Transcript no limitation of movements

LeeChuy, Katherine
Lee, Sidney Abert
Lerma, Daniel Joseph
Legaspi, Roberto Jose
Li, Henry Winston
Li, Kingbherly
Lichauco, Rafael
Lim, Imee Loren
Lim, Jason Morven
Lim, John Harold
Lim, Mary
Lim, Phoebe Ruth
Lim, Syndel Raina
Lipana, Kirk Andrew
Liu, Johanna
Llamas, Camilla Alay
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Name: T. R.
Age: 60
Sex: M
Status: Married
Nationality: Filipino
Date of Birth: 12/10/1949
Place of Birth: Leyte
Religion: Roman Catholic
Eduacational attainment: High School Graduate
Occupation: retired; former Government employee of Military
Shrines Service
• Current Address: Sitio Libanan, Timbio Mariveles, Bataan
• Informant: Patient, Wife, Niece, Nephew
• Reliability: 70%
“Namamaga ang mga kasukasuhan sa paa, binti
at kamay (swelling of the joints of the feet, legs
and hands)”
10 years PTA
5 years PTA
1 year PTA
-complained of joint pains and swelling
-no limitation of movements
-no consult was done; self-medicated with
paracetamol 500mg + ibuprofen 200mg
(alaxan), paracetamol (Biogesic) 500mg,
Amoxicillin 500mg which provided slight relief
-progression of swelling of both hands, elbows, knees
and feet as noticed by the patient and the relatives
- Persistent joint pain with limitation of movement
-self-medicated with the previous drug plus some
herbal medicines
-patient sought consult at a local hospital where he
was diagnosed to have “Gouty arthritis”
-continued with his self-medicated drugs providing
temporary relief
4 monthsPTA
2 weeks PTA
-patient slipped off Mt. Samat which prompted
admission to a local hospital in Bataan.
-The patient claimed that he didn’t receive any
wounds
-He was confined and was placed under observation
for 6 days He was relieved from the swelling through
massaging “hilot”.
-patient accidentally stepped on a sharp object
causing a subsequent development of ulcer in the
wound with some degree of scaling; clean the wound
site with guava leaves and betadine and then would
apply hydrogen peroxide with penicillin
-recurrence of joint pain and swelling; self-medicated
with Mefenamic acid 500 mg and amoxicillin 500 mg
which provided relief
1 week PTA
-progression of joint pain and swelling, graded 10/10
With limitation of movement
-the development of symptoms prompt consult on a
private doctor
ADMISSION (August 24, 2010)
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General: no fever, no weight loss, (-)anorexia, (-) weakness, (-) insomnia
HEENT: no blurring of vision, no eye redness, pain, itchiness, no excessive
lacrimation, no ear pain nor tinnitus, no ear discharge, no epistaxis, no nose
discharge, no anosmia, no obstruction nor sinusitis, no mouth sores, fissures,
bleeding, no dental carries, no throat irritation,
Pulmonary: no hemoptysis, no coughing, no dyspnea, no chest wall
abnormality
Gastrointestinal: (+) abdominal distention, no abdominal pain, no melena nor
hematochezia, no changes in bowel habits
Genitourinary: no hematuria, no dysuria, no urinary frequency, no hesitancy,
no incomplete voiding
Endocrine: no heat or cold intolerance, no polyphagia, no polydipsia, no
polyuria, no thyroid enlargement
Musculoskeletal: see HPI
Hematologic: abnormal bleeding, no easy bruising
• No major hospitalization, unrecalled
immunizations
• No allergy, no previous transfusion
• (-) DM, PTB, Asthma, Cancer
• Siblings - Arthritis
• (-) PTB, DM, thyroid disorders, Hypertension,
cancer
• Cigarette smoker since 10 years old (unrecalled number of
sticks)
• Alcoholic beverage drinker ( 2 bottles; 3x a week and
occasional gin drinker 2-3 bottles/week)
• Diet: mixed and prefers meat and vegetables
• Denies illicit drug use
• He left his home and has lost contact with his parents,
brothers and sisters (he does not recall what age he was
when he left)
• General Survey: conscious, coherent, ambulatory, not in cardiorespiratory
distress, normal speech, appropriate thought process and content and welloriented as to time, place and date
• Vital Signs
