Patients Name: Basuel, Moises Age: 52 Sex: Male Bed

no. 50-1

GENERAL DATA AND PATIENT PROFILE

Chief Complaint: Left knee pain
History of Present Illness:
1 year prior to admission, patient complained of pain on the left knee. He was
the admitted and diagnosed with gouty arthritis. The patient undergo physical
therapy for 4 sessions but stopped due to unavailability of the therapist. Since then,
the patient has been having a difficulty of walking without support associated with
on and off pain on the left knee. Patient took Diclofenac and Prednisone everytime
when pain appears and was noted to have temporary relief.
On the day of admission, patient consulted to his physician regarding his
condition and was given interarticular steroid injection. He was then advised for
admission.
Past medical History:
(+) Hypertension for 12 years; poor compliant
(+) Diabetes Mellitus with maintenance of Metformin 500mg/tab but was poor
compliant
(+) Gouty arthritis for 1 year (admitted)
(-) Bronchial asthma

Personal/ Social History:

Previous smoker stopped age of 35 y/o
Previous alcoholic drinker stopped at age 35 y/o

Family History:
Maternal: Hypertension and Bronchial asthma
Paternal: Hypertension
Both are negative for Diabetes mellitus, Cancer, and Thyroid diseases

Occupational and Environment:

The patient was a former tricycle driver but stopped due to his condition.
Patient stayed at home most of the time and did simple household chores. He lived
together with his family. Their house is concrete bungalow. They used dispenser and
their source of water
Diet:
Patients diet is composed of mostly seafood particularly salt water fishes
since their place is near the sea. Patient seldom eat meat.
Review of Systems:

General Neck
(+) weakness (-) stiffness
(-) fever (-) limited motion
(-) sweats Pulmonary
(-) insomnia (-) Dyspnea
(-) anorexia (-) cough
Skin (-) hemoptysis
(-) rashes Cardiac
(-) Pigmentation (-) chest pain
Endocrine system (-) palpitations
(-) heat cold Gastro-intestinal
intolerance (-) nausea
(-) Thyroid (-) hematemesis
problems (-) dysphagia
(-) Neck surgery (-) abdominal pain
Eye (-) vomiting
(-) visual (-) diarrhea
dysfunction Genitourinary
(-) Redness (-) urinary
(-) Lacrimation frequency
Ear (-) Dysuria
(-) Deafness (-) flank pain
(-) Tinnitus
(-) Discharges
Nose
(-) Epistaxis
(-) sinusitis
(-) obstruction
Mouth
(-) Bleeding
gums
(-) Sores
Throat
(-) Soreness
(-) Tonsillitis
PHYSICAL EXAMINATION
General Appearance

During the interview, patient is awake, coherent, and responsive to verbal stimuli. Patient
has good eye contact.
Vital Signs:
Blood Pressure = 160/100 mmHg
Heart Rate = 90 bpm
Respiratory Rate = 24cpm
Temperature = 37 C

Skin, Hair, Nails

I Patient has a brown complexion not associated with skin pigmentation. Hair is black in
color and has an average texture. Nails with pinkish nail beds, trimmed, clean with no
clubbing.

P Skin is dry, warm to touch with a good skin turgor (2seconds).

Head
I- Skull is normocephalic and facial structures are symmetric. Hair is black, smooth and
resilient and evenly distributed. No presence of lesions or lice in the scalp. No
deformities on the skull noted.
P- No tenderness. No masses or nodules noted upon palpation. Lymph nodes are not
palpable.

Eyes
I- Eyebrows aligned with evenly distributed black hair. Eyelids with symmetric movement.
Pupils are equal and are reactive to light and accommodation. Peripheral vision is intact.
Red reflex present. Normal veins and arteries seen in fundoscopic exam.
P- No tenderness. No masses or nodules noted upon palpation

Ears
I- The auricles are aligned with the outer canthus of the eye. Intact, gray tympanic
membrane on left. With impacted cerumen noted on right.
P- No tenderness and masses noted upon palpation. Pinna recoils when it is folded.

Nose and Sinuses

I- Nasal bridge is intact. Nasal septum is medially located. Mucosa pinkish in color and no
discharges. Nasal hairs present. Nasal flaring not noted.
P- No tenderness and masses noted upon palpation.

Mouth
I- Patients lips are pink and slightly dry. Gums, buccal mucosa and inner lips are pink in
color and no lesions noted. Tongue is medially located. Uvula is centrally located. The
tonsils are pink and there are no discharges noted. Multiple dental caries noted on both
upper and lower premolars and molars.
P- No tenderness and masses noted upon palpation.

Neck
I- Jugular veins are not distended. No mass noted.
P- Lymph nodes are not palpable. Thyroid gland not palpable.

Respiratory system
I- Chest has full and symmetric expansion upon inhalation. Breathing pattern is regular at
24 cycles per minute.
P- Equal tactile fremitus, no tender areas or masses, no heaves, no thrills
P- Resonance on both lung fields.
A Clear breath sounds.

Cardiovascular system
I- Adynamic precordium
P- No heaves, no thrills, PMI at left 5th intercostal space, left midclavicular line
A- Normal heart rate and rhythm. Peripheral pulses are strong and symmetrical.
Abdomen
I- Abdomen is round and symmetrical.

A- Normoactive bowel sounds at 13/min

P- Tympanic sounds noted on percussion
P- Negative for direct and rebound tenderness. No organ enlargement noted.

Muskuloskeletal system
I- Atrophy noted on the left lower leg. The Left knee is warm to touch and swollen.
P- Pain noted on the 2nd metacarpophalangeal joint of the left hand. Pain on the left knee
upon palpation and is positive for effusion upon balloting the patella.

