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History General Data • • • • • • • • • Name: T.B. Age/Sex:60/Male Birthday: Dec. 10, 1949 Address: Mariveles, Bataan Religion: Roman Catholic Occupation: Government Employee Date of Admission: August 24, 2010 Informant: Patient, Wife, Nephew Reliability: 70% • Chief Complaint • “Namamaga ang mga kasukasuhan sa paa, binti, at kamay” History of Present Illness 10 years PTA 5 years PTA • Patient complained of joint pain and swelling which started from the distal foot. •Patient would self-medicate with Paracetamol 500mg + Ibuprofen , 200mg when pain aggravated •No limitation of movement at this period •Patient would notice progression of swelling, pain and size in the knee, hand and finger joints •Patient continued selfmedication •There is now limitation of movement at this period 1 year PTA 4 months PTA 1 week PTA •Patient sought consult in a local hospital in Bataan and was diagnosed to have “Gouty Arthritis”. He was admitted there for 6 days. •Patient mentioned no medications were given •After being discharged from the local hospital patient continued self-medicating. •Patient accidentally slipped off in Mt. Samat and mentioned incurring ulcer on the sole of left foot after. •There was continued swelling of the hands after the incident. •There was recurrence of joint pain and swelling •Patient noted progression of swelling and joint pain and continued limitation of movement hence sought consult. Past Medical History • (-) Asthma, cancer, PTB Family History • Patient run away when he was young so could not give information regarding medical history of his parents and siblings. Personal and Social History • • • • Occasional alcohol drinker (+) smoking since 10 y.o. Denies illicit drug use Mixed Diet Review of Systems • General (-) weight loss (-) Anorexia (-) Weakness (-) insomnia • Skin (+) ulcer on the left foot (-) pruritus, jaundice, itchiness • HEENT (-) visual dysfuntion, redness, itchiness, pain (-) ear discharge, tinnitus, hearing impairment (-) epistaxis, anosmia, discharge, obstruction, sinusitis (-) mouth sores, fissures, bleeding, soreness, tonsillitis (-) neck stiffness, masses, sensation of lump in throat Review of Systems • Pulmonary (-) shortness of breath, dyspnea, hemoptysis, cough (-) chest pain, chest wall abnormality • Cardiovascular (-) palpitations (-) syncope • Gastrointestinal (+) abdominal distention (-)melena, hematochezia, passage of scyballous stool • Genitourinary (-) urinary frequency, urgency, hesitancy, incomplete voiding Review of Systems • Musculoskeletal – See HPI • Psychiatric (-) previously diagnosed with mental disorder (-) irritability, depression • Endocrine (-) heat-cold intolerance (-)polyuria (-) polydipsia (-)polyphagia (-) thyroid enlargement Physical Exam General Survey Wt: 65kg Ht: 165.1cm BMI:23.9 BP: 170/100 Temp:37.2 RR:17cycles PR: 74bpm, regular Stretcher-borne Conscious, coherent, not in respiratory distress Warm dry skin (+) ulcers on soles of left foot HEENT Head: no trauma, no deformities Eyes: pale palpebral conjunctiva, slightly icteric Ears: No deformities, masses, skin lesions nor tragal tenderness Nose: No nasoaural discharge nor hoarseness, nasal septum midline Throat: supple neck, no palpable cervical lymph nodes, trachea midline, thyroid not enlarged Cardiovascular JVP 4cm at 45 degrees Right and Left CAP Gr II with rapid upstroke and gradual dowstroke Adynamic precordium No heaves, lifts nor thrills Apex beat at 5th LICS MCL S1>S2 apex, S2>S1 base No murmurs Pulmonary Symmetrical chest expansion No retractions Resonant on percussion (+) crackles on lower lung bases Gastrointestinal Flabby abdomen Normoactive bowel sounds No palpable mass No tenderness Tympanitic on percussion Liver span 10cm Traube’s space not obliterated No CVA tenderness Genitourinary No flank tenderness Musculoskeletal (+) bipedal edema (+) swelling on the wrist to hand (+) swelling on the toe to foot Swelling is warm to touch (+) ulcer on the sole of left foot Neurologic GCS 15 Alert, oriented as to time, place, person Intact Cranial nerves Salient Features • Subjective – Pertinent Positive • Age: 60 y.o. • Joint pain and swelling for 10 years which started on the foot • Relief of symptoms upon intake of Paracetamol + ibuprofen • Occasional Alcohol drinker – Pertinent Negative • No liver disease • No kidney disease • No pulmonary disease Salient Features • Objective – BP 170/100 – Swelling of the finger, foot, ankle and toe joints – Ulceration on the sole of left foot • Impression Chronic Tophaceous Gout