Transcript History

History
General Data
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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
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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