Name: James Hanson Pt. Encounter Number:
Date: 8/29/2022 Age: 47 Sex: M
SUBJECTIVE
CC:
“pain in the left great toe for 3 days”
HPI:
47 yo male presents to the office c/o pain in the left great toe with associated redness and swelling. He reports that the pain started 3 days ago when it woke him from sleep during the night. He reports he had “a few too many beers with the boys” prior to the onset of the pain. Pain is located in the left great toe joint and has been constant. He describes the pain as severe, throbbing, and pulsating. He reports that the bed sheet, socks or shoes make it worse and he is unable to stand, bear weight or wear a shoe.. Position changes, elevation, rest and aspirin have been ineffective. He did get minimal relief from ice to the area. Rates the pain a 10 on a 1-10 pain scale. Denies trauma to area. He reports he has had some periodic pain mild pain in the joint previously but he has not received care for this condition previously.
Medications: HCTZ 25mg daily for HTN x 10 years
Allergies: NKDA
Medication Intolerances: N/A
Past Medical History: HTN, overweight
Chronic Illnesses/Major traumas: History of clavicle fracture after a fall while intoxicated
Hospitalizations/Surgeries: denies
Preventive/Immunizations: Pt reports he is UTD on all immunizations. TDaP 2018, Flu 2019, Covid # 4/2021, Covid #2 4/2021. Screened and negative for all STD and HIV 3 months ago.
Family History
Both mother and father have history of HTN. Father treated for gouty arthritis in multiple joints. Maternal and paternal grandparents with history of CVD and diabetes.
Social History
Preferred pPt is employed as a lawyer, attended law school in Boston. Never married, lives alone and has no children. Sexually active, interested in women. Lifetime partners 20. Reports condom use 100% of the time. Denies tobacco use. Reports he drinks aprox 7-10 drinks a week, sometimes more. Uses marijuana on the weekends. CAGE score=0.
ROS
General
Denies recent change in weight but reports needing to lose some weight. Denies fever, chills, night sweats, fatigue. Cardiovascular
Denies chest pain, palpitations, dizziness, syncope.
Skin
Denies rashes or bruising. Reports redness and swelling of left great toe with peeling skin.
Respiratory
Denies cough, SOB
Eyes
Denies any problems with eyes, no change in vision.
Gastrointestinal
Denies abdominal pain, nausea, vomiting, constipation.
Ears
Denies ear pain or difficulty hearing.
Genitourinary/Gynecological
Denies dysuria and frequency.
Reports he is sexually active, women only. Uses condoms 100% of the time. Screened for HIV and STD’s 3 months ago, all negative.
Head/Nose/Mouth/Throat
Denies trauma to head. Denies congestion, sore throat.
Musculoskeletal
Denies muscle or joint pain with the exception of the left great toe redness, swelling and pain. ROM intact all joints with the exception of left great toe which is limited due to pain. Denies trauma to area. Denies difficulty ambulating.
Breast
N/A Neurological
Denies syncope, dizziness. Denies numbness or tingling. Denies difficulty with speech, coordination or sensation.
Heme/Lymph/Endo
Denies swollen glands or lymph nodes. Denies bruising or bleeding. Denies being immunocompromised. Psychiatric
Denies depression/SI. Reports some trouble sleeping especially when using alcohol.
OBJECTIVE
Weight 200lbs BMI 28.7 Temp 98.5 BP 129/84 left, 128/82 right
Height 5’10” Pulse 86 Resp 18 O2 sat 99%
General Appearance
Healthy appearing, appropriately dressed, adult male. Alert and oriented; answers questions appropriately.
Skin
Redness and desquamation around left first metatarsophalangeal joint.
HEENT
Head is normocephalic, atraumatic, and without tenderness, visible or palpable masses, depressions or scarring. Hair evenly distributed. Eyes: PERRLA. Visual acuity intact. EOMs intact. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. No mass, trachea midline. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular
Chest normal in appearance, no lifts, heaves, or thrills. S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pedal pulses 3+ bilaterally. No edema.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal
BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly.
Breast
Deferred
Genitourinary
Deferred.
Musculoskeletal
Limping on left foot noted on ambulation, otherwise full ROM seen in all four extremities.
Neurological
Alert and oriented x4, speech clear. No motor deficit noted. Muscles strength 5/5 bilaterally. Sensantion intact bilaterally. Balance stable.
Psychiatric
Pt does not appear depressed or anxious. Maintains eye contact.
Lab Tests
6 Panel Drug Screen-
Amphetamines-negative
Barbituates-negative
Cocaine metabolites-negative
THC-negative
Opiates-negative
PCP-negative
Ethanol, blood- <5mg.dL
CBC
RBC 4
HGB 12
HCT 36
WBC 7
Plt 157
CMP
Glucose 99mg/dL
Calcium 9.8mg/dL
Sodium 138 mEq/L
Chloride 100mEq/L
BUN 19mg/dL
Creatinine 0.9mg/dL
Albumin 4.5g/dL
Total Protein 7.5g/dL
Alk Phos 40 U/L
ALT 20 U/L
AST 15 U/L
Bilirubin 0.5mg/dL
ESR-5mm/hr
CRP-0.5
ANA < or = 1:4
RF Negative
Serum Uric Acid 8.4mg/dL
Synovial Fluid Analysis- positive for uric acid crystals but negative gram stain
Imaging
Left Foot Xray Normal, no radiologic evidence of fracture or bony lesions.
Assessment
Include at least three differential diagnoses
Provide rationale for each differential diagnosis
Final diagnosis
Pathophysiology of primary and rationale for choosing as final
Plan
Medications
Non-pharmacological recommendations
Diagnostic tests
Patient education
Culture considerations
Health promotion
Referrals
Follow up
