LeeChuy, KatherineLee, Sidney Abert

Lerma, Daniel JosephLegaspi, Roberto Jose

Li, Henry WinstonLi, Kingbherly

Lichauco, RafaelLim, Imee Loren

Lim, Jason MorvenLim, John Harold

Lim, MaryLim, Phoebe RuthLim, Syndel Raina

Lipana, Kirk AndrewLiu, Johanna

Llamas, Camilla Alay

• 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

-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

1 year PTA

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 10/10With limitation of movement

-the development of symptoms prompt consult on a private doctor

ADMISSION (August 24, 2010)

• 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 well-oriented 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 Post-transfusion

UNIT REFERENCE RANGE

Hemoglobin 48 117 G/L 120-170

RBC X 10^12/L 4.0-6.0

HCT 0.16 0.36 0.37-0.54

MCV U^3 87 + - 5

MCH Pg 29 + - 2

MCHC 30 32.50 g/dl 34 + - 2

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

DIFFERENTIAL COUNT

NEUTROPHILS 0.89 0.80 0.50 – 0.70

METAMYELOCYTES 0.01

BANDS 0.01 0.00 – 0.05

SEGMENTED 0.89 0.80 0.50 – 0.70

LYMPHOCYTES 0.06 0.13 0.20 – 0.40

MONOCYTES 0.02 0.00 – 0.07

EOSINOPHILS 0.03 0.07 0.00 – 0.05

BASOPHILS 0.00 – 0.01

*Peripheral smear : Hypochromic with anisocytosis and poikilocytosis

8/24 ReferenceCreatinine 2.86 2.29 0.5-1.2Sodium 123 132.48 137-147mmol/LPotassium 4.96 3.8-5mmol/LiPO4 4.5 2.3-4.7 mg/dLIntact PTH 8.2Ionized Calcium 1.66 1.12-1.32Fasting Blood Sugar

78.97 70-110 mg/dL

BUN 65.70 8-23 mg/dLSGPT 36.91 3.8-5 U/LUric Acid 13 3.89 2.7-7.3

8/24 ReferenceTotal Cholesterol

119.78 150-250 mg/dL

Triglycerides 130.33 10-90 mg/dL

HDL 22.03LDL 68.20Total Protein 7.00 6-7.8 g/dL

Albumin 2.57 3.2-4.5 g/dL

Globulin 4.43 2.3-3.5 g/dL

HbA1c 7.90 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

SUBJECTIVE DATA OBJECTIVE DATA

Age: 60

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

(+) swelling on the wrists to hands, ankles to feet, warm to touchPresence of joint deformitiesPresence of ulcers on the legs(+) Bipedal edema(+) Shifting dullnessAbdominal circumference: 98cm(+) venous collateralsSlightly icteric scleraeLow Hgb and Hct on CBC with anisocytosis and poikilocytosisIncreased BUN and creatinine

SALIENT FEATURES

Present Medications

• 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