23 yrs old male. complain of the swollen painful non tender knee for 2 years.... diagmosis and management

Good Afternoon Dear Curofians, Elderly Male, Non Diabetic, presented with these lesions over Trunk, chest n abdomen regions. Had Rt side Great toe trophic ulcer. Sensory loss in lower leg n feet region. ESR 125. Hiv Non reactive. Give your differential diagnosis. Share your management n investigation plan. Regards.

HOMOEOPATHY FOR HEEL PAIN --------------------------------------------------- Heel pain usually affects the underside or back of your heel. Although heel pain is rarely a symptom of a serious condition, it can interfere with your normal activities, particularly exercise. Causes-- The most common causes of heel pain are plantar fasciitis (bottom of the heel) and Achilles tendinitis (back of the heel). Causes of heel pain also include: · Achiles tendinitis · Achiles tendon rupture · Bone tumor · Bursitis · Haglund's deformity · Heel spur · Osteomyelitis · Paget’s disease of bone · Peripheral neuropathy · Plantar fasiitis · Reactive arthritis · Retrocalcaneal bursitis · Rheumatoid arthritis · Sarcoidosis · Stress fractures · Tarsal tunnel syndrome HOMOEOPATHIC REMEDIES Homoeopathic remedies are very effective for curing heel pain safely. Some of the impotant remedies are given below-- CALCAREA FLOUR 30-It is an excellent remedy for heel pain due to calcaneal spur. It is the most effective Homeopathic medicine with the best healing power to dissolve the Calcaneal Spur. This Homeopathic remedy is of great help in all cases of Calcaneal Spur whether painful or not. Calcarea Fluor acts as the best resolving agent for Calcaneal Spur and is considered the first choice of Homeopathic remedy in every case of Calcaneal Spur. It is considered a specific remedy for this condition AMMONIUM CARB 30- Ammonium carb is best for heel pain on standing with tenderness. There is cramps in calf and soles. The big toe painful and wollen. BERBERIS VULGARIS 200- Berberis vulgaris is effective for heel pain which is relieved by putting the entire body weight on them. Pain in the heel as if ulcerated. BORAX 30- Borax is effective for heel pain with burning pain in great toe.There is inflammation of the bulb of toess and stitching pain in soles. AMMONIUM MUR 30-Ammonium Mur is a very effective Homeopathic medicine for heel pain due Calcaneal Spur.Pain in heel on walking. This Homeopathic remedy is of great help in decreasing the pain in heel on walking due to Calcaneal Spur. Ammonium Mur helps in decreasing the pain as well as dissolving the spur. Apart from specific worsening of pain on walking, the person also complains of pain in morning. A few people needing Ammonium Mur may get relief by slight rubbing of the heel. The pain can be stitching or tearing in nature . COLCHICUM AUTUMNALE 30-Colchicum is effective for heel pain due to gout. Pain in big toe and heel. Cannot bear to touch or move it is the guiding symptom. CYCLAMEN 30- Cyclamen is effective for burning boring pain in heels, better by moving about , massage, warmth , worse sitting or standing and by a cold bath. RHUS TOXICODENDRON 200- Rhus Tox is the top remedy for pain in heel on standing due to Calcaneal Spur. Homeopathic medicine Rhus Tox also helps in repairing the muscles and ligaments covering the heel bone, thus preventing further heel damage. Its next action is to dissolve the spur. Rhus Tox thus acts in three spheres for Calcaneal Spur patients — pain relief, strengthening the muscles or ligaments, and dissolving the spur. The pain is stitching in character. The person may feel the pain as being similar to that caused by a splint. Another expression used may be pain as from a nail under the skin. ARANEA DIADEMA 30-Aranea Diadema is considered a top Homeopathic medicines for heel pain due Calcaneal Spur treatment. This Homeopathic remedy is best for getting rid of digging and boring type of pains in heel. The pain may alternate with a numb feeling in the heel. An extreme sensitivity to cold air can also be predominantly present. AURUM MET 30-Pain in heel at night. The pain in heel at night due to Calcaneal Spur is best relieved by Aurum Met.lles tendon. ARISTOLOCHIA MIL. 30-Aristolochia is prescribed when stitching pain in heels occurs with itching. There is cramp like pain in left Achi TARTARIC ACID 3X—Tartaric acid is best for pain in heels and soles.There is tearing pain at soles near the heel, which prevents him setting his foot on the ground after luncheon. LATHYRUS SATIVUS 30-Lathyrus sat. is prescribed when heels do not touch the ground due to pain on walking. The patient walks on the front part