General Data

Patient Name: G.O.

Gender: Male
Birthdate: November 13, 1952
Age: 66 years old
Address: Tubungol, Panabo City
Religion: Roman Catholic

Date of Admission: February 04, 2019 @5:30 AM

Date of Interview: February 07, 2019 @3:33 PM

Chief Complaint: Cough

History of Present Illness:

This is a diagnosed case of pulmonary tuberculosis (1986) undergone 2 years treatment with afb
and chest xray with negative findings

4 years prior to admission, patient had onset of non productive cough, this is not associated with
fever, tachycardia, dyspnea, night sweats, weight loss. however patient noticed joint
inflammation with limited range of motion and tenderness on the right knee. no consultation was
done, patient took alaxan with relief

2 years prior to admission, patient had an onset of fever and generalized body malaise, sought
consultation at a local hospital and was admitted, patient cannot recall the diagnosis however
labs were taken with result of increase potassium and blood pressure, with decrease sodium,
patient was discharged and improved after fews days

2 days prior to admission, patient had onset of cough associated with blood tinged sputum. no
dyspnea, fever, night sweats wt loss, no dizziness no abdominal pain reported. patient sought
consult at this hospital hence this admission

Past Medical History:

Medical: 2015 – Diabetes Mellitus

Medication: Diamacron
Prostate Enlarged
Medication: Tamsulosin
2018 – Heart enlarged
Medication: Aspirin , Glycoprolol

Surgical: 1987 – Tongue biopsy – negative result

Medication: Vitamins clusivol
Psychiatry: No psychiatric illnesses noted

Family History:

The patient’s cannot recalled his family history of illnesses, however he can only recall his aunt
who is hypertensive

Personal and Social History

Patient is married and has three children. At the age of 60, he retired working at the banana
plantation who describe that he has managerial task, and had no weight bearing activity. Patient’s
educational attainment is highschool graduate In samar, leyte. Since he is retired, the only thing
that keeps him busy is their mini sari-sari store. He is a non–smoker but a drinker of alcoholic
beverages especially beer. He drinks once a week with his co-workers, he cannot quantify how
much but he said he drinks a lot. However, he opted to stop drinking, 4 years ago.

Review of Systems:

General: Weight gain (from 68 kgs to 72 kgs)

Skin: no skin rashes or itchiness
Head: no history of head trauma or dizziness
Eyes: no eye discharges or itchiness
Ears: no ear discharges or itchiness
Nose: no epistaxis or obstruction
Mouth/Throat: no sore throat and bleeding gums
Neck: no head stiffness
Respiratory: no shortness of breath or dyspnea
Cardiovascular: no cyanosis
Gastrointestinal: no loss of appetite, constipation, tenderness, diarrhea and epigastric pain
Urinary: no hematuria, kidney or bladder infections
Genitalia, Anus and Rectum: no discharges or swelling
Musculoskeletal: no muscle weakness
Extremities: no edema
Hematologic: no bruising or bleeding
Endocrine: no known thyroid problems
Physical Exam:

General Appearance:
Patient was seen lying on bed awake, conscious, responsive to verbal and tactile stimuli;
well-groomed and afebrile.

Anthropometric measurement:
Height: 6 feet
Weight: 158.4 pounds
BMI: 21.5. Normal

Vital Signs:
PR: 92 bpm, within normal range
CR: 98 bpm, within normal range
RR: 16 cpm, within normal range
Temp: 35.8’c, within normal range
BP: 120/80 mmhg, within normal range

SKIN:
I – Brown skin complexion. No Redness/flushing noted. No visible skin lesions. No
jaundice. No pallor.
Pa – Moist, soft and smooth, warm to touch. No palpable nodules or masses. Good skin
turgor.

HEENT:
Head:
I – Head is round, normocephalic with smooth skull contour. No scalp lesions noted.
Hair is black with some white strands and evenly distributed. Patient has lesser hair.
Eyes:
 I – Eyes are brown, with white sclera and pinkish palpebral conjunctiva. Pupils are
round and equally reactive to light with positive accommodation. No corneal opacities
seen. Eyebrows are evenly distributed. Eyeballs are not sunken. No discharges,
discoloration nor periorbital edema. No eyelid droopiness noted. Good visual acuity and
extraocular muscles are intact.
Pa – No tenderness on periorbital area

Ears:
I – Symmetrical in size and shape. Ear canal is not inflamed. There are no lesions, masses,
and discharges noted in both ears.

Nose:
I – Nasal septum is in midline. Nasal turbinates not inflamed. No septal deviation and
nasal flaring. Both nares are patent. Discharges are not noted in both nares.
Pa – Absence of masses and tenderness on frontal and maxillary sinuses.

Mouth and Throat:

I – Lips are pink in color and no lesions noted. Dryness of oral cavity noted. Oral
mucosa and gums are pink without lesions. Tongue at midline, freely movable, dry and
whitish with no lesions. Palatine tonsils are not inflamed. Uvula is in midline.

NECK:
I – Neck is supple. Normal range of motion. Trachea is in midline. Jugular veins are not
distended.
Pa – No lesions and tenderness. No lymphadenopathy.

