A- SOFT, NO TENDERNESSCNS-TONE

NORMAL IN ALL LIMBSPOWER 5/5 IN ALL LIMBSREFLEXESBICEPS +2 +2TRICEPS + 2

+2SUPINATOR +1 +1KNEE +2 +2ANKLE + 1 +1PLANTAR FLEXION FLEXIONORTHO

REFFERAL:I/V/O KNEE PAIN SINCE 5 YEARS AND BACKPAIN SINCE ONE MONTH.DIAGNOSED

WITH GRADE 1 L3-L4 SPONDYLOLISTHESIS WITH GRADE 4 B/L OA KNEETREATED WITH T.

XYKAA 1G FOR 5 DAYST.PAN 40 MG FOR 5DAYST. SHELCAL CT 15 DAYSPHYSIO-IFT B/L

KNEEDERMA REFFERAL:I/V/O GENERALISED BODY ITCHING.DIAGNOSIS ?PRURITUS ( 2ND

TO RAISED LEVELS OF CREATININE )TREATEMENT LIQUID PARAFFINE BD FOR 2

WEEKSTAB TECZINI 5MG PO SOSOPTHO REFFERALI/V/O DIABETIC RETINOPAHY AND HTN

RETINOPATHYDIAGONISIS NORMAL STUDYNO EVIDENCE OF DIABETIC RETINOPAHY AND

HTN RETINOPATHYCOURSE IN HOSPITAL :60 YEAR OLD MALE CAME WITH C/O C/O CHEST

PAIN SINCE 10 DAYS ,BACK ACHE SINCE 1 MONTH ,KNEE PAIN SINCE 5 YEARS NECK PAIN

SINCE 15 DAYS ,TINGLING AND NUMBNESS OF B/L LOWER LIMBS SINCE 6 MONTHS,LOSS

OF APPETITE SINCE 10 DAYS WITH K/C/O TYPE 2 DIABETIS SINE 1 AND HALF YEAR AND

K/C/O HYPERTENSION SINCE 3 MONTHS.PATIENT WAS INVESTIGATED THOUROUGHLY AND

DIAGNOSED AS CERVICAL SPONDYLOSIS ,GRADE 1 L3-L4 SPONDYLOLISTHESIS WITH

GRADE 4 B/L OA KNEE ,CHRONIC KIDNEY DISEAS STAGE 3A ,K/C/O TYPE 2 DM SINCE 1 1/2

YEAR WITH DIABETIC NEUROPATHY.ORTHOPEDIC OPINION WAS TAKEN AND ADVISED FOR

MRI LS SPINE ,BUT PATIENT WAS NOT WILLING FOR IT SO HE WAS STARTED TREATING

WITH OHAS ,SUPPORTIVE TREATMENT WAS GIVEN. HE WAS IMPROVED CLINICALLY AND

WAS DISCHARGED IN HEMODYNMAMICALLY STABLE CONDITION

Investigation

Name Value RangeRFT 16-05-2025 04:56:PMUREA 46 mg/dl 42-12 mg/dlCREATININE 1.7 mg/dl

1.3-0.9 mg/dlURIC ACID 6.1 mmol/L 7.2-3.5 mmol/LCALCIUM 9.9 mg/dl 10.2-8.6

mg/dlPHOSPHOROUS 3.2 mg/dl 4.5-2.5 mg/dlSODIUM 136 mmol/L 145-136 mmol/LPOTASSIUM

3.8 mmol/L. 5.1-3.5 mmol/L.CHLORIDE 99 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) 16-05-2025 04:56:PMTotal Bilurubin 0.71 mg/dl 1-0 mg/dlDirect

Bilurubin 0.18 mg/dl 0.2-0.0 mg/dlSGOT(AST) 19 IU/L 35-0 IU/LSGPT(ALT) 17 IU/L 45-0

IU/LALKALINE PHOSPHATASE 191 IU/L 128-56 IU/LTOTAL PROTEINS 7.1 gm/dl 8.3-6.4

gm/dlALBUMIN 4.4 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.63COMPLETE URINE EXAMINATION (CUE)

16-05-2025 04:56:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY

1.010ALBUMIN +SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL

CELLS 2-4RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS

AbsentOTHERS Nil

Anti HCV Antibodies - RAPID 16-05-2025 04:56:PM Non ReactiveHBsAg-RAPID 16-05-2025

04:56:PM Negative

POST LUNCH BLOOD SUGAR 16-05-2025 04:59:PM 118 mg/dl 140-0 mg/dl

HEMOGRAM:

HEMOGLOBIN-15GM/DL

TLC-13300 CELLS/CUMM

RBC-4.71MILLIONS /CUMM

PLATELETS -2.65 LAKHS/CUMM

USG ABD AND PELVIS:

B/L GRADE 1 RPD CHANGES

2D ECHO:

NO RWMA

TRIVALENT TR+ ;NO PAH ;NO MR/AR/PR

SCLEROTIC AV ;NO AS/MS;IAS INTACT

EF=60%RVSP=35MM HG

GOOD LV SYSTOLIC DYSFUNCTIONAL

GRADE 1 DIASTOLIC DYSFUNCTIONAL+

MINIMAL PE+;NO LV CLOT

IVC SIZE (0.9CM) COLLAPSING

Treatment Given(Enter only Generic Name)

TAB.METFORMIN 500MG PO/BD

TAB.SITAGLIPTIN 50MG PO/BD

TAB.XYKAA 1GM PO/BD

TAB. PAN 40 MG PO/OD

TAB.TECZINE 5MG PO/SOS

TAB.SHELCAL-CT PO/OD

LIQUID PARAFFIN FOR LOCAL APPLICATION TWICE DAILY

STRICT DIABETIC DIET

Advice at Discharge

STRICT DIABETIC DIET

TAB.METFORMIN 500MG PO/BD TO BE CONTINUED

TAB.SITAGLIPTIN 50MG PO/BD TO BE CONTINUED

TAB.XYKAA 1GM PO/BD FOR 5 DAYS

TAB. PAN 40 MG PO/OD FOR 7 DAYS

TAB.TECZINE 5MG PO/SOS

TAB REJUNEX CD3 PO/OD FOR 30 DAYS

LIQUID PARAFFIN FOR LOCAL APPLICATION TWICE DAILY FOR 2 WEEKS

Diagnosis

CHRONIC KIDNEY DISEASE

? LUMBAR SPONDYLOSIS

? B/L OA KNEE

K/C/O HTN SINCE 5 YEARS

PERIPHERAL NEUROPATHY

Case History and Clinical Findings

C/O LOWER BACK PAIN SINCE 2 MONTHS

HISTORY OF PRESENTING ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS BACK THEN HE DEVELOPED

LOWER BACK PAIN WHICH IS INSIDIOUS IN ONSET ,GRADUALLY PROGRESSIVE ,DRAGGING

TYPE OF PAIN ASSOCIATED WITH TINGLING &NUMBNESS ,WHICH IS NOT RADIATING TO

LOIN TO GROIN , NO HISTORY OF FEVER ,BURNING MICTURITION ,URINARY

INCONTINENCE,PEDALEDEMA ,SHORTNESS OF BREATH, ORTHOPNEA,PND,CHEST PAIN ,

PALPITATIONS,ABDOMINAL DISCOMFORT,HEADACHE,WEAKNESS,GIDDINESS,LOOSE

STOOLS,CONSTIPATION.

HISTORY OF PAST ILLNESS:

K/C/O CKD SINCE 4 YEARS .ON MEDICATION -

SODIUM BICARBONATE PO/OD

SEVELAMER CARBONATE

K/C/O HTN SINCE 5 YEARS ON REGULAR MEDICATION TELMA 20MG PO/OD

K/C/O TYPE 2 DM SINCE 2 YEARS ASTHMSA,EPILEPSY,CVA,CAD

PERSONAL HISTORY

MARRIED, MIXED DIET, APPETITE LOST, REGULAR BOWEL AND BLADDER MOVEMENTS,

NO KNOWN ALLERGIES,NO ADDICTIONS

O/E:-

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA

PRESENTATION VITALS:-

TEMPERATURE- AFEBRILE

BP - 130/80 MMHG

PR- 80 BPM

RR-20 CPM

SPO2- 99% ON ROOM AIR

GRBS 112MG/DL

SYSTEMIC EXAMINATION:-

CVS-S1,S2 PRESENT, NO MURMURS

RS- B/L AE PRESENT. NVBS

P/A- SOFT, NO TENDERNESS

CNSTONE NORMAL IN ALL LIMBS

POWER 5/5 IN ALL LIMBS

REFLEXES

BICEPS +2 +2

TRICEPS + 2 +2

KNEE +2 +2

ANKLE + 1 +1

PLANTAR EXTENSION EXTENSION

Investigation

RFT DONE ON - 26-05-2025 UREA 102 mg/dl 50-17 mg/dlCREATININE 4.3 mg/dl 1.3-0.8

mg/dlURIC ACID 6.1 mmol/L 7.2-3.5 mmol/LCALCIUM 9.9 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 4.3

mg/dl 4.5-2.5 mg/dlSODIUM 138 mmol/L 145-136 mmol/LPOTASSIUM 3.0 mmol/L. 5.1-3.5

mmol/L.CHLORIDE 105 mmol/L 98-107 mmol/L

LIVER FUNCTION TEST (LFT) DONE ON 26-05-2025

Total Bilurubin 0.52 mg/dl 1-0 mg/dlDirect Bilurubin 0.16 mg/dl 0.2-0.0 mg/dlSGOT(AST) 17 IU/L 35-0

IU/LSGPT(ALT) 10 IU/L 45-0 IU/LALKALINE PHOSPHATASE 316 IU/L 128-56 IU/LTOTAL

PROTEINS 7.1 gm/dl 8.3-6.4 gm/dlALBUMIN 4.40 gm/dl 4.6-3.2 gm/dlA/G RATIO 1.63HBsAg-RAPID

DONE ON 26-05-2025 - Negative

Anti HCV Antibodies - RAPID DONE ON 26-05-2025 -Non Reactive

COMPLETE URINE EXAMINATION (CUE) 26-05-2025 05:26:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

ABG 27-05-2025 02:36:PMPH 7.21PCO2 26.9PO2 84.5HCO3 10.5St.HCO3 12.2BEB -15.8BEecf -

15.8TCO2 23.3O2 Sat 95.4O2 Count 10.6

RFT 28-05-2025 UREA 91 mg/dl 50-17 mg/dlCREATININE 4.1 mg/dl 1.3-0.8 mg/dlURIC ACID 6.0

mmol/L 7.2-3.5 mmol/LCALCIUM 9.8 mg/dl 10.2-8.6 mg/dlPHOSPHOROUS 4.5 mg/dl 4.5-2.5

mg/dlSODIUM 140 mmol/L 145-136 mmol/LPOTASSIUM 3.5 mmol/L. 5.1-3.5 mmol/L.CHLORIDE

106 mmol/L 98-107 mmol/L

Treatment Given(Enter only Generic Name)

T. NODOSIS 500MG PO/OD

T. SEVELAMER CARBONATE PO/BD

T. TELMA 20MG PO/OD

T. ULTRACET PO/OD

T. PAN 40MG PO/OD

T. PREGABA NT 75/10 PO/HS

Advice at Discharge

T. NODOSIS 500MG PO/OD TO BE CONTINUED

T. SHELCAL XT PO/OD X 30 DAYS

T. CINOD BETA 10/25 PO/ OD TO BE CONTINUED

T. ULTRACET PO/OD

T. PREGABA NT 75/10 PO/HS X 15 DAYS

TAB. OROFER XT (0-1-0) X 30 DAYS

FLUID RESTRICTION <1.5 LITER/DAY

SALT RESTRICTION <2GM/DAY

Diagnosis

BILATERAL OSTEOARTHRITIS KNEE WITHLUMBAR SPONDYLOSIS

Case History and Clinical Findings

C/O B/L KNEE PAIN SINCE 1MONTH

C/O LOW BACK PAIN RADIATING TO B/L LOWER LIMB SINCE 2MONTHS ,TINGLING+

NO H/O TRAUMA

PATIENT WAS APPARENTLY ASUMPTOMATIC1MONTH AGO THEN DEVELOPEDLOW BACK

PAIN RADIATINGTO LOWER LIMBS ASSOCIATED WITH LOWER LIMBS AND B/L KNEE PAIN

SINCE 2MONTHS WHICH IS INSIDIOUS IN ONSET PROGRESSIVE IN NATURE AGGRAVATED

ON MOVEMENTS AND NOT RELIEVED ON REST AND MEDICATION

K/C/O DM SINCE 2 YEARS

N/K/C/O HTN,EPILEPSY,ASTHMA,CAD,CVA

LOCAL EXAMINATION OF B/L KNEE:[LT>RT]