– Systemic BP: (RUE) 170/100
(LUE) 170/100
– PR: 74 beats/minute
– RR: 17 cycles/minute
– Temperature (axillary): 37.2oC
• Anthropometric mesaurement
-Ht: 5’1” Wt kg 71 kgs BMI: 29.9
• Skin: Warm, moist skin, no active dermatoses, no jaundice
• HEENT: Pale palpebral conjunctivae, slightly icteric sclera,
pupils ERTL 2-3mm, no exophthalmos, no tragal tenderness,
no aural discharge, supple neck, no distended neck veins, no
palpable cervical lymph nodes, thyroid gland not enlarged
• Pulmonary: Symmetrical chest expansion, no subcostal
retractions, unimpaired tactile and vocal fremiti ,(+) crackles
on both lower lung bases, no wheezes, no rhonchi, resonant,
clear breath sounds
• Cardiovascular: Adynamic precordium, AB at 6th LICS MCL, no
heaves, no lifts, no thrills, S1>S2 apex,S2>S1 base; Pulses were
full and equal in all extremities, (+) bipedal edema, no cyanosis
and clubbing
• Gastrointestinal: flabby abdomen, (+) venous collaterals,
normoactive bowel sounds, tympanitic upon percussion,no
masses palpated, (+) shifting dullness , Traube’s space not
obliterated, Liver span: 10cm, , (-) murphy’s sign
abdominal circumferece:98 cm
• Genitourinary: (-) CVA tenderness
• Musculoskeletal: deformed joints on the wrist, (+) swelling on the
wrists to hands, ankles to feet, warm to touch
• Neurologic Exam
• Mental status: Conscious, awake, alert GCS 15
• Pupils 2-3mm, isocoric ERTL, EOMs full and equal, no ptosis, no nystagmus
• No facial asymmetry, can shrug shoulders, can turn head against
resistance
• MMT: 5/5 all extremities
• No sensory deficits
• Can do FTNT, APST with ease
• Reflexes:
• Superficial: (+) Gag and corneal reflex
• Deep Tendon: (++) on all extremities
• No Babinski, nuchal rigidity, Brudzinski, Kernig’s
Physical Examination
Physical Examination
Physical Examination
Physical Examination
COMPLETE BLOOD COUNT
*8/24
Posttransfusion
UNIT
REFERENCE RANGE
Hemoglobin
48
117
G/L
120-170
X 10^12/L
4.0-6.0
RBC
HCT
0.16
0.36
0.37-0.54
MCV
U^3
87 + - 5
MCH
Pg
29 + - 2
g/dl
34 + - 2
MCHC
30
32.50
RDW
11.6 – 14.6
MPV
fL
7.4 – 10.4
PLATELET
802
450
x 10^9 / L
150 – 450
WBC
19.8
8.50
x 10^9 / L
4.5 – 10.0
NEUTROPHILS
0.89
0.80
METAMYELOCYTES
0.01
BANDS
0.01
SEGMENTED
0.89
0.80
0.50 – 0.70
LYMPHOCYTES
0.06
0.13
0.20 – 0.40
MONOCYTES
0.02
EOSINOPHILS
0.03
DIFFERENTIAL COUNT
BASOPHILS
0.50 – 0.70
0.00 – 0.05
0.00 – 0.07
0.07
0.00 – 0.05
0.00 – 0.01
*Peripheral smear : Hypochromic with anisocytosis and poikilocytosis
8/24
Creatinine
2.86
Sodium
123
Potassium
4.96
iPO4
4.5
Intact PTH
8.2
Ionized Calcium 1.66
Fasting Blood
78.97
Sugar
BUN
65.70
SGPT
36.91
Uric Acid
13
2.29
132.48
Reference
0.5-1.2
137-147mmol/L
3.8-5mmol/L
2.3-4.7 mg/dL
1.12-1.32
70-110 mg/dL
3.89
8-23 mg/dL
3.8-5 U/L
2.7-7.3
Total
Cholesterol
Triglycerides
HDL
LDL
Total Protein
Albumin
Globulin
HbA1c
8/24
119.78
Reference
130.33
22.03
68.20
7.00
2.57
4.43
7.90
10-90 mg/dL
150-250 mg/dL
6-7.8 g/dL
3.2-4.5 g/dL
2.3-3.5 g/dL
4.0-6.0
Other Ancillary procedures:
• Fecal occult blood test – (+)
• ECG – Sinus rhythm with left ventricular
hypertrophy
• Urinalysis: albumin- negative, sugar –
negative, RBC-0-2/hpf, Pus cell-1-4/hpf
SALIENT FEATURES
SUBJECTIVE DATA
OBJECTIVE DATA
Age: 60
(+) swelling on the wrists to hands,
ankles to feet, warm to touch
Presence of joint deformities
Presence of ulcers on the legs
(+) Bipedal edema
(+) Shifting dullness
Abdominal circumference: 98cm
(+) venous collaterals
Slightly icteric sclerae
Low Hgb and Hct on CBC with
anisocytosis and poikilocytosis
Increased BUN and creatinine
Sex: M
Swelling of joints of hands, feet and legs
Recurrent joint pains
Limitation of movements
Alcoholic beverage drinker
Siblings- (+) Arthritis
Diagnosed to have gouty Arthritis
Present Medications
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Omeprazole 40 mg tab OD
Amlodipine 10 mg tab OD
Clindamycin 300 mg cap q 6
Ciprofloxacin 250 mg tab BID
Given Colchicine as follows to treat acute
gout: 2 tabs now then 1 tablet after 6 hours
• Cold compress x 10-15 mins TID on inflamed
joints