of the feet. MEZEREUM 30-Pain by touching. Mezereum is best for heel pain due to spur and it is worse by touching. For patients complaining of pain in heel spur when touched, Mezereum is the best remedy. The patient may show an increased sensitivity to cold air. PETROLEUM 200-Petroleum is prescribed when stitching pain in heels as if by splinters. The heels are rough with cracks and fissures. The complaints are worse in winter. PULSATILLA NIG. 30-Pulsatilla is prescribed when pricking of nails like pain occurs in heels. The patient puts the feet outside the blanket to cool them as it has a pleasing effect on the pain. PHYTOLACCA DEC. 30-Phytolacca dec is best when aching pain in heels occurs , which is relieved by elevating the feet. The nature of the pain is like electric shocks. RUTA GRAVEOLENS 30-Pain in heel extending to Achilles tendon. The tendon that connects the calf muscle present in the back of the leg to heels is known as Tendo Achilles. For patients who have pain in heel due to Calcaneal Spur with the extension of pain in Tendo Achilles, the best Homeopathic remedy for relief is Ruta. Ruta is of great help in bony and tendon complaints. RANUNCULUS BULBOSUS 30-Ranunculus is best for acute pain in heels. There is pulsative stitches in the left heel on standing. SILICEA 30- Silicea is prescribed when tearing pain in the heels is present due to sprained ankles. Soreness in feet from instep through to the sole. VALERIANA 30-Valeriana is prescribed when stinging pain in heels is present while sitting.

*Restless leg syndrome (RLS* ☝ *Today about*☝ Definition Restless leg syndrome (RLS) or Willis-Ekbom disease(WED) is a common cause of painful legs. The leg pain of restless leg syndrome typically eases with motion of the legs and becomes more noticeable at rest. Restless leg syndrome also features worsening of symptoms and leg pain during the early evening or later at night. Restless leg syndrome Restless leg syndrome is often abbreviated RLS; it has also been termed shaking leg syndrome. Night time involuntary jerking of the legs during sleep is also known as periodic leg/limb movement disorder. History The first known medical description of RLS was by Sir Thomas Willis in 1672. Willis emphasized the sleep disruption and limb movements experienced by people with RLS. Initially published in Latin (De Anima Brutorum, 1672) but later translated to English (The London Practice of Physick, 1685), The term “fidgets in the legs” has also been used as early as the early nineteenth century. Subsequently, other descriptions of RLS were published, including those by Francois Boissier de Sauvages (1763), Magnus Huss (1849), Theodur Wittmaack (1861), George Miller Beard (1880), Georges Gilles de la Tourette (1898), Hermann Oppenheim (1923) and Frederick Gerard Allison (1943). However, it was not until almost three centuries after Willis, in 1945, that Karl-Axel Ekbom (1907–1977) provided a detailed and comprehensive report of this condition in his doctoral thesis, Restless legs: clinical study of hitherto overlooked disease. Ekbom coined the term “restless legs” and continued work on this disorder throughout his career. He described the essential diagnostic symptoms, differential diagnosis from other conditions, prevalence, relation to anemia, and common occurrence during pregnancy. Epidemiology Except perhaps in Asian populations, RLS is a common disorder, occurring in about 10% of the population. The age-adjusted prevalence of RLS determined by telephone interviews in a random population of 1803 adults in Kentucky was 10%. A Canadian survey of 2019 adults estimated the prevalence of RLS symptoms at 17% for women and 13% for men. A population-based survey in West Pomerania, Germany, of 4107 subjects found an overall 10.6% prevalence. Using standardized questions in face-to-face interviews, Rothdach et al. reported an overall prevalence of 9.8% in 369 participants ages 65-83 years in Augsburg, Germany. In a study from Japan, 4612 participants living in urban residential areas were assessed for a single symptom of RLS by a self-administered questionnaire of the following two items: (1) Have you ever been told you jerk your legs or kick sometimes and (2) have you ever experienced sleep disturbance due to a creeping sensation or hot feeling in your legs? The prevalence of RLS ranged from 3% in women ages 20-29 years to 7% in women ages 50-59 years and correlated with age. In contrast to the first three studies, RLS had a higher prevalence in men than women, with the difference reaching significance in those 40-49 years old; in men there was no positive correlation with