PATIENT WAS IN SUPINE POSITION ON HARD COUCH WITH BOTH ASIS AT SAME LEVEL

RIGHT LEFT

SWELLING ABSENT ABSENT

SKIN NORMAL NORMAL

TENDERNESS ABSENT PRESENT OVER PATELLA

LOCAL RISE OF TEMPERATURE PRESENT PRESENT

CREPITUS ABSENT PRESENT

PATELLAR TAP ABSENT ABSENT

ROM 0-90 0-70

SENSATIONS INTACT INTACT

DISTAL PULSES PRESENT PRESENT

LOCAL EXAMINATION OF LS SPINE:

DEFORMITY ABSENT

SKIN - NORMAL

SWELLING - ABSENT

TENDERNESS- PRESENT OVER L3-L4 REGION

LT RT

TONE NORMAL NORMAL

SLRL 120 120

HIP 5/5 5/5

KNEE 5/5 5/5

ANKLE 5/5 5/5

SENSATIONS INTACT INTACT

DISTAL PULSES FELT FELT

Treatment Given(Enter only Generic Name)

PT WAS CLINICORADIOLOGICALLY DIAGNOSED WITHBILATERAL OSTEOARTHRITIS KNEE

WITH LUMBAR SPONDYLOSIS AND CONSERVATIVE TREATED WITH

1. TAB. XYKAA 1GM PO/BD

2. TAB. PAN 40 MG PO/OD

3. TAB. SHELCAL CT PO/OD

4.TAB.TRIGABANTIN 100 MG PO/HS

5.T.MYORIL 4MG PO/BD

6.PHYSIO IFT B/L KNEE LOWER BACK

Advice at Discharge

1. TAB. XYKAA 1GM PO/BD FOR 7 DAYS

2. TAB. PAN 40 MG PO/OD X 7 DAYS

3. TAB. SHELCAL CT PO/OD X 14 DAYS

4.TAB.TRIGABANTIN 100 MG PO/HS

5.T.MYORIL 4MG PO/BD

Diagnosis

LUMBAR SPONDYLOSIS WITH B/L OSTEOARTHRITIS KNEE

Case History and Clinical Findings

C/O B/L KNEE PAIN SINCE 15 DAYS

C/O LOW BACK PAIN SINCE 1 MONTH RADIATING TO B/L LOWER LIMBS

TINGLING, NUMBNESS PRESENT

PATIENT WAS APPARENTLY ASUMPTOMATIC 1 MONTH AGO THEN DEVELOPED PAIN IN B/L

KNEE RADIATING TO LOWER LIMBSWHICH WAS INSIDIOUS IN ONSET PROGRESSIVE IN

NATURE AGGRAVATED ON MOVEMENTS

K/C/O HTN 2yrs

N/K/C/O DM, CAD, TB, EPILEPSY, ASTHMA

LOCAL EXAMINATION OF B/L KNEE:

PATIENT WAS IN SUPINE POSITION ON HARD COUCH WITH BOTH ASIS AT SAME LEVEL

RIGHT LEFT

SWELLING PRESENT ABSENT

SKIN NORMAL NORMAL

TENDERNESS PRESENT OVER MTL PRESENT OVER MTL

LOCAL RISE OF TEMPERATURE ABSENT ABSENT

CREPITUS ABSENT PRESENT

PATELLAR TAP ABSENT ABSENT

ROM 0-90 0-90

SENSATIONS INTACT INTACT

DISTAL PULSES PRESENT PRESENT

Treatment Given(Enter only Generic Name)

PATIENT WAS CLINICORADIOLOGICALLY DIAGNOSED AS LUMBAR SPONDYLOSIS WITH B/L

OSTEOARTHRITIS KNEE AND WAS TREATED WITH

1.TAB.XYKAA 1 GM PO/BD

2.TAB.PAN 40 MG PO/OD

3.TAB.SHELCAL CT PO/OD

4.T.TRIGABANTIN 100 MG PO/HS

5.PHYSIO-IFT B/L KNEE AND LOW BACK

Advice at Discharge

1.TAB.XYKAA 1 GM PO/BD X7 DAYS

2.TAB.PAN 40 MG PO/OD X 7 DAYS

3.TAB.SHELCAL CT PO/OD X 14 DAYS

4.T.TRIGABANTIN 100 MG PO/HS

5.PHYSIO-IFT B/L KNEE AND LOW BACK

Diagnosis

B/L OSTEOARTHRITIS OF KNEE

Case History and Clinical Findings

CHIEF COMPLAINTS:

PATIENT CAME WITH CHIEF COMPLAINT OF B/L KNEE PAIN SINCE 10 MONTHS

NO H/O TRAUMA

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 10 MONTHS AGO THEN HE DEVELOPED

B/L KNEE PAIN ,WHICH IS INSIDIOUS IN ONSET GRADUALLY PROGRESSIVE,AGGRAVATED

ON MOVEMENT, RELIEVED ON REST.

NOT ASSOCIATED WITH URINARY INCONTINENCE

NO H/O TRAUMA

NO H/O FEVER, VOMITINGS, LOOSE STOOLS,HEAD INJNURY,LOC,BURNING

MICTURITION,BLADDER AND BOWEL INCONTINENCE

PAST HISTORY:

K/C/O HTN DM SINCE 3YEARS

N/k/C/O TB , ASTHMA,EPILEPSY

GENERAL EXAMINATION:

TEMP - 98.4F

PR 82 BPM

RR- 18CPM

BP-110/80 MMHG

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF RIGHT KNEE

SKIN- NORMAL

SWELLING -

NO LOCAL RISE OF TEMPERATURE

TENDERNESS +

ROM- 0-90DEGREE

CREPITUS -

SENSATIONS - INTACT

DISTAL PULSES +

LOCAL EXAMINATION OF LEFT KNEE

SKIN- NORMAL

SWELLING ABSENT

NO LOCAL RISE OF TEMPERATURE

TENDERNESS +

ROM- 0-90 DEGREE

CREPITUS -

SENSATIONS - INTACT

DISTAL PULSES +

Treatment Given(Enter only Generic Name)

PATIENT WAS CLINICORADIOLOGICALLY DIAGNOSED AS BILATERAL OA KNEE TREATED

CONSERVATIVELY WITH ANALGESICS,CALCIUM SUPPLEMENTS AND PHYSIOTHERAPY.

Advice at Discharge

1. TAB. XYKAA 1GM PO/BD X 1WEEK

2. TAB. PAN 40 MG PO/OD X 1WEEK

3. TAB. SHELCAL-CT PO/OD PO/OD X 2WEEKS

Diagnosis

GRADE I L4-L5 SPONDYLOLISTHESIS WITH DISC BULGE, L2-L3,L3-L4 TOTAL CANAL

STENOSIS

Case History and Clinical Findings

C/O LOW BACK ACHE SINCE 1 YEAR

H/O TRAUMA 1 YEAR BACK(SLIP AND FALL FROM BIKE)

NO H/O LOC/NAUSEA/VOMITING

PATIENT WAS APPARENTLY ALRIGHT 1 YR AGO, THEN SHE STARTED HAVING PAIN IN

LOWER BACK,SUDDEN IN ONSET, GRADUALLY PROGRESSIVE IN NATURE, AGGRAVATED

ON MOVEMENTS, RELIEVED PARTIALLY ON REST AND MEDICATIONS. ASSOSIATED WITH

RADIATING , TINGLING, NUMBNESS TO RIGHT LOWER LIMB FROM HIP TO ANKLE.

NO H/O BLADDER AND BOWEL INCONTINENCE/LOC/NAUSEA/VOMITING

PAST HISTORY:

K/C/O HTN 2 YRS AND ON REGULAR MEDICATIONS

K/C/O BA

N/K/C/O/DM/HYPOTHYROIDSM/CVA/CAD

O/E:

PATIENT IS C/C/C

AFEBRILE

PR- 82 / MIN

BP- 130/90 MM HG

L/E OF SPINE:

SWELLING- NO

SKIN- NORMAL

NO DEFORMITY

LOCAL RISE OF TEMP- ABSENT

TENDERNESS- L5-S1 LEVEL

L R

SLRT 90 90

POWER

HIP 5/5 5/5

KNEE 5/5 5/5

ANKLE 5/5 5/5

EHL 4/5 5/5

FHL 5/5 5/5

SENSATIONS DECREASED INTACT

DISTAL PULSES + +

PULMONOLOGY REFERRAL WAS DONE ON 27/1/25 I/V/O COUGH AND H/O ASTHMA

ADVISED:

NEB WITH DUOLIN 6TH HOURLY

BUDECORT 12TH HOURLY

SYP.ASCORYL -LS 2TSP PO/TID

PULMONOLOGY REVIEW REFERRAL WAS DONE ON 29/01/25 AND ADVICED:

CST

Investigation

COMPLETE BLOOD PICTURE (CBP) 24-01-2025 06:08:PM

HAEMOGLOBIN 11.1 gm/dl

TOTAL COUNT 7700 cells/cumm

NEUTROPHILS 78 %

LYMPHOCYTES 20 %

EOSINOPHILS 00 %

MONOCYTES 02 %

BASOPHILS 00 %

PLATELET COUNT 3.55

SMEAR Normocytic normochromic

COMPLETE URINE EXAMINATION (CUE) 24-01-2025 06:08:PM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN Nil

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 2-3

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS NilCASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

RFT 24-01-2025 06:08:PM

UREA 38 mg/dl

CREATININE 0.9 mg/dl

URIC ACID 3.8 mmol/L

CALCIUM 9.6 mg/dl

PHOSPHOROUS 3.2 mg/dl

SODIUM 136 mmol/L

POTASSIUM 3.9 mmol/L.

CHLORIDE 99 mmol/L

LIVER FUNCTION TEST (LFT) 24-01-2025 06:08:PM

Total Bilurubin 0.61 mg/dl

Direct Bilurubin 0.17 mg/dl

SGOT(AST) 15 IU/L

SGPT(ALT) 11 IU/L

ALKALINE PHOSPHATASE 99 IU/L

TOTAL PROTEINS 6.3 gm/dl

ALBUMIN 3.49 gm/dl

A/G RATIO 1.24

HBsAg-RAPID 24-01-2025 06:08:PM Negative

Anti HCV Antibodies - RAPID 24-01-2025 06:08:PM Non Reactive

POST LUNCH BLOOD SUGAR 25-01-2025 09:42:AM 153 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 29-01-2025 11:12:AM

SODIUM 136 mmol/L

POTASSIUM 3.7 mmol/L

CHLORIDE 104 mmol/L

SPUTUM FOR C/S

NO PATHOGENIC ORGANISM GROWN

PFT DONE ON 29/01/25 S/O RESTRICTIVE PATTERN

Treatment Given(Enter only Generic Name)

PATIENT WAS CLINIRADIOLOGICALLY DIAGNOSED AS GRADE I L4-L5

SPONDYLOLYSTHESIS, PAC DONE.

DURING THE COURSE OF HOSPITAL STAY PT WAS TREATED WITH ANTACIDS,

ANALGESICS, MULTIVITAMINS,INHALATIONAL

CORTICOSTEROIDS,MUCOLYTIC,LEUKOTRIENE RECEPTOR ANTAGONIST.

