48 yr old male with problem in left knee joint

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan

A 48 yr old male resident of west Bengal presented with 

Chief complaints:
Difficulty in walking on the left lower limb since 2weeks 

History of presenting illness:
Patient was apparently asymptomatic 2 weeks back then he met with an accident (fell down from bike )
From then he is unable to walk due to problem in left knee associated with slight swelling 
which is not associated with pain,skin changes ,fever

Daily Routine
Wakes up at 6:30 am 
He complets his bath till 9 Am 
Then he takes his break fast at 9 am and heads towards kolkatha by train for his job 
Then he takes his lunch at 2:00 pm then he drinks tea at 4 pm 
Then he returns to home till 8:30pm via train and takes his dinner at 10:30 pm and then he sleeps at 12:00pm 
 He used to go to his work daily since he meet with this accident he is going once in 2-3 days 

Past history:
No similar  complaints in the past 
Not a known case of DM,Htn,asthma,epilepsy,CAD,CVD,TB

Family history:
Non significant

Personal history 
Diet: mixed
Sleep : adequate
Appetite:normal 
Bladder and bowel movement: normal and regular 
Addiction:nil
No allergies
 
No medical history 

General examination 
Patient is conscious, coherent and cooperative 
Well oriented to time place and person 
No Pallor 
No icterus
No cynosis
No clubbing 
No koilonychia
No lymphadenopathy 
No pedal oedema 









Investigations

Provisional diagnosis
Partial Tear in the anterior cruciate ligament associated with mild inflammation 

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