Extremities
I- Atrophy noted on the lower left leg. Unable to extend the left knee with tenderness upon
active and passive range of movement.

Cranial nerve exam:

Cranial Nerve I Can smell on both nostrils.
Cranial Nerve II Intact visual fields
Cranial Nerve III Pupils equally reactive to light and accommodation
Cranial Nerve IV Can gaze up
Cranial Nerve V normal biting, can perceive sensation on ophthalmic, maxillary and
mandibular areas, (+) corneal reflex upon introduction of stimulus
Cranial Nerve VI- Can do lateral gaze
Cranial Nerve VII - Face symmetrical on wrinkling of the forehead, smiling and grinning
Cranial Nerve VIII - Normal hearing acuity
Cranial Nerve IX & X - Normal gag reflex and swallowing, clarity of voice
Cranial XI - No atrophy or fasciculations of the trapezius, can shrug shoulders
Cranial XII - Tongue on midline

Cerebellar function
Can do nose-to-finger activity and hand supination/pronation activity.

Motor Muscle testing

Upper extremity
 Arm abduction 5/5
Elbow flexion and extension 5/5
Extension at wrist 5/5
Finger flexion 5/5

Lower extremity
Hip flexion 5/5
Hip extension 5/5
Knee flexion and extension 3/5
Ankle dorsiflexion 5/5
Toe flexion 5/5

Reflexes
(-) pathologic reflexes

SALIENT FEATURES

General Data and Patient Profile

- 52 y/o male
- (+) gouty arthritis
- (+) History of hypertension
- (+) History of diabetes mellitus
- Pain on left knee since last year
- Difficulty of walking for a year
- Patients diet mainly seafood (fish)
Physical Examination
- Blood pressure of 160/100
- Atrophy on left lower leg.
- Left knee is warm to touch and swollen. Pain upon palpation and is positive for
effusion
- Left knee difficult to extend with gradual limitation of movement
- Pain on the 2nd metacarpophalangeal joint of the left hand and is difficult to flex
Differential Diagnoses
BURSITIS This condition is ruled in This condition is ruled out
because of the localized since the patient do not have
It is a painful condition that tenderness on the knee, warm a history of trauma event and
affects the small, fluid-filled to touch, painful and reduced no painful passive range of
sacs- called bursee- that active range of motion. motion. The patient is
cusgion the bones, tendons positive for effusion upon
andmuscles near the joints. balloting the patella to which
in the case of bursitis, no
effusion is present.
RHEUMATOID ARTHRITIS This condition is ruled in This condition is ruled out
because of the limitation and since it is multiarticular in
Chronic inflammatory disease pain upon active and passive nature. Also, the patient do
of unknown etiology marked motion on the left knee, and not have flexor tendon
by symmetric, peripheral presence of swelling and synovitis- which is a hallmark
polyarthritis. effusion. His history of for this condition.Pulmonary,
smoking contributed for this cardiac, hematologic
disease as well as his age complications do not exhibit
since it is most common in this patient. Fever,
between ages 25- 55. anorexia, and weight loss
may be seen in Rheumatoid
arthritis, to which the patient
do not have.
OSTEOARTHRITIS This condition is ruled out This condition is ruled out
because of the limitation and since the affected joint is
A type of joint disease that pain upon active and passive warm and is monoarticular in
results from breakdown of motion on the left knee. involvement. This disease is
joint cartilage and underlying Increase of age is the most somehow not associated with
bone. potent factor of this disease. warm since it is non-
inflammatory and is usually
polyarticualr.Cannot
completely be ruled out until
additional
diagnostic/laboratory
procedure can be done such
as joint fluid analysis and
serum uric acid.
PRIMARY WORKING DIAGNOSIS
Chronic Gouty Arthritis; Diabetes Mellitus type 2; Hypertension stage 2

DISCUSSION
Gout is a type of arthritis that causes inflammation, usually in one joint. It is caused by
an elevated uric acid level in the bloodstream and accumulation of uric acid crystals in tissues of
the body. Uric acid crystals in the joint cause the inflammation of the joint leading to pain,
redness, heat, swelling, and reduced range of motion. Uric acid is normally found in the body
as a byproduct of the way the body breaks down certain proteins called purines. Males and post-
menopausal women are at risk for this disease.
History and PE: Present with excruciating joint pain of sudden onset. It is most
commonly affects the first MTP joint. Joints are erythematous, swollen, and exquisitely
tender. Several events may precipitate gouty arthritis: dietary excess (seafood), trauma,
surgery, trauma, excessive ethanol ingestion, and comorbid illness.
Gouty arthritis has 4 stages:
Asymptomatic Hyperuricemia: hyperuricemia (>6-7 umol/L) in the absence of gouty
arthritis and uric nephrolithiasis.
Acute gouty arthritis: an acute arthritis initially affecting the MTP of the first toe
(podagra) followed by recurring episodes of acute mono- or oligoarthritis
Intercritical gout: asymptomatic periods between gouty arthritis
Chronic tophaceous gout: occurs in untreated gouty arthritis, characterized by persistent
low grade inflammation of joints with sporadic flares. This may associated with tophi formation
or atrophy of the affected the limb due to inactivity.
Diagnosis of gouty arthritis is mainly clinical. Laboratory tests such as synovial fluid
analysis and serum uric acid may differentiate the disease from other types of arthritis. A
strongly negative birefringent needle-shaped monosodium urate (MSU) crystals both intra and
extracellularly strongly suggests gouty arthritis.