PATIENT IS NOW BEING DISCHARGED UNDER HEMODYNAMICALLY STABLE CONDITION

Advice at Discharge

1.TAB.XYKAA 1GMPO/BD X 5DAYS

2.TAB.PAN 40 MG PO/OD X 5 DAYS

3.TAB.EVION-LC PO/OD X 14 DAYS

4.TAB.TRIGANANTIN 100MG PO/H/S X 14 DAYS

Diagnosis

LUMBAR SPONDYLOSIS

Case History and Clinical Findings

CHIEF COMPLAINTS:

C/O PAIN IN LOW BACK REGION SINCE 3YRS

H/O PAIN RADIATING TO LEFT LOWER LIMB TILL KNEE

NO H/O BURNING MICTURITION

NO H/O TRAUMA

NO H/O FEVER

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YRS AGO THEN DEVELOPED PAIN IN THE

LOWER BACK REGION WHICH WAS INSIDIOUS IN ONSET, PROGRESSIVE IN NATURE

AGGRAVATED ON BENDING FORWARD AND LIFTING HEAVY WEIGHT RELEIVED ON REST

PAST HISTORY:

N/K/C/O HTN/DM/HYPOTHYROID/CVA/CAD

ON GENERAL EXAMINATION:

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY ,EDEMA

TEMP:98.6 F

PR:82BPM

RR:20CPM

BP:130/90MMHG

SPO2:98%@RA

CVS- S1,S2 HEARD NO MURMURS

RS-BAE +NVBS

PA- SOFT ,NNON TENDER

CNS-NFND

LOCAL EXAMINATION OF LS SPINE:

SKIN : NORMAL

SWELLING : ABSENT

LOCAL RISE IN TEMPERATURE: ABSENT

TENDERNESS:PRESENT OVER LEFT WRIST JOINT

DEFORMITY- PRESENT

RT LF

SLRT - 0-90 0-90

HIP - 5/5 5/5

KNEE- 5/5 5/5

ANKLE- 5/5 5/5

EHC- 5/5 5/5

DISTAL PULSE- PRESENT PRESENT

SENSATION- INTACT INTACT

Investigation

RFT 25-01-2025 06:27:PM UREA34 mg/dlCREATININE0.7 mg/dlURIC ACID2.0 mmol/LCALCIUM9.8

mg/dlPHOSPHOROUS3.9 mg/dlSODIUM139 mmol/LPOTASSIUM4.2 mmol/L.CHLORIDE101

mmol/LLIVER FUNCTION TEST (LFT) 25-01-2025 06:27:PM Total Bilurubin0.68 mg/dlDirect

Bilurubin0.17 mg/dlSGOT(AST)34 IU/LSGPT(ALT)24 IU/LALKALINE PHOSPHATASE142

IU/LTOTAL PROTEINS7.0 gm/dlALBUMIN4.1 gm/dlA/G RATIO1.45COMPLETE BLOOD PICTURE

(CBP) 25-01-2025 06:27:PM HAEMOGLOBIN11.7 gm/dlTOTAL COUNT4700

cells/cummNEUTROPHILS50 %LYMPHOCYTES38 %EOSINOPHILS05 %MONOCYTES07

%BASOPHILS00 %PLATELET COUNT2.45SMEARNormocytic normochromicCOMPLETE URINE

EXAMINATION (CUE) 25-01-2025 06:27:PM COLOURPale

yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINNilSUGARNilBILE

SALTSNilBILE PIGMENTSNilPUS CELLS2-3EPITHELIAL CELLS2-3RED BLOOD

CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNil

Treatment Given(Enter only Generic Name)

1. TAB XYKAA 1GM PO/BD

2.TAB EVLOV- LC PO/OD

3.PHYSIO LEFT BACK STRENGTHENING EXERCISES.

Advice at Discharge

1. TAB XYKAA 1GM PO/BD X5 DAYS

2. TAB PAN 40 MG PO/OD X 5 DAYS

3. TAB SHELCAL CT PO/OD X 15 DAYS

Diagnosis

B/L OSTEO ARTHRITIS OF KNEE

Case History and Clinical Findings

CHEIF COMPLAINTS:

C/O LOW BACK ACHE SINCE 2 YEARS

HOPI:

PATIENT WAS APPARENTLY ALRIGHT 2 YEARS AGO SINCE THEN SHE STARTED HAVING

PAIN IN THE LOWER BACK SPONTANEOUS IN ONSET, PROGRESSIVE IN NATURE ,

AGGRAVATED ON MOVEMENTS, RELIVED PARTIALLY ON REST AND MEDICATIONS. NOT

ASSOCIATED WITH ANY RADIATING PAIN, TINGLING NUMBNESS.

NO H/O TRAUMA/FEVER/BURNING MICTURITION/ BOWEL AND BLADDER INCONTINENCE.

PAST HISTORY:

K/C/O HTN/DM SINCE 2YEARS

N/K/C/O HYPOTHYROID/CVA/CAD

H/O HYSTRECTOMY 15 YEARS AGO

ON GENERAL EXAMINATION:

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY ,EDEMA

TEMP:98.6 F

PR:72BPM

RR:20CPM

BP:120/70MMHG

SPO2:98%@RA

GRBS:126 MG/DL

CVS- S1,S2 HEARD NO MURMURS

RS-BAE +NVBS

PA- SOFT ,NNON TENDER

CNS-NFND

LOCAL EXAMINATION OF LS SPINE:

SKIN : NORMAL

SWELLING : ABSENT

LOCAL RISE IN TEMPERATURE: ABSENT

TENDERNESS: DIFFUSE MIDLINE

RT LT

SWELLING AB AB

SKIN NORMAL NORMAL

LOCAL RISE OF TEMP AB AB

TENDERNESS DIFFUSE DIFFUSE

FFB 5 5

ROM F/E 5-110 5-110

CREPITUS +NT +NT

SENATIONS : INTACT INTACT

DISTAL PULSES: FELT FELT

Investigation

COMPLETE BLOOD PICTURE (CBP) 28-01-2025 06:21:PMHAEMOGLOBIN 11.5 gm/dlTOTAL

COUNT 6100 cells/cummNEUTROPHILS 55 %LYMPHOCYTES 36 %EOSINOPHILS 03

%MONOCYTES 06 %BASOPHILS 00 %PLATELET COUNT 2.0SMEAR Normocytic

normochromicCOMPLETE URINE EXAMINATION (CUE) 28-01-2025 06:21:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-4RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilRFT 28-01-2025

06:21:PMUREA 31 mg/dlCREATININE 0.8 mg/dlURIC ACID 3.5 mmol/LCALCIUM 10.2

mg/dlPHOSPHOROUS 3.97 mg/dlSODIUM 138 mmol/LPOTASSIUM 4.5 mmol/L.CHLORIDE 103

mmol/LLIVER FUNCTION TEST (LFT) 28-01-2025 06:21:PMTotal Bilurubin 0.72 mg/dlDirect

Bilurubin 0.18 mg/dlSGOT(AST) 14 IU/LSGPT(ALT) 10 IU/LALKALINE PHOSPHATASE 153

IU/LTOTAL PROTEINS 6.8 gm/dlALBUMIN 4.18 gm/dlA/G RATIO 1.60

Treatment Given(Enter only Generic Name)

TAB HIFENAC-P PO BD

TAB PAN 40 MG PO OD

TAB SHELCAL CT PO OD

TAB LIMCEE 500 MG PO OD

TAB EVION-LC PO BD

IFT B/L KNEE

Advice at Discharge

TAB HIFENAC-P PO BD

TAB PAN 40 MG PO OD

TAB SHELCAL CT PO OD

TAB LIMCEE 500 MG PO OD

TAB EVION-LC PO BD

IFT B/L KNEE

Diagnosis

GRADE IV B/L OA KNEE

Case History and Clinical Findings

CHIEF COMPLAINTS: B/L KNEE PAIN (LEFT MORE THAN RIGHT) SINCE 12 MONTHS

HISTORY OF PRESENTING ILLNESS: THE PATIENT WAS APPARENTLY ASYMPTOMATIC 12

MONTHS AGO THEN HE DEVELOPED B/L KNEE PAIN WHICH IS OF DRAGGING TYPE ,

INSIDIOUS IN ONSET , GRADUALLY PROGESSIVE RADIATING TO BOTH THE LEGS

AGGREVATED ON MOEMENTS RELIEVED BY REST AND MEDICATION ASSOSCIATED WITH

MORNING STIFFNESS,TINGLING AND NUMBNESS OF LOWER LIMBS

PAST HISTORY: NO H/O TRAUMA

KC/O DM SINCE 5 YRS

N/KC/O HTN,ASTHMA, TB, EPILEPSY, CAD, CVD

GENERAL EXAMINATION:

PT IS C/C/C

TEMP 98.2 F

PR 88 BPM

RR- 19 CPM

BP-120/70 MMHG

SPO2 98% RA

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

L/E OF B/L KNEE:

GAIT: UNSTABLE , ASSISTED WITH STICK CARRYING ON HIS LEFT HAND

ATTITUDE:PATIENT IS IN SUPINE POSITION WITH BOTH PATELLA AND MEDIAL MALLEOLUS

ARE AT SAME LEVEL, PATELLA FACING OUTWARDS AND LATERALLY

DEFORMITY- VARUS DEFORMITY IS SEEN

RIGHT LEFT

SKIN- NORMAL NORMAL

SWELLING ABSENT MILD

LOCAL RISE ABSENT ABSENT

OF TEMPERATURE

TENDERNES: MILD PRESENT-DIFFUSE

CREPITUS PRESENT PRESENT

ROM 0-130 0-100

SENSATIONS: INTACT INTACT

DISTAL PULSES : FELT FELT

Investigation

COMPLETE BLOOD PICTURE (CBP) 26-05-2025 05:56:PMHAEMOGLOBIN 13.0 gm/dlTOTAL

COUNT 7700 cells/cummNEUTROPHILS 53 %LYMPHOCYTES 37 %EOSINOPHILS 03

%MONOCYTES 07 %BASOPHILS 0 %PLATELET COUNT 2.78SMEAR Normocytic normochromic

RFT 26-05-2025 06:47:PMUREA 21 mg/dlCREATININE 0.9 mg/dlURIC ACID 3.6 mmol/LCALCIUM

9.9 mg/dlPHOSPHOROUS 4.0 mg/dlSODIUM 135 mmol/LPOTASSIUM 4.3 mmol/L.CHLORIDE 102

mmol/LLIVER FUNCTION TEST (LFT) 26-05-2025 06:47:PMTotal Bilurubin 0.51 mg/dlDirect

Bilurubin 0.16 mg/dlSGOT(AST) 18 IU/LSGPT(ALT) 10 IU/LALKALINE PHOSPHATASE 140

IU/LTOTAL PROTEINS 5.8 gm/dlALBUMIN 3.78 gm/dlA/G RATIO 1.87

Treatment Given(Enter only Generic Name)

THE PATIENT WAS CLINICORADIOLOGICALLY DIAGNOSED GRADE 1V B/L OA KNEE AND

WAS TREATED CONSERVATIVELY WITH-1.TAB HIFENAC-P PO/BD

2.TAB PAN 40 MG PO/OD

3.TAB SHELCAL CTPO/OD

4.TAB.NEUROKIND-LC PO/HIS

4.PHYSIO IFT TO B/L KNEE Q/E

Advice at Discharge

1.TAB HIFENAC-P PO/BD X 7 DAYS

2.TAB PAN 40 MG PO/OD X 7 DAYS

3.TAB SHELCAL CTPO/OD X 7 DAYS

4.TAB.NEUROKIND-LC PO/HIS X 7 DAYS

4.PHYSIO IFT TO B/L KNEE Q/E

Diagnosis

LUMBAR SPONDYLOSIS

Case History and Clinical Findings

C/O LOW BACK PAIN SINCE 8 DAYS

H/O TRAUMA 8DAYS AGO

TINGLING PRESENT

NUMBNESS PRESENT

HISTORY OF PRESENTING ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC 8 DAYS AGO THEN HE DEVELOPED LOW BACK

PAIN SUDDEN ONSET, PROGRESSIVE IN NATURE RADIATING TO RIGHT LOWER LIMB

ASSOCIATED WITH TINGLING AND NUMBNESS

AGGRAVATED ON MOVEMENTS AND NOT RELIEVED WITH REST AND MEDICATION

NO H/O TRAUMA

NO H/O FEVER

PAST HISTORY:

N/K/C/O HTN, DM, TB ASTHMA, CAD, CVA

LOCAL EXAMINATION OF LS SPINE:

DEFORMITY ABSENT

SKIN - NORMAL

SWELLING - ABSENT

LOCAL RISE OF TEMP - ABSENT

TENDERNESS - ABSENT

LT RT

POWER 5/5 5/5

HIP 5/5 5/5

KNEE 5/5 5/5

ANKLE 5/5 5/5

FHL 5/5 5/5

EHL 5/5 5/5

SENSATIONS INTACT INTACT

DISTAL PULSES PRESENT PRESENT

Investigation

RFT 27-05-2025 06:18:PMUREA 25 mg/dlCREATININE 0.9 mg/dlURIC ACID 2.5 mmol/LCALCIUM

9.9 mg/dlPHOSPHOROUS 3.1 mg/dlSODIUM 140 mmol/LPOTASSIUM 4.3 mmol/L.CHLORIDE 104

mmol/LLIVER FUNCTION TEST (LFT) 27-05-2025 06:18:PMTotal Bilurubin 0.49 mg/dlDirect

Bilurubin 0.18 mg/dlSGOT(AST) 17 IU/LSGPT(ALT) 10 IU/LALKALINE PHOSPHATASE 142

IU/LTOTAL PROTEINS 6.7 gm/dlALBUMIN 3.93 gm/dlA/G RATIO 1.42COMPLETE BLOOD

PICTURE (CBP) 27-05-2025 06:18:PMHAEMOGLOBIN 13.4 gm/dlTOTAL COUNT 6500

cells/cummNEUTROPHILS 54 %LYMPHOCYTES 36 %EOSINOPHILS 03 %MONOCYTES 07

%BASOPHILS 0 %PLATELET COUNT 1.71SMEAR Normocytic normochromicCOMPLETE URINE

EXAMINATION (CUE) 27-05-2025 06:18:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION

AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS

2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS

DEPOSITS AbsentOTHERS Nil

Treatment Given(Enter only Generic Name)

THE PATIENT IS CLINICORADIOLOGICALLY DIAGNOSED ASLUMBAR SPONDYLOSIS AND

CONSEVATIVELY TREATED WITH

1. TAB XYKAA 1GM PO/BD

2. TAB. PAN 40 PO/OD

3. TAB. TRIGABANTIN 100 MG PO/HS

4. TAB. EVION LC PO/BD

Advice at Discharge

1. TAB XYKAA 1GM PO/BD X5DAYS

2. TAB. PAN 40 PO/OD X5DAYS

3. TAB. TRIGABANTIN 100 MG PO/HS X10DAYS

4. TAB. EVION LC PO/BD X 10 DAYS

Diagnosis

BILATERAL OSTEOARTHRITIS KNEE [ RIGHT >LEFT ] ,LUMBAR SPONDYLOSIS

Case History and Clinical Findings

CHIEF COMPLAINTS:

C/O PAIN IN BOTH KNEES AND LOW BACK SINCE 4-5 YEARS

HOPI:

PATIENT WAS APPARNTLY ASYMPTOMATIC 4-5 YEARS BACK, THEN DEVELOPED PAIN IN

BOTH KNEES, INSIDIOUS IN ONET, CONTINUOUS, DRAGGING TYPE, AGGREVATED WITH

MOVEMENTS AND NOT RELIEVED WITH REST AND MEDICATION.