CHEST and LUNGS:

I – Symmetrical lung expansion. No striations, rashes and pigmentations.
Pa – Equal tactile fremitus felt on both lung fields. No tenderness, mass or lesions noted.
Pe – Lungs on both fields are resonant
A – Normal breath sounds were heard, no wheezing and crackles or rhonchi sounds
CARDIOVASCULAR SYSTEM:
I – Apex beat noted at 5th intercostal space
Pa – No abnormal pulsations. Peripheral pulses are bilaterally equal. Thrills and heaves
not noted. Apex beat at
A – Regular heart rate rhythm heard upon auscultation

ABDOMEN:
I – Abdomen is soft and globular in contour, no visible organ enlargement or mass noted.
No lesions noted.
A - Normoactive bowel sounds at 10 /minute
Pe – Resonance at the epigastric area, dullness at the right upper quadrant.
Pa – Abdomen is soft and nontender. No palpable masses nor hepatosplenomegaly.
Spleen and kidneys are not felt. No costovertebral angle tenderness. Rectum not assessed.

EXTREMITIES:
I – Nails are short and clean, convex in curvature, and intact to the epidermis. Nail beds
are pink in color. Full and equal pulses noted on both upper and lower extremities.
Negative herberden nodes, No rheumatoid nodules, No stiffness during rest

Pa – No crepitations. Capillary refill time less than 2 seconds.

MUSCULOSKELETAL:
I – decrease range of motion on the right leg and difficulty on ambulation,
Pa – warm to touch, tenderness, and redness noted on the right knee

GENITOURINARY:
I – not assessed
Cranial Nerves:
CN I: Sense of smell is intact.
CN II & III: Both pupils constrict when light is shone into each eye simultaneously.
CN III, IV & VI: Extraocular muscles intact.
CN V: Muscles of mastication are intact.
CN VII: Face is symmetric. Patient was able to smile and frown.
CN VIII: Able to follow and detect direction of sound.
CN IX & X: intact gag reflex
CN XI: Turns head side to side at will with no head lagging
CN XII: No tongue deviation was noted.

Salient features

Pertinent Positive Pertinent Negative

Male Negative herberden nodes
66 years old Stiffness during rest
noticed joint inflammation with limited range Negative weight bearing activity
of motion and tenderness on the right knee No rheumatoid nodules
decrease range of motion on the right leg and
difficulty on ambulation
warm to touch, tenderness, and redness noted
on the right knee

Differential Diagnosis

Rule In Rule Out

Osteoarthritis decrease range of motion on Stiffness during rest
 the right leg and difficulty on Onset morning
ambulation Negative heberden nodes
warm to touch, tenderness, Affected side weight bearing
and redness noted on the right Negative weight bearing
knee activity
Rheumatoid Arthritis noticed joint inflammation Chronic
with limited range of motion Symmetric
and tenderness on the right Involve peripheral Joint
knee Onset 4th and 5th decade of life
warm to touch, tenderness, Morning stiffness
and redness noted on the right No rheumatoid nodules
knee
Gouty Arthritis Male Cannot be rule out
66 years old
noticed joint inflammation
with limited range of motion
and tenderness on the right
knee
decrease range of motion on
the right leg and difficulty on
ambulation
warm to touch, tenderness,
and redness noted on the right
knee

Impression: Gouty Arthritis: Hypertension stage 2; Diabetes Mellitus type 2

Case discussion:
Gout is a metabolic disease that most often affects middle-aged to elderly men and
postmenopausal women. It results from an increased body pool of urate with hyperuricemia. It
typically is characterized by episodic acute arthritis or chronic arthritis caused by deposition of
MSU crystals in joints and connective tissue tophi and the risk for deposition in kidney
interstitium or uric acid nephrolithiasis.

Acute arthritis is the most common early clinical manifestation of gout. Usually, only one joint is
affected initially, but polyarticular acute gout can occur in subsequent episodes. The
metatarsophalangeal joint of the first toe often is involved, but tarsal joints, ankles, and knees
also are affected commonly. Especially in elderly patients or in advanced disease, finger joints
may be involved. Inflamed Heberden’s or Bouchard’s nodes may be a first manifestation of
gouty arthritis. The first episode of acute gouty arthritis frequently begins at night with
dramatic joint pain and swelling. Joints rapidly become warm, red, and tender, with a clinical
appearance that often mimics that of cellulitis. Early attacks tend to subside spontaneously within
3–10 days, and most patients have intervals of varying length with no residual symptoms
until the next episode. Several events may precipitate acute gouty arthritis: dietary excess,
trauma, surgery, excessive ethanol ingestion, hypouricemic therapy, and serious medical
illnesses such as myocardialinfarction and stroke. After many acute mono- or oligoarticular
attacks, a proportion of gouty patients may present with a chronic nonsymmetric synovitis,
causing potential confusion with rheumatoid arthritis. Less commonly, chronic gouty arthritis
will be the only manifestation, and, more rarely, the disease will manifest only as periarticular
tophaceous deposits in the absence of synovitis. Women represent only 5–20% of all patients
with gout. Most women with gouty arthritis are postmenopausal and elderly, have osteoarthritis
and arterial hypertension that causes mild renal insufficiency, and usually are receiving
diuretics. Premenopausal gout is rare. Kindreds of precocious gout in young females caused by
decreased renal urate clearance and renal insufficiency have been described.