age. Face-to-face interviews of 157 consecutive individuals ages 55 years and older participating in a health screening program and 1000 consecutive individuals ages 21 years and older from a primary health care center in Singapore yielded much lower prevalence data. Using IRLSSG criteria, the prevalence of RLS in this predominantly Asian population was 0.6% in the older (1 male) and 0.1% (1 female) in the younger cohorts. In the Kentucky and Singapore studies, there was no gender difference; however, in the two German studies, the prevalence was higher in women and in the Japanese study it was higher in men. The Canadian study reported a significantly higher occurrence of bedtime leg restlessness in women. Types Restless legs syndrome (RLS) can be either primary or secondary, and the causes vary. Primary RLS is a neurological disorder. Although the majority of people with RLS begin to experience symptoms in their middle years, some may have signs of the problem in childhood. Their symptoms may slowly progress for years before becoming a regular occurrence. Secondary RLS tends to be more severe than the primary type and stems from another underlying condition, including the following: Anemia or low blood-iron levels Folate deficiency Nerve damage due to diabetes or other conditions Kidney disease or dialysis Attention deficit disorder (ADD) Attention deficit/hyperactivity disorder (ADHD) Pregnancy Rheumatoid arthritis Parkinson’s disease Risk factors RLS/WED can develop at any age, even during childhood. The disorder is more common with increasing age and more common in women than in men. Restless legs syndrome usually isn’t related to a serious underlying medical problem. However, RLS/WED sometimes accompanies other conditions, such as: Peripheral neuropathy: This damage to the nerves in your hands and feet is sometimes due to chronic diseases such as diabetes and alcoholism. Iron deficiency: Even without anemia, iron deficiency can cause or worsen RLS/WED. If you have a history of bleeding from your stomach or bowels, experience heavy menstrual periods or repeatedly donate blood, you may have iron deficiency. Kidney failure: If you have kidney failure, you may also have iron deficiency, often with anemia. When kidneys don’t function properly, iron stores in your blood can decrease. This, with other changes in body chemistry, may cause or worsen RLS/WED. Causes The cause of restless leg syndrome is unknown in most people. However, restless leg syndrome has been associated with Pregnancy, Obesity, Smoking, Iron deficiency and anemia, Nerve disease, Polyneuropathy (which can be associated with hypothyroidism, heavy metal toxicity, toxins, and many other conditions), Other hormone diseases such as diabetes, and Kidney failure (which can be associated with vitamin and mineral deficiency). Some drugs and medications have been associated with restless leg syndrome including: Caffeine, Alcohol, H2-histamine blockers (such as ranitidine [Zantac] and cimetidine [Tagamet]), and certain antidepressants (such as amitriptyline [Elavil, Endep]). Occasionally, restless leg syndrome run in families. Recent studies have shown that restless leg syndrome appears to become more common as a person ages. Also, poor venous circulation of the legs (such as with varicose veins) can cause restless leg syndrome. Symptoms The International Restless Legs Syndrome Study Group described the following symptoms of restless legs syndrome (RLS): Strange itching, tingling, or “crawling” sensations occurring deep within the legs; these sensations may also occur in the arms. A compelling urge to move the limbs to relieve these sensations Restlessness — floor pacing, tossing and turning in bed, rubbing the legs Symptoms may occur only with lying down or sitting. Sometimes, persistent symptoms worsen while lying down or sitting and improve with activity. In very severe cases, the symptoms may not improve with activity. Other symptoms of RLS include the following: Sleep disturbances and daytime sleepiness Involuntary, repetitive, periodic, jerking limb movements that occur either in sleep or while awake and at rest; these movements are called periodic leg movements of sleep or periodic limb movement disorder. Up to 90% of people with RLS also have this condition. In some people with RLS, the symptoms do not occur every night but come and go. These people may go weeks or months without symptoms (remission) before the symptoms return again. Complications Restless legs syndrome rarely results in any serious consequences. However, in some cases severe and persistent symptoms can cause considerable mental