H/O TRAUMA 2 YEARS BACK

PAIN IN LOW BACK SINCE 4-5YEARS, NON RADIAITNG, NO TINGLING AND NUMBNESS

PAST HISTORY:

N/K/C/O HTN,DM/HYPOTHYROID/CVA/CAD

ON GENERAL EXAMINATION:

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY ,EDEMA

TEMP:98.4 F

PR:82BPM

RR:19CPM

BP:110/80MMHG

SPO2: 98%@RA

CVS- S1,S2 HEARD NO MURMURS

RS-BAE +NVBS

PA- SOFT ,NNON TENDER

CNS-NFND

LOCAL EXAMINATION OF B/L KNEE :

RIGHT LEFT

DEFORMITY: VALGUS: 10 -

SKIN : NORMAL NORMAL

SWELLING: SUPRAPATELLAR SUPRAPATELLAR

LOCAL RISE : ABSENT ABSENT

IN TEMPERATURE

TENDERNESS: PRESENT OVER MJL PRESENT OVER MJL

ROM: 0-110 0-110

CREPITUS: PRESENT PRESENT

SENSATIONS: INTACT INTACT

DISTAL PULSES: PRESENT PRESENT

LOCAL EXAMINATION OF LS SPINE:

DEFROMITY: ABSENT

SKIN - NORMAL

SWELLING - ABSENT

LOCAL RISE OF TEMPERATURE - ABSENT

TENDERNESS PRESENT AT L4-L5 PARASPINAL

RIGHT LEFT

SLRT 90 90

HIP - F,E 5/5 5/5

KNEE- F,E 5/5 5/5

ANKLE-F,E 5/5 5/5

EHL AND FHL 5/5 5/5

DISTAL PULSES PRESENT PRESENT

SENSATIONS INTACT INTACT

Treatment Given(Enter only Generic Name)

1. TAB. XYKAA 1G PO BD

2. TAB PAN 40 MG PO OD

3.TAB SHELCAL CT PO OD

4. TAB. MVT PO OD

5. PHYSIO- IFT TO B/L KNEE QSE

Advice at Discharge

1. TAB. XYKAA 1G PO BD

2. TAB PAN 40 MG PO OD

3.TAB SHELCAL CT PO OD

4. TAB. MVT PO OD

5. PHYSIO- IFT TO B/L KNEE QSE

Diagnosis

B/L OA KNEE WITH LUMBAR SPONDYLOSIS

Case History and Clinical Findings

PATIENT CAME TO HOSPITAL WITHJ COMPLAINTS OF BILATERAL KNEE PAIN SINCE 3

MONTHS

NO HISTORY OF TRAUMA, NO HISTORYY OF FEVER

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 MONTHS AGO THEN HE DEVELOPED

BILATETRAL KNEE PAIN (RIGHT>LEFT) WHICH WAS GRADUAL IN ONSET, PROGRESSIVE IN

NATURE, AGGRAVATED WITH MOVEMENTS AND RELIEVED ON REST AND MEDICATIONS

KNOWN CASE OF HYPERTENSION SINCE THREE YEARS

KNOWN CASE OF DIABETES MILLETUS SINCE 2 YEARS

N/K/C/O TUBERCULOSIS, EPILEPSY, ASTHMA, CAD,

CKD, CARDIOVASCULAR ACCIDENTS.

ON EXAMINATION

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY ,EDEMA

TEMP:AFEBRILE

PR:82BPM

RR:20CPM

BP:110/90MMHG

CVS- S1,S2 HEARD NO MURMURS

RS-BAE +NVBS

PA- SOFT ,NON TENDER

CNS-NFND

L/E OF B/L KNEE:

ATTITUDE:PATIENT IS IN SUPINE POSITION,RIGHT HIP IN SLIGHTLY FLEXED

POSITION,RIGHT FOOT EXTERNAL ROTATED,LATERAL BORDER TOUCHING COUCH

RIGHT LEFT

SKIN- NORMAL NORMAL

SWELLING PARAPATELLAR PARAPATELLAR

LOCAL RISE ABSENT ABSENT

OF TEMPERATURE

TENDERNES: MJL MJL

CREPITUS PRESENT PRESENT

FFD 5 0

ROM 5-100 0-110

SENSATIONS:INTACT INTACT

DISTAL PULSES : FELT FELT

Treatment Given(Enter only Generic Name)

THE PATIENT IS CLINICORADIOLOGICALLY DIAGNOSED AS B/L OA KNEE WITH LUMBAR

SPONDYLOSIS

1.TAB .XYKAA 1GM PO/BD

2.TAB PAN 40 MG PO/OD

3.TAB SHELCAL CTPO/OD

Advice at Discharge

1.TAB .XYKAA 1GM PO/BD X 7DAYS

2.TAB PAN 40 MG PO/OD X 7DAYS

3.TAB SHELCAL CTPO/OD X 15DAYS

Diagnosis

BILATERAL OA KNEE

Case History and Clinical Findings

PATTIENT CAME TO HOSPITAL WITH COMPLAINTS OF B/L KNEE PAIN SINCE 2 YEARS

HOPI:

PATIENT WAS APPARENTLY ALRIGHT 2 YEARS AGO, THEN HE DEVELOPED PAIN IN B/L

KNEE WHICH IS SUDDEN IN ONSET, GRADUALLY PROGRESSIVE , AGGRAVATED ON

MOVEMENTS, RELIEVED ON REST AND MEDICATIONS, NON RADIATING, WITH DIURNAL

VARIATION MORE IN THE MORNING, THROBBING TYPE.

ASSOCIATED WITH TINGLING AND NUMBNESS, MORNING STIFFNESS

KNOWN CASE OF DIABETES MILLETUS SINCE 3 YEARS

N/K/C/O HYPERTENSION, TUBERCULOSIS, EPILEPSY,

ASTHMA, CAD, CKD, CARDIOVASCULAR ACCIDENTS.

ON EXAMINATION

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY ,EDEMA

TEMP:AFEBRILE

PR:82BPM

RR:20CPM

BP:110/90MMHG

CVS- S1,S2 HEARD NO MURMURS

RS-BAE +NVBS

PA- SOFT ,NON TENDER

CNS-NFND

L/E OF B/L KNEE:

ATTITUDE:PATIENT IS IN SUPINE POSITION,RIGHT HIP IN SLIGHTLY FLEXED

POSITION,RIGHT FOOT EXTERNAL ROTATED,LATERAL BORDER TOUCHING COUCH

RIGHT LEFT

SKIN- NORMAL NORMAL

SWELLING ABSENT ABSENT

LOCAL RISE ABSENT ABSENT

OF TEMPERATURE

TENDERNES: DIFFUSE DIFFUSE

CREPITUS PRESENT PRESENT

FFD 5 5

ROM 0-180 0-130

SENSATIONS:INTACT INTACT

DISTAL PULSES : FELT FELT

Treatment Given(Enter only Generic Name)

1.TAB .XYKAA 1GM PO/BD

2.TAB PAN 40 MG PO/OD

3.TAB SHELCAL CTPO/OD

4.TAB NEUROKIND LC -PO/OD

Advice at Discharge

1.TAB .XYKAA 1GM PO/BD X 7DAYS

2.TAB PAN 40 MG PO/OD X 7DAYS

3.TAB SHELCAL CTPO/OD X 15DAYS

4.TAB NEUROKIND LC -PO/OD X 7DAYS

Diagnosis

RHEUMATOID ARTHRITIS

Case History and Clinical Findings

CHIEF COMPLAINTS:

C/O MULTIPLE JOINT PAINS SINCE 3 YEARS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YEARS BACK, THEN SHE

DEVELOPEDMULTIPLE JOINT PAINS ,INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE IN

NATURE,AGGRAVATED WITH MOVEMENTS AND DAILY ACTIVITY, NOT RELIEVED BY TAKING

REST.

NO H/O LOC/ENT BLEED

NO H/O TRAUMA/BURNING MICTURITION/ BOWEL AND BLADDER INCONTINENCE,FEVER

PAST HISTORY:

K/C/O RHEUMATOID ARTHRITIS SINCE 3 YEARS,USED MEDICATION FOR 1 YEAR AND

STOPPED

N/K/C/O DM/HTN/HYPOTHYROID/CVA/CAD/TB/ASTHMA

H/O HYSTERECTOMY

ON GENERAL EXAMINATION:

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY ,EDEMA

TEMP:98.4 F

PR:82BPM

RR:19CPM

BP:110/70MMHG

SPO2: 98%@RA

CVS- S1,S2 HEARD NO MURMURS

RS-BAE +NVBS

PA- SOFT ,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF LS SPINE

ATTITUDE: NORMAL

SKIN: NORMAL

SWELLING :ABSENT

TENDERNESS: PRESENT

DEFORMITY : ABSENT

NO LOCAL RISE OF TEMPERATURE

SENSATION - INTACT

DISTAL PULSES- PRESENT

Investigation

RFT 12-02-2025 UREA 29 mg/dlCREATININE 0.9 mg/dlURIC ACID 3.8 mmol/LCALCIUM 9.6

mg/dlPHOSPHOROUS 4.6 mg/dlSODIUM 142 mmol/LPOTASSIUM 4.2 mmol/L.CHLORIDE 103

mmol/L

LIVER FUNCTION TEST (LFT) 12-02-2025 Total Bilurubin 0.63 mg/dlDirect Bilurubin 0.17

mg/dlSGOT(AST) 25 IU/LSGPT(ALT) 14 IU/LALKALINE PHOSPHATASE 98 IU/LTOTAL PROTEINS

6.7 gm/dlALBUMIN 3.97 gm/dlA/G RATIO 1.45

HBsAg-RAPID 12-02-2025 Negative

Anti HCV Antibodies - RAPID 12-02-2025 Non Reactive

COMPLETE BLOOD PICTURE (CBP) 12-02-2025 HAEMOGLOBIN 10.8 gm/dlTOTAL COUNT 5500

cells/cummNEUTROPHILS 50 %LYMPHOCYTES 39 %EOSINOPHILS 04 %MONOCYTES 07

%BASOPHILS 00 %PLATELET COUNT 1.99SMEAR Normocytic normochromic

COMPLETE URINE EXAMINATION (CUE) 12-02-2025 COLOUR Pale yellowAPPEARANCE

ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS

NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS

NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

Treatment Given(Enter only Generic Name)

TAB.XYKKA IG PO/BD

TAB PAN 40 MG PO OD

TAB.ULTRACET PO/OD

TAB.MVT PO/OD

Advice at Discharge

TAB.XYKKA IG PO/BD X 1 WEEK

TAB PAN 40 MG PO OD X 1 WEEK

TAB.ULTRACET PO/OD X 1 WEEK

TAB.MVT PO/OD X 1 WEEK

Diagnosis

DEGENERATIVE LUMBAR SPONDYLOSIS

Case History and Clinical Findings

C/O BILATERAL KNEE PAIN SINCE 2 YEARS

LOW BACK ACHE SINCE 2 YEARS

HOPI

THE PATIENT WAS APPARTENTLY NORMAL 2 YEARS BACK THEN SHE DEVELOPED

BILATERAL KNEE PAIN AND LOWER BACK ACHE WHICH IS GRADUAL IN ONSET,

PROGRESSIVE ,THE PAIN IS AGGRAVATED ON MOVEMENTS AND NOT RELIVED ON TAKING

REST

NO H/O TRAUMA

NO H/O FEVER

NO CREPITUS

PAST HISTORY:

N/K/C/O DM, HTN, CVA, CAD, ASTHMA, EPILEPSY, TB, THYROID DISORDERS

GENERAL EXAMINATION:

