Gout Jane Doe

NSG 6435

Faculty

Chief Complaint

M.C. is a 55 year old Caucasian male presenting with complaints of pain, with redness and

swelling in his right great toe.

HPI

Historian: (include this information for patients <16 y/o and older patients PRN) Patient is an obese male who reports pain, redness and swelling in right great toe(location) which started 3 days ago(Onset) and has progressively gotten worse(duration). He describes the pain as a burning constant(character) pain irritated with any touch or friction(aggravating). He tried over the counter ibuprofen(alleviating) and states it did mildly help the with the pain. The pain does radiate to the entire foot(radiation) and he cannot bear weight. He rates the pain as a 10/10 on the pain scale(severity). He mentions that he does have daily ethanol ingestion and was recently started on chlorthalidone for hypertension (HTN), which he feels contributed to the flare(temporal). Medical History • Kidney stones in 2012 • HTN • Obesity • No Surgeries Medication Lists • Ibuprofen – 800mg- tid • Chlorthalidone 25mg- daily • No Known Allergies Family Medical History Summary Father- Died at 72yrs old- hypertension, heart disease, and renal failure. Mother- Died at age 65 of breast Cancer. Sister- Age 55- Alive and well - HTN Paternal Grandfather- Unknown Paternal Grandmother – Died at age 82yr- Heart Disease Maternal Grandmother- Dies at 87yr- Stroke- HTN and Diabetes Paternal Grandfather- Died at 62 yrs in a car accident Social History C.M – Is divorced and lives alone. He was married for 20 years and has 1 male child age 28yr. He works full-time as a manager of a local Tires Plus. He rents an apartment in the local town in which he works. He is in a monagomous relationship with a female partner for past 2 years. C.M. does not smoke. He drinks 2-3 alcoholic drinks per day. He reports sleeping 5-6 hours daily, and exercises twice weekly. He drinks 2-3 caffeinated beverages per day and eats at a fast food restaurant 4-5 days a week. He does eat beef daily. He does report a history of methamphetamine abuse from ages 20-22. He was admitted to a drug rehabilitation program and has been drug free for 30 years. Patient Profile Activities of Daily Living (age appropriate): independent Safety Practices: 2 firearms in home secured in a gun closet Changes in daycare/school/after-school care: (address if appropriate) Developmental History: (provide a history of development over the child’s lifespan. If child is 1y/o or younger, provide birth history also) Review of Systems • CONSTITUTIONAL: No night sweats. No fatigue, malaise, lethargy. No fever or chills. • HEENT: Eyes: No visual changes. No eye pain. No eye discharge. ENT: No runny nose. No epistaxis, No sinus pain. No sore throat. No odynophagia. No ear pain. No congestion. • BREASTS: No breast pain, soreness, lumps, or discharge. • RESPIRATORY: No cough. No whe