distress, chronic insomnia, and daytime sleepiness. In addition, since restless legs syndrome (RLS) is worse when resting, people with severe RLS may avoid daily activities that involve long periods of sitting, such as going to movies or traveling long distances. Diagnosis and test There’s no single test for diagnosing restless legs syndrome. A diagnosis will be based on your symptoms, your medical and family history, a physical examination, and your test results. Your GP should be able to diagnose restless legs syndrome, but they may refer you to a neurologist if there’s any uncertainty. There are four main criteria your GP or specialist will look for to confirm a diagnosis. These are: an overwhelming urge to move your legs, usually with an uncomfortable sensation such as itching or tingling your symptoms occur or get worse when you’re resting or inactive your symptoms are relieved by moving your legs or rubbing them your symptoms are worse during the evening or at night Blood tests Your GP may refer you for blood tests to confirm or rule out possible underlying causes of restless legs syndrome. For example, you may have blood tests to rule out conditions such as anaemia, diabetes and kidney function problems. It’s particularly important to find out the levels of iron in your blood because low iron levels can sometimes cause secondary restless legs syndrome. Low iron levels can be treated with iron tablets. Sleep tests If you have restless legs syndrome and your sleep is being severely disrupted, sleep tests such as a suggested immobilisation test may be recommended. The test involves lying on a bed for a set period of time without moving your legs while any involuntary leg movements are monitored. Occasionally, polysomnography may be recommended. This is a test that measures your breathing rate, brain waves and heartbeat throughout the course of a night. The results will confirm whether you have periodic limb movements in sleep (PLMS). Treatment and medications Treatment for RLS is targeted at easing symptoms. In people with mild to moderate restless legs syndrome, lifestyle changes, such as beginning a regular exercise program, establishing regular sleep patterns, and eliminating or decreasing the use of caffeine, alcohol, and tobacco, may be helpful. Treatment of an RLS-associated condition also may provide relief of symptoms. Other non-drug RLS treatments may include: Leg massages Hot baths or heating pads or ice packs applied to the legs Good sleep habits A vibrating pad called Relaxis Medications may be helpful as RLS treatments, but the same drugs are not helpful for everyone. In fact, a drug that relieves symptoms in one person may worsen them in another. In other cases, a drug that works for a while may lose its effectiveness over time. Drugs used to treat RLS include: Dopaminergic drugs, which act on the neurotransmitter dopamine in the brain. Mirapex, Neupro, and Requip are FDA-approved for treatment of moderate to severe RLS. Others, such as levodopa, may also be prescribed. Benzodiazepines, a class of sedative medications, may be used to help with sleep, but they can cause daytime drowsiness. Narcotic pain relievers may be used for severe pain. Anticonvulsants, or antiseizure drugs, such as Tegretol, Lyrica, Neurontin, and Horizant. Although there is no cure for restless legs syndrome, current treatments can help control the condition, decrease symptoms, and improve sleep. Lifestyle and home remedies Making simple lifestyle changes can help alleviate symptoms of RLS/WED. Try baths and massages: Soaking in a warm bath and massaging your legs can relax your muscles. Apply warm or cool packs: Use of heat or cold, or alternating use of the two, may lessen your limb sensations. Try relaxation techniques: such as meditation or yoga. Stress can aggravate RLS/WED. Learn to relax, especially before bedtime. Establish good sleep hygiene: Fatigue tends to worsen symptoms of RLS/WED, so it’s important that you practice good sleep hygiene. Ideally, have a cool, quiet, comfortable sleeping environment; go to bed and rise at the same time daily; and get adequate sleep. Some people with RLS/WED find that going to bed later and rising later in the day helps in getting enough sleep. Exercise: Getting moderate, regular exercise may relieve symptoms of RLS/WED, but overdoing it or working out too late in the day may intensify symptoms. Avoid caffeine: Sometimes cutting back on caffeine may help restless legs. Try to avoid caffeine-containing products, including chocolate and caffeinated beverages, such as coffee, tea and soft drinks, for a few weeks to see if this helps.

