1st February, 2023
TO WHOM IT MAY CONCERN
MEDICAL REPORT
RE: M. C WCA|5993|2023, 54 YEARS OLD, FEMALE
Diagnosis: Right Knee Transient Synovitis with background Right knee Osteoarthritis
Treatment: Antibiotics, Analgesics
Date of Admission: 30/01/2023
Date of Discharge: 02/02/2023
The above named patient presented to this facility 5 days ago (24th Jan 2023) on account of recurrent right knee pain. Right knee pain was insidious in onset, discomforting, worse on ambulating and relieved by rest.
On examination of the both knees, there was no swelling, differential warmth or limitation of joint movement but she had crepitations bilaterally on both knees.
Blood investigations:
FBC: WBC: 7.12 PCV: 44.19 PLT: 425
CRP: 27.4 mg/l
Imaging: (Bilateral Knee MRI )
MRI of both Knees showed bilateral early knee osteo- arthritic changes, more on the right side, with associated mild supra patellar bursitis, loss of joint spaces as well as swollen/inflamed synovial lining and joint effusion.
Following clinical and radiological evaluation (MRI of both Knees) an assessment of Right knee Osteoarthritis was made and was commenced on conservative management which includes lifestyle modification, adequate rest, knee brace and analgesics (Tab Arthrotec 75mg bd)
Despite above conservative measures she developed progressive difficulty in walking due to increasing pain on the right knee following which she represented again on the 30th Jan 2023.
Clinical examinations revealed hot, inflamed and swollen right knee joint with limitation of movement due to pain.
A diagnosis of acute exerbation of osteoarthritis was made to rule out septic artiritis. Based on this diagnosis she was admitted and commenced on IV rocephin 1G 12hrly for 5 days, IM diclofenac 75mg stat, then tabs diclofenac 50mg twice daily. She was also booked to be reviewed by orthopaedic surgeon.
She had marked clinical improvement a day post admission. And is currently doing well.
She was subsequently reviewed by the Orthopedic surgeon today (2/02/2023) who made an assessment of Transient Synovitis .IV Antibiotics was stopped and she was commenced on Tabs Levofloxacin 500mg dly for 2 weeks and Tabs Arthrotec 75mgn bd for 1 week.
She is to be reviewed again in 2 weeks. (16/02/2023)
Please revert, if need be, for any clarification.
Yours sincerely,
Ukandu Chinedu MD
For Team Wellington Clinics Abuja.
.