TEMP. - AFEBRILE

BP - 110/80 MM/HG

PR - 82 BPM

RR - 18 CPM

SPO2 - 99%

GRBS - 110 MG/DL

SYSTEMIC EXAMINATION:

CVS - S1,S2 +

CNS - NFND

RS - BAE+

P/A - SOFT, NON TENDER

LOCAL EXAMINATION OF LS SPINE:

DEFORMITY ABSENT

SKIN - NORMAL

SWELLING - ABSENT

LOCAL RISE IN TEMP. - ABSENT

TENDERNESS - PRESENT OVER L3, L4, L5

LT RT

POWER

HIP 5/5 5/5

KNEE 5/5 5/5

ANKLE 5/5 5/5

FHL 5/5 5/5

EHL 5/5 5/5

SENSATIONS INTACT INTACT

DISTAL PULSES FELT FELT

LOCAL EXAMINATION OF BILATERAL KNEE:

ATTITUDE: PATIENT IN SUPINE POSITION WITH BOTH ASIS AT SAME LEVEL, PATELLA

FACING LATERALLY

LEFT KNEE

SKIN NORMAL

SWELLING MILD SUPRA PATELLAR SWELLING PRESENT

LOCAL RISE IN TEMP ABSENT

TENDERNESS ALONG MEDIAL AND LATERAL JOINT LINE

VARUS 5 DEGREES

FFD 5 DEGREES

ROM 5-110 DEGREES

CREPITUS PRESENT

DISTAL PULSES PRESENT

SENSATONS INTACT

RIGHT KNEE

SKIN NORMAL

SWELLING MILD SUPRAPATELLAR

LOCAL RISE IN TEMP ABSENT

TENDERNESS PRESENT AT MEDIAL AND LATERAL JOINT LINE

VARUS 5 DEGREES

FFD 5 DEGREES

ROM 5-110 DEGREES

DISTAL PULSES PRESENT

CREPITUS PRESENT

Investigation

COMPLETE BLOOD PICTURE (CBP) 19-02-2025 07:07:PMHAEMOGLOBIN 11.3 gm/dlTOTAL

COUNT 8100 cells/cummNEUTROPHILS 74 %LYMPHOCYTES 22 %EOSINOPHILS 01

%MONOCYTES 03 %BASOPHILS 00 %PLATELET COUNT 2.75SMEAR microcytic hypochromic

COMPLETE URINE EXAMINATION (CUE) 19-02-2025 07:07:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilHBsAg-RAPID 19-02-

2025 07:07:PM Negative

Anti HCV Antibodies - RAPID 19-02-2025 07:07:PM Non ReactiveRFT 19-02-2025 07:07:PMUREA

12 mg/dlCREATININE 0.8 mg/dlURIC ACID 2.0 mmol/LCALCIUM 9.8 mg/dlPHOSPHOROUS 2.8

mg/dlSODIUM 140 mmol/LPOTASSIUM 4.3 mmol/L.CHLORIDE 106 mmol/L

LIVER FUNCTION TEST (LFT) 19-02-2025 07:07:PMTotal Bilurubin 0.48 mg/dlDirect Bilurubin 0.19

mg/dlSGOT(AST) 16 IU/LSGPT(ALT) 24 IU/LALKALINE PHOSPHATASE 73 IU/LTOTAL PROTEINS

6.3 gm/dlALBUMIN 3.8 gm/dlA/G RATIO 1.59

Treatment Given(Enter only Generic Name)

TAB HIFENAC P PO BD

TAB PAN 40MG PO OD

TAB TRIGABATIN 100MG PO H/S

TAB EVION LC PO BD

PHYSIO IFT LOW BACK AND KNEE

Advice at Discharge

TAB HIFENAC P PO BD X 1 WEEK

TAB PAN 40MG PO OD X 1 WEEK

TAB TRIGABATIN 100MG PO H/S X 1 WEEK

TAB EVION LC PO BD X 1 WEEK

PHYSIO IFT LOW BACK AND KNEE

36 to 50 (named as 1 )

Diagnosis

B/L OA KNEE

Case History and Clinical Findings

C/O B/L OA KNEE PAIN SINCE 4 YEARS.

HISTORY OF PRESENTING ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC 4 YEARS AGO AND THEN HE DEVELOPED B/L

KNEE PAIN INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE IN NATURE , AGGRAVATED

ON MOVEMENTS, RELIVED ON REST.

PAST HISTORY:

K/C/O HTN SINCE 2 YEARS

N/K/C/O DM, CAP, CVA, HYPOTHYROIDISM

ON GENERAL EXAMINATION:

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY ,EDEMA

TEMP:98.6 F

PR:79 BPM

RR:18 CPM

BP:110/70 MMHG

SPO2:100%

SYSTEMIC EXAMINATION:

CVS- S1,S2 HEARD, NO MURMURS

RS-BAE +NVBS

PA- SOFT ,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF B/L KNEE:

ATTITUDE: PATIENT IN SUPINE POSITION BOTH ASIS AT SAME LEVELS , KNEE IN FLEXION.

RT LT

SWELLING - DIFFUSE SWELLING OVER KNEE DIFFUSE SWELLING OVER KNEE

PRESENT PRESENT

SKIN : NORMAL NORMAL

NO LOCAL RISE ABSENT ABSENT

OF TEMPERATURE:

TENDERNESS: PRESENT (MJL) PRESENT ( MJL)

CREPITUS PRESENT PRESENT

ROM 20- 90 10- 110

SENATIONS : INTACT INTACT

DISTAL PULSES: FELT FELT

Treatment Given(Enter only Generic Name)

PATIENT WAS CLINICO - RADIOLOGICALLY DIAGNOSED AS B/L OA KNEE AND PLANNED FOR

CONSERVATIVE MANAGEMENT.

Advice at Discharge

1. TAB. XYKAA 1GM PO/ BD

2. TAB. PAN 40MG PO/BD

3. TAB. SHELCAL CT PO/ OD

4. PHYSIO- IFT TO B/L LNEE QSE

2.Diagnosis

B/L OA KNEE GRADE IV

Case History and Clinical Findings

CHIEF COMPLAINTS-

PATIENT CAME WITH CHIEF COMPLAINT OF B/L KNEE PAIN SINCE 8 YEARS

NO H/O TRAUMA

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 8 YEARS AGO THEN HE DEVELOPED

PAIN OVER BOTH KNEE PAIN WHICH WAS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE

IN NATURE AGGRAVATED ON MOVEMENTS AND RELIEVED ON REST AND MEDICATION

NO H/O TRAUMA

NO H/O FEVER, VOMITINGS, LOOSE STOOLS,HEAD INJNURY,LOC,BURNING

MICTURITION,BLADDER AND BOWEL INCONTINENCE

PAST HISTORY:

N/K/C/O HTN DM, TB , ASTHMA,EPILEPSY

GENERAL EXAMINATION:

TEMP - AFEBRILE

PR 82 BPM

RR- 16CPM

BP-110/70 MMHG

GRBS: 110MG/DL

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF RIGHT KNEE

FFD -5

SKIN- NORMAL

SWELLING MILD PREPATELLAR

NO LOCAL RISE OF TEMPERATURE

TENDERNESS + IN MJL

ROM- 5-100 DEGREE

VARUS- 10 DEGREE

CREPITUS- PRESENT

SENSATIONS - INTACT

DISTAL PULSES +

FFD 10 DEGREE

LOCAL EXAMINATION OF LEFT KNEE

FFD -5

SKIN- NORMAL

SWELLING MILD PREPATELLAR

NO LOCAL RISE OF TEMPERATURE

TENDERNESS + IN MJL

ROM- 5-100 DEGREE

VARUS- 10 DEGREE

CREPITUS- PRESENT

SENSATIONS - INTACT

DISTAL PULSES +

FFD 10 DEGREE

Investigation

RFT 10-06-2025 06:36:PMUREA 30 mg/dlCREATININE 0.9 mg/dlURIC ACID 3.4 mmol/LCALCIUM

10.0 mg/dlPHOSPHOROUS 3.04 mg/dlSODIUM 140 mmol/LPOTASSIUM 3.9 mmol/L.CHLORIDE

104 mmol/LLIVER FUNCTION TEST (LFT) 10-06-2025 06:36:PMTotal Bilurubin 0.97 mg/dlDirect

Bilurubin 0.18 mg/dlSGOT(AST) 18 IU/LSGPT(ALT) 15 IU/LALKALINE PHOSPHATASE 130

IU/LTOTAL PROTEINS 6.2 gm/dlALBUMIN 3.97 gm/dlA/G RATIO 1.78COMPLETE BLOOD

PICTURE (CBP) 10-06-2025 06:36:PMHAEMOGLOBIN 11.7 gm/dlTOTAL COUNT 5900

cells/cummNEUTROPHILS 52 %LYMPHOCYTES 35 %EOSINOPHILS 03 %MONOCYTES 10

%BASOPHILS 00 %PLATELET COUNT 2.41SMEAR Normocytic normochromicCOMPLETE URINE

EXAMINATION (CUE) 10-06-2025 06:36:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION

AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS

2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS NilCRYSTALS NilCASTS NilAMORPHOUS

DEPOSITS AbsentOTHERS NilInvestigation

Treatment Given(Enter only Generic Name)

1.T ULTRACET PO BD

2.T PAN 40MG PO OD

3.TAB.SHELCAL CT PO/OD

4.PHYSIO IFT B/L KNEE AND B/L NECK

Advice at Discharge

1.T ULTRACET PO BD FOR 7 DAYS

2.T PAN 40MG PO ODFOR 7 DAYS

3.TAB.SHELCAL CT PO/ODFOR 15 DAYS

3. Diagnosis

GRADE II L5 - S1 SPONDYLOLISTHESIS

Case History and Clinical Findings

C/O LOW BACK ACHE SINCE 2 YEARS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 2 YEARS AGO THEN DEVELOPED PAIN IN LOW

BACK,PAIN IS INSIDIOUS ONSET,DRAGGING TYPE,RADIATING TO BOTH LOWER LIMBS

ASSOCIATED WITH TINGLING AND NUMBNESS, AGGRAVATED WITH MOVEMENTS AND NOT

RELIEVED ON REST AND MEDICATION.

NO H/O TRAUMA

NO H/O HEAD INJURY,LOC , ENT BLEED , VOMITING , SEIZURES

NO NEUROLOGICAL DEFICITS

PAST HISTORY

N/K/C/O DM, HTN, TB, ASTHMA, EPILEPSY, CVA, CD AND THYROID DISORDERS

PERSONAL HISTORY

APPETITE : NORMAL

SLEEP : ADEQUATE

BOWEL : REGULAR

BLADDER : NORMAL

NO HABITS AND ADDICTIONS

FAMILY HISTORY : NOT SIGNIFICANT

O/E

PATIENT C/C/C

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY ,EDEMA

TEMP:98.4 F

PR: 88BPM

RR: 18CPM

SPO2 : 98% AT ROOM AIR

BP: 110/80 MM HG

GRBS: 100 MG/DL

CVS- S1,S2 HEARD NO MURMURS

RS-BAE +NVBS

PA- SOFT ,NON TENDER

CNS-NFND

CHEST COMPRESSION TEST NEGATIVE

PELVIS COMPRESSION TEST NEGATIVE

L/E OF LS SPINE

SKIN-NORMAL

SWELLING-ABSENT

TENDERNESS - PRESENT ON L4,L5,S1 SPINAL AND PARASPINAL REGION

ROM FLEXION AND EXTENSION PAINFUL

LOCAL RISE OF TEMPERATURE-ABSENT

DEFORMITY-NOT SEEN

RIGHT LEFT

POWER

SLRT 70 DEGREE 70 DEGREE

HIP-FLEXION 5/5 5/5

EXTENSION 5/5 5/5

KNEE-FLEXION 5/5 5/5

EXTENSION 5/5 5/5

ANKLE-FLEXION 5/5 5/5

EXTENSION 5/5 5/5

EHL 5/5 5/5

FHL 5/5 5/5

SENSATIONS DECREASED OVER L4,L5,S1DERMATOMES INTACT

DISTAL PULSES FELT FELT

Investigation

COMPLETE BLOOD PICTURE (CBP) 24-02-2025 04:09:PM

HAEMOGLOBIN 12.9 gm/dl

TOTAL COUNT 7500 cells/cumm

NEUTROPHILS 53 %

LYMPHOCYTES 37 %

EOSINOPHILS 03 %

MONOCYTES 07 %

BASOPHILS 00 %

PLATELET COUNT 2.07

SMEAR Normocytic normochromic

HBsAg-RAPID 24-02-2025 04:46:PM Negative

Anti HCV Antibodies - RAPID 24-02-2025 04:46:PM Non Reactive

RFT 24-02-2025 04:46:PM

UREA 25 mg/dl

CREATININE 0.9 mg/dl

URIC ACID 3.9 mmol/L

CALCIUM 9.8 mg/dl

PHOSPHOROUS 4.0 mg/dl

SODIUM 142 mmol/L

POTASSIUM 4.0 mmol/L.