*PSORIASIS* Skin lesion characterized by erythematous, scaly papule or plaque. Sharply defined skin lesion. *SITE:* Usually Extensor surface involved mainly knee, elbow, hand, lumbosacral region, scalp involved. Lesion developed at site of trauma *(KOBNER’S PHENOMENON)* also seen in Lichen Planus, Viral warts, Pityriasis rubra piloris. Skin lesion covered with Silvery Scales. On scrapping of scales leaves behind punctuate bleeding spot called *AUSPITZ SIGN.* *Different Clinical Forms of Psoriasis:*  *Nummular (Discoid) Psoriasis:* Most common form, coin shaped lesion.  *Guttate Psoriasis :* Rain Drops like small lesion.  *Palmo-plantar Psoriasis :* Sterile pus in palm and soles.  *Genital Psoriasis :* Lesion on Penis or Vulva.  *Erythrodermic Psoriasis :* Exfoliative dermatitis like lesion.  *Generalised Psoriasis:* Lesion over whole body.  *Scalp Psoriasis :* Lesion Present but no Alopecia.  *Nail Psoriasis :* Nails are affected. *Histological Changes in Skin Lesion:*  *Parakeratosis :* Immature cell in stratum corneum.  *Acanthosis :* Hyperplaisa of Stratum Malphighian layer.  Loss of glandular cell layer.  Dialated and tortuous blood vessesls around dermal Papillae. *Nail Changes in Psoriasis :*  Pitting  Subungual hyperkeratosis.  Destruction of Nail Palate.  Oncholysis (Separation of nail Palate from nail bed).  Discolouration of Nail Palate. Psoriatic arthritis :  Asymetrical oligoarthritis(Most of Cases)  Symettrical seronegative arthritis (RF-ve).  Arthritis of DIP joint. *Homoeopathic Treatment:*  ARSENICUM ALBUM : Dry, rough, scaly eruptions with Itching followed by burning. Generally worse after cold and scratching. Sometimes SULPHUR one dose require where arsenic is prescribed to complete the case as it is complementary of Arsenic.  BORAX : Itching on back of finger joints with intense itching and stinging. Aggravated from warm and ameliorated from cold weather. Unhealthy skin.  KALIUM ARSENICUM : Dry, Scaly ruption with intense itching worse after undressing ,change of weather , warmth. Patient is chilly and sensitive to cold.  ARSENICUM IODATUM : Dry, scaly eruptions with exfoliation of skin in large scales leaving raw excluding surface beneath. If history of TUBERCULOSIS is present then it acts better than any remeady.  HYDROCOTYLE ASIATICA : Excessive thickening of skin with marked exfoliation of skin. Specially indicated in “Psoriasis Gyrate” .  SEPIA OFFICINALIS : Dry, scaly thick crust upon joints and on elbows. Psorotic lesion especially over bends of the joints. Peeling off skin of palms and soles.  MEZERIUM : Especially for Scalp Psoriasis where there is thick exudates of purulent pus under the crust. Itching aggravate in bed.  CHRUSAROBINUM : Especially indicated in psoriasis with vesicular eruptions, foul smelling discharge with crust formation. *DrSaurabh Suman Prasad* *Intern* Dr. Yarubir Sinha Homoeopathic Medical College and Hospital laheriasarai,Darbhanga *Bihar*