Transcript MEDICAL HISTORY

MEDICAL HISTORY
• U.S. 28 year old male, catholic, married, born
on May 6, 1981, works as a tricycle driver
since 2001, residing in Caloocan City with
wife.
• Chief Complaint:
History of Present Illness
7 Yrs PTA
•White scales of the scalp resembled dandruff when scratched
(no consult)
• Few mos. later: pustules and papules that later coalesced to
erythematous plaques topped with scales spread all over his
body affecting his back, trunk, upper and lower extremities and
his face  consult at UST Dermatology OPD; punch biopsy:
Psoriasis – medications: PUVA therapy (once in 2002),
Methotrexate 1 tab BID for 1 wk, Dermovate with Petroleum
Jelly and LCD, Hydroxizine (Iterax) for pruritus 3x/day prn 
resolution of Symptoms
2 Yrs PTA
• Reappearance of lesions
• Painful swelling of distal and proximal joints of the fingers of
right and left hands and feet (self-medication: Naproxen 
temporary relief)
• Gradual limitation of in the movement of digits
• Consult to Rheumatologist, prescribed with Celebrex and
requested for further lab work-ups; but patient lost to follow-up
1 Yr PTA
• Pain and swelling in both knees, noted to be limping, and pain
when walking down the stairs
• Relieved by rest or sitting down
1 month PTA
• Swelling of both knees with increasing severity of pain (no
consult)
1 week PTA
• Pain in the hips extending down to his ankles
• More difficulty in ambulating
5 days PTA
• Consulted an Orthopedic Surgeon in Marikina; was told to have
excess fluid in knee joints & advised arthrocentesis (pt. opted not
to)
4 days PTA
•Fever [undocumented] (self-medication: Paracetamol 
temporary lysis of fever)
• Persistence of pain and fever  consult at FEU Hospital (X-Ray
of leg: soft tissue swelling); advised admission but refused due to
financial constraints; referred to USTH for further evaluation &
management
ADMISSION
Past Medical History
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(-) DM
(-) HPN
(-) Joint surgery
(-) history of trauma
(-) Allergy
Diagnosed with dengue fever (2nd year high
school)
• Excision of cyst at the back (2007)
Family History
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(+) Myocardial Infarction – father
(+) DM – father
(-) HPN
(-) stroke
(-) Psoriasis
(-) Cancer
(-) Arthrides
Personal & Social History
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Smoker: 16-22 y/o (1-2 sticks per day)
Occasional Alcoholic Beverage Drinker
Denies Illicit Drug Use
3 past sexual partners, all protected
Review of Systems
• No wt. loss, no loss of appetite
• No hearing loss, no nasal congestion, no
cough
• No dyspnea, orthopnea, cyanosis
• No chest pain, palpitations
• No abdominal pain, diarrhea, constipation
• No dysuria, frequency, change in character of
urine
PHYSICAL EXAMINATION
General Survey
• Conscious, coherent, oriented as to time, place and
person, not in cardio-respiratory distress
Vital Signs
• BP 120/70 mmHg, PR 83 bpm, RR 20 cpm, T 36.6 °C
Skin
• Warm moist skin, (+) erythematous plaques topped
with scales all over the body, (+) hyperpigmented
patches over the extremitie, (+) oil spots, (+) nail
pitting, (+) onychodystrophy
HEENT
• Pink palpebral conjunctivae, anicteric sclerae, no nasoaural discharge, no tragal tenderness, moist buccal
mucosa, nonhyperemic PPW, tonsils not enlarged
Neck
• Supple neck, trachea midline, no palpable cervical lymph
nodes, thyroid gland not enlarged
Cardiovascular
• Adynamic precordium, AB at 5th LICS, MCL; no murmurs
• All pulses full and equal
Respiratory
• Symmetric chest expansion, no retractions, clear breath
sounds on all lung fields, no crackles, no wheezes
Abdomen
• Flat abdomen, NABS, soft, nontender, no
masses
Musculoskeletal
• (+) sausage-shaped 4th digit of the right hand
• (+) swelling and tenderness, both knees, DIP
4th R digit of the hand, R ankle
• (+) flexed 5th left digit and the 4th R digit of the
hand
• Cannot flex the PIP and DIP of the right 2nd
digit of the hand
Neurological
• Conscious, oriented to person, place and time,
can follow commands
• GCS 15 E4V5M6; pupils 2-3 mm, isocoric ERTL,
V1,V2,V3 intact; intact hearing, can swallow, (+)
gag reflex, can shrug shoulders, tongue midline
on protrusion
• Motor: MMT 5/5 on both UE; 4/5 on both LE, no
atrophy
• Cerebellum: no deficits, can do FTNT, APST, HTST
• Sensory: no sensory deficits
• DTRs: 2+ on the UE, LE not assessed
• (-) Babinski; no nuchal rigidity
SALIENT FEATURES
• History of Psoriasis
• Painful swelling of distal and proximal joints of
the fingers of right and left hands and feet
• Gradual limitation of in the movement of digits
• Pain and swelling in both knees (increasing
severity of pain), limping, and pain when walking
down the stairs (difficulty in ambulating);
Relieved by rest or sitting down
• Pain in the hips extending down to ankle
• excess fluid in knee joints
• Persistence of pain and fever
• X-ray of leg: soft tissue swelling
SALIENT FEATURES
• (+) erythematous plaques topped with scales
all over the body, (+) hyperpigmented patches
over the extremitie, (+) oil spots, (+) nail
pitting, (+) onychodystrophy
• (+) sausage-shaped 4th digit of the right hand
• (+) swelling and tenderness, both knees, DIP
4th R digit of the hand, R ankle
• (+) flexed 5th left digit and the 4th R digit of the
hand
• Cannot flex the PIP and DIP of the right 2nd
digit of the hand