CHLORIDE 104 mmol/L

LIVER FUNCTION TEST (LFT) 24-02-2025 04:46:PM

Total Bilurubin 0.54 mg/dl

Direct Bilurubin 0.16 mg/dl

SGOT(AST) 112 IU/L

SGPT(ALT) 119 IU/L

ALKALINE PHOSPHATASE 219 IU/L

TOTAL PROTEINS 7.0 gm/dl

ALBUMIN 3.9 gm/dl

A/G RATIO 1.28

T3, T4, TSH 25-02-2025 05:52:PM

T3 1.09 ng/ml

T4 10.16 micro g/dl

TSH 4.00 micro Iu/ml

COMPLETE BLOOD PICTURE (CBP) 28-02-2025 06:29:AM

HAEMOGLOBIN 11.9 gm/dl

TOTAL COUNT 9100 cells/cumm

NEUTROPHILS 80 %

LYMPHOCYTES 15 %

EOSINOPHILS 01 %

MONOCYTES 04 %

BASOPHILS 00 %

PLATELET COUNT 1.78

SMEAR Normocytic normochromic

Treatment Given(Enter only Generic Name)

PATIENT WAS CLINICORADIOLOGICALLY DIAGNOSED AS,GRADE II L5 - S1

SPONDYLOLISTHESIS, PAC WAS DONE ON 25/2/25 .UNDERWENT L5 - S1 PSF + L5

LAMINECTOMY + PLIF AND PATIENT SHIFTED TO POST OP UNDER HEMODYNAMICALLY

STABLE CONDITION, EVENTUALLY CONVERTED TO ORAL MEDICATIONS, ASD DONE ON

POD 2,5,10 DRESSING DONE AND WOUND HEALTHY.

DURING THE COURSE OF HOSPITAL STAY PT WAS TREATED WITH IVF, ANTIBIOTICS,

ANTACIDS, ANALGESICS, MULTIVITAMINS.

PATIENT IS NOW BEING DISCHARGED UNDER HEMODYNAMICALLY STABLE CONDITION

Advice at Discharge

1)TAB. CEFTAS-CL 200 MG PO/BD FOR 7 DAYS

2)TAB XYKAA 1 G PO BD FOR 7 DAYS

3)TAB. PAN 40MG PO/OD X 7DAYS

4)TAB.LIMCEE 500MG PO/OD X 15DAYS

5)TAB. TRIGABANTIN 100 MG PO/HS X 7 DAYS

6)TAB.EVION LC PO/OD X 7 DAYS

7) SYP.ASCORIL 15 ML PO/SOS

8) RIGHT HIP BEDSIDE PHYSIOTHERAPY

Diagnosis

B/L OA KNEE

Case History and Clinical Findings

PATIENT COMPLAINS OF BILATERAL KNEE PAIN SINCE 2 YEARS AND NECK PAIN SINCE 1

MONTH

HOPI:

THE PATIENT WAS APPARENTLY ASYMPTOMATIC 2 YEARS BACK THEN HE DEVELOPED B/L

KNEE PAIN WHICH WAS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE IN NATURE,

AGGRAVATED WITH MOVEMENTS AND REKIEVED WITH REST AND MEDICATION, PAIN IS

ASSOCIATED WITH CERVICAL PAIN WHICH WAS GRADUALLY PROGRESSIVE AND

AGGRAVATED WITH MOVEMENTS.

N/K/C/O DM, HTN, TB, ASTHMA, EPILEPSY, CAD, CVA

NO PREVIOUS SURGICAL HISTORY

NO H/O FEVER, VOMITINGS, LOOSE STOOLS,HEAD INJNURY,LOC,BURNING

MICTURITION,BLADDER AND BOWEL INCONTINENCE

ON EXAMINATION

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY ,EDEMA

TEMP:AFEBRILE

PR:82BPM

RR:20CPM

BP:110/90MMHG

CVS- S1,S2 HEARD NO MURMURS

RS-BAE +NVBS

PA- SOFT ,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF RIGHT KNEE

SKIN- NORMAL

SWELLING- DIFFUSE SWELLING PRESENT

NO LOCAL RISE OF TEMPERATURE

TENDERNESS + IN MJL

ROM- 15-100 DEGREE

CREPITUS- PRESENT

PATELLAR TAP - ABSENT

FLUCTUATION TEST - ABSENT

SENSATIONS - INTACT

DISTAL PULSES +

LOCAL EXAMINATION OF LEFT KNEE

SKIN- NORMAL

SWELLING - DIFFUSE SWELLING PRESENT

NO LOCAL RISE OF TEMPERATURE

TENDERNESS + IN MJL

ROM- 20-100 DEGREE

CREPITUS- PRESENT

PATELLAR TAP - ABSENT

FLUCTUATION TEST - ABSENT

SENSATIONS - INTACT

DISTAL PULSES +

Investigation

SERUM CREATININE 06-06-2025 06:37:PM 1.1 mg/dl

COMPLETE BLOOD PICTURE (CBP) 06-06-2025 08:47:PMHAEMOGLOBIN 12.7 gm/dlTOTAL

COUNT 9100 cells/cummNEUTROPHILS 53 %LYMPHOCYTES 37 %EOSINOPHILS 02

%MONOCYTES 08 %BASOPHILS 00 %PLATELET COUNT 2.65SMEAR Normocytic

normochromicCOMPLETE URINE EXAMINATION (CUE) 06-06-2025 08:47:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 3-5EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

Treatment Given(Enter only Generic Name)

THE PATIENT IS CLINICORADIOLOGICALLY DIAGNOSED AS B/L OSTEOARTHRITIS OF KNEE.

THE PATIENT IS GIVEN ANALGESICS AND CALCIUM SUPPLEMENTS

1TAB.XYKAA 1GM PO/OD

2.TAB PAN 40MG PO/OD

3.TAB SHELCAL CT PO/OD

4. LIMEE 500MGPO/OD

5. PHYSIOTHERAPY - IFT B/L KNEE AND KNEE ROM EXERCISES

Advice at Discharge

1. TAB XYKAA 1GM PO/BD X 3 DAYS

2. TAB PAN 40MG PO/OD X 3 DAYS

3. TAB SHELCAL CT PO/OD X 7 DAYS

4. TAB LIMCEE 500MG PO/OD X 7 DAYS

5. Diagnosis

RHEUMATOID ARHTRITIS

Case History and Clinical Findings

PATIENT CAME WITH COMPLAIINTS OF MULTIPLE JOINT PAINS SINCE 6 MONTHS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 6 MONTHS BACK, AND THEN SHE STARTED

DEVELOPINGMULTIPLE JOINT PAINS INSIDIOUS IN ONSET PROGRESSIVE IN NATURE NON

RADIATING TYPE AND AGGRAVATED ON MOVEMENTS,RELEIVED PARTIALLY ON

MEDICATIONS

NO H/O TRAUAMA, BURNING MICTURITION,BOWEL AND BLADDER INCONTINENCE

PAST HISTORY:

NOT A KNOWN CASE OF DM, HYPERTENSION, CAD, CVA AND THYROID DISORDERS

GENERAL EXAMINATION:

PT IS C/C/C

TEMP 98 F

PR 78 BPM

RR- 23 CPM

BP-120/70 MMHG

SPO2 98% RA

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

L/E OF B/L KNEE:

RIGHT LEFT

SKIN- NORMAL NORMAL

SWELLING DIFFUSE AROUND KNEE DIFFUSE AROUND KNEE

LOCAL RISE ABSENT ABSENT

OF TEMPERATURE

TENDERNES: MJL, MJL,

CREPITUS PRESENT PRESENT

ROM COMPLETE ,PAINFUL COMPLETE ,PAINFUL

SENSATIONS:INTACT INTACT

DISTAL PULSES : FELT FELT

Investigation

COMPLETE BLOOD PICTURE (CBP) 25-02-2025 06:30:PMHAEMOGLOBIN 12.7 gm/dlTOTAL

COUNT 12300 cells/cummNEUTROPHILS 55 %LYMPHOCYTES 35 %EOSINOPHILS 05

%MONOCYTES 05 %BASOPHILS 00 %PLATELET COUNT 3.66SMEAR Normocytic normochromic

with Leukocytosis

COMPLETE URINE EXAMINATION (CUE) 25-02-2025 06:30:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-4RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilHBsAg-RAPID 25-02-

2025 06:30:PM Negative

Anti HCV Antibodies - RAPID 25-02-2025 06:30:PM Non ReactiveRFT 25-02-2025 06:30:PMUREA

19 mg/dlCREATININE 0.6 mg/dlURIC ACID 2.0 mmol/LCALCIUM 10.0 mg/dlPHOSPHOROUS 2.4

mg/dlSODIUM 137 mmol/LPOTASSIUM 3.5 mmol/L.CHLORIDE 103 mmol/L

LIVER FUNCTION TEST (LFT) 25-02-2025 06:30:PMTotal Bilurubin 0.63 mg/dlDirect Bilurubin 0.19

mg/dlSGOT(AST) 28 IU/LSGPT(ALT) 30 IU/LALKALINE PHOSPHATASE 278 IU/LTOTAL

PROTEINS 7.4 gm/dlALBUMIN 3.82 gm/dlA/G RATIO 1.07Investigation

Treatment Given(Enter only Generic Name)

1. TAB ULTRACET PO BD

2. TAB PAN 40 MG PO OD

3. TAB SHELCAL CT PO OD

4. TAB MVT PO OD

5. PHYSIO B/L KNEE

Advice at Discharge

1. TAB ULTRACET PO BD X5DAYS

2. TAB PAN 40 MG PO OD X5DAYS

3. TAB SHELCAL CT PO OD X15DAYS

4. TAB MVT PO OD X 15DAYS

5. PHYSIO BILATERAL KNEE

6. Diagnosis

DEGENERATIVE LUMBAR SPONDYLOSIS

Case History and Clinical Findings

PATIENT CAME WITH CHIEF COMPLAINT OF BILATERAL KNEE PAIN AND LOWER BACK PAIN

SINCE 6 MONTHS

NO H/O TRAUMA

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 6 MONTHS AGO THEN HE

DEVELOPEDLOWER BACK PAIN RADIATING TO RIGHT LOWER LIMB WHICH WAS INSIDIOUS

IN ONSET, GRADUALLY PROGRESSIVE IN NATURE AGGRAVATED ON MOVEMENTS AND

RELIEVED ON REST AND MEDICATION

NO H/O TRAUMA

NO H/O FEVER, VOMITINGS, LOOSE STOOLS,HEAD INJNURY,LOC,BURNING

MICTURITION,BLADDER AND BOWEL INCONTINENCE

PAST HISTORY:

K/C/O DM SINCE 3 YRS

N/K/C/O HTN , TB , ASTHMA,EPILEPSY

GENERAL EXAMINATION:

TEMP - 98.4 F

PR 88 BPM

RR- 14 CPM

BP-110/80 MMHG

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF LS SPINE:

NO DEFORMITY

SKIN - NORMAL

SWELLING - ABSENT

LOCAL RISE IN TEMP. - ABSENT

TENDERNESS - PRESENT PRESENT OVER L4-L5 LEVEL IN MID LINE

LT RT

SLRT 90 90

POWER 5/5 5/5

HIP 5/5 5/5

KNEE 5/5 5/5

ANKLE 5/5 5/5

FHL 5/5 5/5

EHL 5/5 5/5

SENSATIONS INTACT INTACT

DISTAL PULSES FELT FELT

Investigation

COMPLETE BLOOD PICTURE (CBP) 18-06-2025 07:17:PMHAEMOGLOBIN 12.3 gm/dlTOTAL

COUNT 8800 cells/cummNEUTROPHILS 58 %LYMPHOCYTES 34 %EOSINOPHILS 02

%MONOCYTES 06 %BASOPHILS 00 %PLATELET COUNT 2.6SMEAR Normocytic normochromic

COMPLETE URINE EXAMINATION (CUE) 18-06-2025 07:17:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN TraceSUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

RFT 18-06-2025 07:17:PMUREA 24 mg/dlCREATININE 0.8 mg/dlURIC ACID 2.5 mmol/LCALCIUM

9.9 mg/dlPHOSPHOROUS 4.0 mg/dlSODIUM 136 mmol/LPOTASSIUM 4.3 mmol/L.CHLORIDE 104

mmol/L

LIVER FUNCTION TEST (LFT) 18-06-2025 07:17:PMTotal Bilurubin 0.88 mg/dlDirect Bilurubin 0.20

mg/dlSGOT(AST) 39 IU/LSGPT(ALT) 16 IU/LALKALINE PHOSPHATASE 241 IU/LTOTAL

PROTEINS 6.4 gm/dlALBUMIN 3.94 gm/dlA/G RATIO 1.60

Treatment Given(Enter only Generic Name)

PATIENT WAS CLINIC0-RADIOLOGICALLU DOAGNOSED WITH DEGENERATIVE LUMBAR

SPONDYLOSIS

1.TAB XYKAA 1 GM PO/BD

2.TAB.PAN 40 MG PO/OD

3.TAB.SHELCAL CT PO/OD

4.PHYSIOTHERAPY IFT TO LOW BACK -BACK STRENGTHENING EXERCISES

Advice at Discharge

1.TAB XYKAA 1 GM PO/BD X 1 WEEK

2.TAB.PAN 40 MG PO/OD X 1 WEEK

3.TAB.SHELCAL CT PO/OD X 2 WEEK

4.PHYSIOTHERAPY IFT TO LOW BACK -BACK STRENGTHENING EXERCISES

7. Diagnosis

GRADE IV B/L OA KNEE

Case History and Clinical Findings

CHIEF COMPLAINTS:

C/O OF PAIN IN B/L KNEE SINCE 15 TO 16 YEARS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 16 YEARS BACK, THEN SHE DEVELOPED PAIN

IN B/L KNEE ,INSIDIOUS IN ONSET,CONTINUES,DRAGGING TYPE ,AGGRAVATED WITH

MOVEMENTS AND DAILY ACTIVITY, RELIEVED BY TAKING REST AND MEDICATION.

NO H/O LOC/ENT BLEED

NO H/O FEVER

NO H/O TRAUMA/BURNING MICTURITION/ BOWEL AND BLADDER INCONTINENCE.

PAST HISTORY:

N/K/C/O DM/HTN/HYPOTHYROID/CAD

H/O CVA 1 YEAR BACK ON MEDICATION.

ON GENERAL EXAMINATION:

NO PALLOR ,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY ,EDEMA

TEMP:98.4 F

PR:82BPM

RR:19CPM

BP:110/70MMHG

SPO2: 98%@RA

CVS- S1,S2 HEARD NO MURMURS

RS-BAE +NVBS

PA- SOFT ,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF B/L KNEE

RIGHT LEFT

SKIN: NORMAL NORMAL

SWELLING : SUPRAPATELLAR SUPRAPATELLAR

TENDERNESS MJL MJL

DEFORMITY : VARUS 5TH DEGREE VARUS 5TH DEGREE

LOCAL RISE OF TEMPERATURE ABSENT ABSENT

CREPITUS PRESENT PRESENT

ROM 0 - 100 DEGREE 0 - 110 DEGREE

SENSATIONS - INTACT INTACT

DISTAL PULSES- PRESENT PRESENT

Investigation

COMPLETE BLOOD PICTURE (CBP) 05-03-2025 07:02:PM

HAEMOGLOBIN 12.7 gm/dl

TOTAL COUNT 9000 cells/cumm

NEUTROPHILS 45 %

LYMPHOCYTES 45 %

EOSINOPHILS 05 %

MONOCYTES 05 %

BASOPHILS 00 %

PLATELET COUNT 3.0

SMEAR Normocytic normochromic

COMPLETE URINE EXAMINATION (CUE) 05-03-2025 07:02:PM

COLOUR Pale yellow

APPEARANCE Clear

REACTION Acidic

SP.GRAVITY 1.010

ALBUMIN Nil

SUGAR Nil

BILE SALTS Nil

BILE PIGMENTS Nil

PUS CELLS 2-3

EPITHELIAL CELLS 2-3

RED BLOOD CELLS Nil

CRYSTALS Nil

CASTS Nil

AMORPHOUS DEPOSITS Absent

OTHERS Nil

RFT 05-03-2025 07:03:PM

UREA 22 mg/dl

CREATININE 0.8 mg/dl

URIC ACID 3.5 mmol/L

CALCIUM 9.8 mg/dl

PHOSPHOROUS 3.3 mg/dl

SODIUM 141 mmol/L

POTASSIUM 3.9 mmol/L.

CHLORIDE 104 mmol/L

LIVER FUNCTION TEST (LFT) 05-03-2025 07:03:PM

Total Bilurubin 0.55 mg/dl

Direct Bilurubin 0.18 mg/dl

SGOT(AST) 17 IU/L

SGPT(ALT) 13 IU/L

ALKALINE PHOSPHATASE 183 IU/L

TOTAL PROTEINS 7.0 gm/dl

ALBUMIN 4.0 gm/dl

A/G RATIO 1.37

Treatment Given(Enter only Generic Name)

T.XYKAA PO/BD

T.PAN 40 MG PO/OD

T.SHELCAL -CT PO/OD

T.CLIMIDIPINE 10 MG + TELMA 40 MG PO/OD

PHYSIOTHERAPY IFT B/L KNEE

Advice at Discharge

T.XYKAA PO/BD X 7DAYS

T.PAN 40 MG PO/OD X 7DAYS

T.SHELCAL -CT PO/OD X 7DAYS

T.CLIMIDIPINE 10 MG + TELMA 40 MG PO/OD X 15 DAYS

PHYSIOTHERAPY IFT B/L KNEE

8. Diagnosis

B/L OSTEOARTHRITIS KNEE

Case History and Clinical Findings

CHIEF COMPLAINTS-

PATIENT CAME WITH CHIEF COMPLAINT OF B/L KNEE PAIN SINCE 1 YEAR

NO H/O TRAUMA

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 1 YEAR AGO THEN HE DEVELOPED PAIN

OVER BOTH KNEE PAIN WHICH WAS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE ,

AGGRAVATED ON MOVEMENT , RELEVIED ON REST , NON RADIATING TYPE ASSOCIATED

WITH TINGLING AND NUMBNESS AND CALF MUSCLE TENDERNESS

H/O TRAUMA 1 MONTH AGO

NO H/O FEVER, VOMITINGS, LOOSE STOOLS,HEAD INJNURY,LOC,BURNING

MICTURITION,BLADDER AND BOWEL INCONTINENCE

PAST HISTORY:

N/K/C/O HTN DM, TB , ASTHMA,EPILEPSY

GENERAL EXAMINATION:

TEMP - 98.4F

PR 82 BPM

RR- 18CPM

BP-110/80 MMHG

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF RIGHT KNEE

SKIN- NORMAL

SWELLING ABSENT

NO LOCAL RISE OF TEMPERATURE

TENDERNESS +

ROM- 0-130 DEGREE

CREPITUS- PRESENT

SENSATIONS - INTACT

DISTAL PULSES +

LOCAL EXAMINATION OF LEFT KNEE

SKIN- NORMAL

SWELLING ABSENT

NO LOCAL RISE OF TEMPERATURE

TENDERNESS SUPRAPATELLAR

ROM- 0-130 DEGREE

CREPITUS- PRESENT

SENSATIONS - INTACT

DISTAL PULSES +

Investigation

Name Value

Name ValueCOMPLETE BLOOD PICTURE (CBP) 21-06-2025 05:57:PMHAEMOGLOBIN 14.9

gm/dlTOTAL COUNT 5700 cells/cummNEUTROPHILS 48 %LYMPHOCYTES 40 %EOSINOPHILS

04 %MONOCYTES 08 %BASOPHILS 00 %PLATELET COUNT 1.61SMEAR Normocytic

normochromic

COMPLETE URINE EXAMINATION (CUE) 21-06-2025 05:57:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN traceSUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilRFT 21-06-2025

05:57:PMUREA 28 mg/dlCREATININE 0.9 mg/dlURIC ACID 2.8 mmol/LCALCIUM 9.3

mg/dlPHOSPHOROUS 3.4 mg/dlSODIUM 136 mmol/LPOTASSIUM 4.4 mmol/L.CHLORIDE 98

mmol/L

LIVER FUNCTION TEST (LFT) 21-06-2025 05:57:PMTotal Bilurubin 0.66 mg/dlDirect Bilurubin 0.18

mg/dlSGOT(AST) 47 IU/LSGPT(ALT) 48 IU/LALKALINE PHOSPHATASE 133 IU/LTOTAL

PROTEINS 6.8 gm/dlALBUMIN 4.3 gm/dlA/G RATIO 1.75

Treatment Given(Enter only Generic Name)

PT WAS CLINICORADIOLOGICALLY DIAGNOSED WITHB/L OSTEOARTHRITIS KNEE AND

CONSERVATIVE TREATED WITH

1.TAB HIFENAC-PO/BD

2.TAB PAN 40MG PO/BD

3.TAB SHELCAL CT PO/OD

4.PHYSIO IFT B/L KNEE

5.TAB TRIGABANTIN PO/HS

Advice at Discharge

8. 1.TAB HIFENAC-PO/BD X 5 DAYS

9. 2.TAB PAN 40MG PO/BD X 5 DAYS

10. 3.TAB SHELCAL CT PO/OD X 15 DAYS

11. 4.TAB TRIGABANTIN PO/HS X 5 DAYS

9. Diagnosis

THROMBOCYTOPENIA WITH RECUREENT HYPOGYLCEMIA

Case History and Clinical Findings

C/O PAIN ABDOMEN SINCE 2 DAYS WITH ABDOEN DISTENSION,H/O FEVER SINCE 5 DAYS

,NO H/O VOMITINGS,NO H/O SOB

K/C/O DM SINCE 3 MONTHS

NO H/O HTN ASTHMA EPILEPSY

O/E-AFEBRILE, BP 150/90 MMHG ,PR-90BPM, RR-19CPPM

G/E- PT IS C/C/C MODERATLEY BUILT AND NOURISHED

NO PALOR ICTERUS CYANOSIS CLUBBING LYMPHADENOPATHY EDAL EDEMA

S/E -

P /A- SHAPE -DISTENDED,NO TENDERNESS.NO ORGANOMEGALY,HERNIAM ORIFICES FREE

CVS S1 S2 HEARD,NO MURMURS

CNS - HGHER MENTAL FUNCTIONS-NORMAL MOTOR SYSTEM- INTACT SENSORY SYSTEM-

INTACT CRANIAL NERVE EXAMINATION - NORMAL

RS- TRACHEA MIDLINE NVBS HEARD,NO WHEEZE,NO ADVENTIOUS SOUNDS

Treatment Given(Enter only Generic Name)

2 D-5 GIVEN FOR UNCTOLLABLE SUGARS

FOLEY'S INSERTED-OUTCOME -1500ML

Advice at Discharge

IN VIEW OF RECURRENT HYPOGLYCEMIA GIVE 5 D AS MAINTENANCE DOSE

IN VIEW OF THROMBOCYTOENIA PREFER FFP TRANSFUSION

10. Diagnosis

B/L OA KNEE

Case History and Clinical Findings

CHIEF COMPLAINTS-

PATIENT CAME WITH CHIEF COMPLAINT OF B/L KNEE PAIN SINCE 2 YEARS

NO H/O TRAUMA

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 2 YEARS AGO THEN HE DEVELOPED

PAIN OVER BOTH KNEE PAIN WHICH WAS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE

IN NATURE AGGRAVATED ON MOVEMENTS AND RELIEVED ON REST AND MEDICATION

NO H/O TRAUMA

NO H/O FEVER, VOMITINGS, LOOSE STOOLS,HEAD INJNURY,LOC,BURNING

MICTURITION,BLADDER AND BOWEL INCONTINENCE

PAST HISTORY:

K/C/O DM ON MEDICATION since 5 yrs

K/C/O HTN ON MEDICATION since 2 yrs

N/K/C/O TB , ASTHMA,EPILEPSY

GENERAL EXAMINATION:

TEMP -98.6 F

PR 78 BPM

RR- 18 CPM

BP-130/90 MMHG

GRBS: 110MG/DL

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF RIGHT KNEE

SKIN- NORMAL

SWELLING - ABSENT

NO LOCAL RISE OF TEMPERATURE

TENDERNESS + IN MJL , DIFFUSE

ROM- 0-90 DEGREE

CREPITUS- ABSENT

SENSATIONS - INTACT

DISTAL PULSES +

FFD 10 DEGREE

LOCAL EXAMINATION OF LEFT KNEE

SKIN- NORMAL

SWELLING - ABSENT

NO LOCAL RISE OF TEMPERATURE

TENDERNESS + IN MJL ,DIFFUSE

ROM-0-90 DEGREE

CREPITUS- ABSENT

SENSATIONS - INTACT

DISTAL PULSES +

Investigation

COMPLETE BLOOD PICTURE (CBP) 02-07-2025 07:12:PM HAEMOGLOBIN14.9 gm/dlTOTAL

COUNT7500 cells/cummNEUTROPHILS63 %LYMPHOCYTES28 %EOSINOPHILS03

%MONOCYTES06 %BASOPHILS00 %PLATELET COUNT2.86SMEARNormocytic

normochromicCOMPLETE URINE EXAMINATION (CUE) 02-07-2025 07:12:PM COLOURPale

yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMINNilSUGARNilBILE

SALTSNilBILE PIGMENTSNilPUS CELLS2-3EPITHELIAL CELLS2-3RED BLOOD

CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilRFT 02-07-2025

07:12:PM UREA21 mg/dlCREATININE0.9 mg/dlURIC ACID5.1 mmol/LCALCIUM10.0

mg/dlPHOSPHOROUS2.5 mg/dlSODIUM136 mmol/LPOTASSIUM3.5 mmol/L.CHLORIDE99

mmol/LLIVER FUNCTION TEST (LFT) 02-07-2025 07:12:PM Total Bilurubin1.30 mg/dlDirect

Bilurubin0.25 mg/dlSGOT(AST)16 IU/LSGPT(ALT)10 IU/LALKALINE PHOSPHATASE130

IU/LTOTAL PROTEINS6.4 gm/dlALBUMIN4.13 gm/dlA/G RATIO1.93Investigation

Treatment Given(Enter only Generic Name)

1. TAB .XYKAA 1 GM PO/BD

2. TAB . PAN 40 MG PO/BD

3. TAB. SHELCAL CT PO/BD

4. PHYSIO IFT - B/L OA KNEE .

KNEE ROM EXERCISES

Advice at Discharge

1. TAB .XYKAA 1 GM PO/BD X 15 DAYS

2. TAB . PAN 40 MG PO/BD X 15 DAYS

3. TAB. SHELCAL CT PO/BD X 15 DAYS

4. PHYSIO IFT - B/L OA KNEE .

KNEE ROM EXERCISES

11. Diagnosis

GRADE III B/L OSTEOARTRITIS KNEE (RT>LT)

Case History and Clinical Findings

CHIEF COMPLAINTS-

PATIENT CAME WITH CHIEF COMPLAINT OF B/L KNEE PAIN SINCE 2 YEARS

NO H/O TRAUMA

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 2 YEARS AGO THEN HE DEVELOPED

PAIN OVER BOTH KNEE PAIN WHICH WAS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE

IN NATURE AGGRAVATED ON WALKING AND SQUATTING AND RELIEVED ON REST AND

MEDICATION.TINGLING SENSATION IS PRESENT . NUMBNESS ABSENT.

NO H/O TRAUMA

NO H/O FEVER, VOMITINGS, LOOSE STOOLS,HEAD INJNURY,LOC,BURNING

MICTURITION,BLADDER AND BOWEL INCONTINENCE

PAST HISTORY:

K/C/O HTN SINCE 6 MONTHS ON TAB. TELMA 40

N/K/C/O DM, TB , ASTHMA,EPILEPSY

GENERAL EXAMINATION:

TEMP -98 F

PR 86 BPM

RR- 16 CPM

BP-120/90 MMHG

GRBS: 110MG/DL

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF KNEE

ATTITUDE - PATIENT IN SUPINE POSITION . BOTH ASIS AT SAME LEVEL KNEE AT FLEXION.

RIGHT LEFT

SKIN- NORMAL NORMAL

SWELLING - DIFFUSE DIFFUSE

LOCAL RISE OF TEMPERATURE ABSENT ABSENT

TENDERNESS PRESENT AT MJL PRESENT AT MJL

ROM- 10-110 DEGREE 10-100 DEGREE

CREPITUS- PRESENT PRESENT

SENSATIONS - INTACT INTACT

DISTAL PULSES PRESENT PRESENT

FFD 10 DEGREE 10 DEGREE

Investigation

COMPLETE URINE EXAMINATION (CUE) 08-07-2025 06:30:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN TraceSUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS NilCOMPLETE BLOOD

PICTURE (CBP) 08-07-2025 06:30:PMHAEMOGLOBIN 12.4 gm/dlTOTAL COUNT 5400

cells/cummNEUTROPHILS 47 %LYMPHOCYTES 42 %EOSINOPHILS 03 %MONOCYTES 08

%BASOPHILS 00 %PLATELET COUNT 1.74SMEAR Normocytic normochromicRFT 08-07-2025

06:30:PMUREA 37 mg/dlCREATININE 1.3 mg/dlURIC ACID 6.2 mmol/LCALCIUM 10.0

mg/dlPHOSPHOROUS 2.8 mg/dlSODIUM 136 mmol/LPOTASSIUM 3.1 mmol/L.CHLORIDE 99

mmol/LLIVER FUNCTION TEST (LFT) 08-07-2025 06:30:PMTotal Bilurubin 0.61 mg/dlDirect

Bilurubin 0.15 mg/dlSGOT(AST) 26 IU/LSGPT(ALT) 10 IU/LALKALINE PHOSPHATASE 116

IU/LTOTAL PROTEINS 6.6 gm/dlALBUMIN 3.96 gm/dlA/G RATIO 1.50

Treatment Given(Enter only Generic Name)

1. TAB .XYKAA 1 GM PO/BD

2. TAB . PAN 40 MG PO/BD

3. TAB. SHELCAL CT PO/BD

4. PHYSIO IFT - B/L OA KNEE

5. TAB. TELMA 40 MG PO/OD

Advice at Discharge

1. TAB .XYKAA 1 GM PO/BD X 5 DAYS

2. TAB . PAN 40 MG PO/BD X 5 DAYS

3. TAB. SHELCAL CT PO/BD X 5 DAYS

4.TAB. TELMA 40 MG PO/ODX 5 DAYS

12. Diagnosis

B/L OA KNEE

Case History and Clinical Findings

CHIEF COMPLAINTS-

C/O B/L KNEE PAIN SINCE YEARS.

HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 5 YEARS AGO THEN SHE DEVELOPED

PAIN OVER BOTH KNEE PAIN WHICH WAS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE

IN NATURE AGGRAVATED ON MOVEMENTS AND RELIEVED ON REST AND MEDICATION

NO H/O TRAUMA

PAST HISTORY:

N/K/C/O HTN DM, TB , ASTHMA,EPILEPSY

GENERAL EXAMINATION:

TEMP - 98.6 F

PR 88 BPM

RR- 18CPM

BP-120/80 MMHG

SYSTEMIC EXAMINATION:

CVS S1 S2 HEARD,NO MURMURS

RS-BAE +,NVBS HEARD

PER ABDOMEN -SOFT,NON TENDER

CNS-NFND

LOCAL EXAMINATION OF RIGHT KNEE

SKIN- NORMAL

SWELLING MILD

NO LOCAL RISE OF TEMPERATURE

TENDERNESS + IN MJL

ROM- 10-110 DEGREE

SENSATIONS - INTACT

DISTAL PULSES +

FFD- 10 DEGREE

LOCAL EXAMINATION OF LEFT KNEE

FFD - 10 DEGREE

SKIN- NORMAL

SWELLING MILD

NO LOCAL RISE OF TEMPERATURE

TENDERNESS + IN MJL

ROM- 10-110 DEGREE

SENSATIONS - INTACT

DISTAL PULSES +

Investigation

Name Value

Name ValueRFT 22-04-2025 07:08:PMUREA 24 mg/dlCREATININE 0.7 mg/dlURIC ACID 3.5

mmol/LCALCIUM 10.0 mg/dlPHOSPHOROUS 3.8 mg/dlSODIUM 139 mmol/LPOTASSIUM 3.9

mmol/L.CHLORIDE 103 mmol/L

LIVER FUNCTION TEST (LFT) 22-04-2025 07:08:PMTotal Bilurubin 1.03 mg/dlDirect Bilurubin 0.20

mg/dlSGOT(AST) 27 IU/LSGPT(ALT) 12 IU/LALKALINE PHOSPHATASE 166 IU/LTOTAL

PROTEINS 7.7 gm/dlALBUMIN 4.09 gm/dlA/G RATIO 1.13COMPLETE BLOOD PICTURE (CBP) 22-

04-2025 07:08:PMHAEMOGLOBIN 12.1 gm/dlTOTAL COUNT 7600 cells/cummNEUTROPHILS 50

%LYMPHOCYTES 40 %EOSINOPHILS 02 %MONOCYTES 08 %BASOPHILS 00 %PLATELET

COUNT 1.80SMEAR Normocytic normochromic

COMPLETE URINE EXAMINATION (CUE) 22-04-2025 07:08:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

Treatment Given(Enter only Generic Name)

THE PATIENT IS CLINICORADIOLOGICALLY DIAGNOSD WITH B/L OA KNEE. THE PATIENT IS

TREATD CONSERVATIVELY USING

1) TAB. XYKAA 1G PO/OD

2) TAB PAN 40 MG PO/OD

TAB SHELCAL CT PO/ OD

PHYSIO IFT KNEE

Advice at Discharge

1) TAB. XYKAA 1G PO/OD

2) TAB PAN 40 MG PO/OD

TAB SHELCAL CT PO/ OD

PHYSIO IFT KNEE

13. Diagnosis

LUMBAR SPONDYLOSIS

Case History and Clinical Findings

C/O LOW BACK PAIN SINCE 2 YEARS

NO H/O TRAUMA OR FEVER

PATIENT WAS APPERENTLY ASSYMPTOMATIC 2 YEARS AGO THEN DEVELOPED PAIN IN

LOW BACK WHICH IS SUDDEN IN ONSET AND GRADUALLY INCREASED

N/K/C/O DM,TB,ASTHMA,HTN,EPILEPSY

PERSONAL HISTORY:

DIET:MIXED

SLEEP:ADEQUATE

BOWEL AND BLADDER:REGULAR

ADDICTIONS:NO

APPETITE:NORMAL

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND

PERSON.

NO PALLOR,ICTERUS CYANOSIS,CLUBBING,LYMPHADENOPATHY,EDEMA.

VITALS:

TEMPERATURE:AFEBRILE

BP:110/70 MM HG

PR:88 BPM

RR:19 CPM

SYSTEMIC EXAMINATION:

CVS:S1,S2 HEARD NO MURMURS.

RS:BAE +,NO MURMURS

PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY

CNS:NO FOCAL NEUROLOGICAL DEFICITS.

LOCAL EXAMINATION:

L/E OF LS SPINE:

SKIN NORMAL

SWELLING ABSENT

TENDERNESS ABSENT

NO LOCAL RISE OF TEMPERATURE

DEFORMITY ABSENT

RT LT

SLRT ACTIVE 0-40 0-40

PASSIVE 0-60 0-70

POWER

HIP FLEXION 5/5 5/5

EXTENSION 5/5 5/5

KNEE FLEXION 5/5 5/5

EXTENSION 5/5 5/5

ANKLE DORSIFLEXION 5/5 5/5

PLANTAR FLEXION 5/5 5/5

EHL 5/5 5/5

FHL 5/5 5/5

DISTAL PULSES PRESENT PRESENT

SENSATIONS INTACT INTACT

Investigation

RFT 13-05-2025 07:15:PMUREA 17 mg/dlCREATININE 0.8 mg/dlURIC ACID 5.2 mmol/LCALCIUM

9.8 mg/dlPHOSPHOROUS 4.3 mg/dlSODIUM 137 mmol/LPOTASSIUM 3.6 mmol/L.CHLORIDE 99

mmol/L

LIVER FUNCTION TEST (LFT) 13-05-2025 07:15:PMTotal Bilurubin 0.96 mg/dlDirect Bilurubin 0.18

mg/dlSGOT(AST) 18 IU/LSGPT(ALT) 12 IU/LALKALINE PHOSPHATASE 190 IU/LTOTAL

PROTEINS 7.5 gm/dlALBUMIN 4.0 gm/dlA/G RATIO 1.18COMPLETE BLOOD PICTURE (CBP) 13-

05-2025 07:15:PMHAEMOGLOBIN 11.8 gm/dlTOTAL COUNT 9800 cells/cummNEUTROPHILS 45

%LYMPHOCYTES 45 %EOSINOPHILS 05 %MONOCYTES 05 %BASOPHILS 00 %PLATELET

COUNT 3.19SMEAR Normocytic normochromic

COMPLETE URINE EXAMINATION (CUE) 13-05-2025 07:15:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN NilSUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 2-3EPITHELIAL CELLS 2-4RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

Treatment Given(Enter only Generic Name)

THE PATIENT IS CLINICORADIOLOGICALLY DIAGNOSED ASLUMBAR SPONDYLOSIS AND

CONSERVATIVELY MANAGED WITH

1)TAB . XYKAA 1 GM PO/BD

2)TAB. PAN 40 MG PO/OD

3)TAB.TRIGABANTIN 100MG PO/HS

4)TAB. EVION LC PO/BD

5)PHYSIO IFT LOW BACK .

Advice at Discharge

1)TAB . XYKAA 1 GM PO/BD X 15DAYS

2)TAB. PAN 40 MG PO/OD X15DAYS

3)TAB.TRIGABANTIN 100MG PO/HSX 15DAYS

4)TAB. EVION LC PO/BD X 15DAYS

5)PHYSIO IFT LOW BACK

Nithin Chakravarthy

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