Gouty Arthritis
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
Elderly male patient who is a farmer by occupation , chronic alcoholic .
Presented to opd with
History of pain at right metatarsal joint since 5 months , associated with joint swelling and fever for which he used to get Injections from local RMP .
Complaining of right ankle and left knee joint pains since 1 week .
H/ o fever since 1 week
No small joint pains ,no early mrng stiffness .
No restriction of movements at UL joints
On examination -
Local rise of temp +
Tenderness at 1 st MTp +
Left knee joint - swollen and inflamed .
Pallor+
No Comborbidties
Serum uric acid -7.7
Serum creatinine -2.2
Diagnosis - Gouty / septic arthritis
Anemia under evalation .
AKI - secondary to analgesic abuse
SOAP NOTES
WARD CASE DAY 1
S
Pain at the MP joint resolved
O
Pallor +
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 90/60 mmHg
RR 14 cpm
SpO2 99% at room air
PR 82 bpm
CVS S1 S2 +
RS NVBS +
P/A soft, non tender
CNS no FAD
A
GOUTY ARTHRITIS WITH MICROSCOPIC HYPOCHROMIC ANEMIA ? IDA
P
1. Inj TRAMADOL 1 amp in 100ml NS over 30 min
2. Tab WYSOLONE 5mg po od
3. Tab COLCHICINE 0.5 mg po od
4. Tab OROFER XT po bd
5. GRBS 8th hrly
6. BP 8th hrly
SOAP NOTES
WARD CASE DAY 2
S
Pain at the MP joint resolved
O
Pallor +
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 90/60 mmHg
RR 17 cpm
SpO2 99% at room air
PR 66 bpm
CVS S1 S2 +
RS NVBS +
P/A soft, non tender
CNS no FAD
A
GOUTY ARTHRITIS WITH MICROSCOPIC HYPOCHROMIC ANEMIA ? IDA
P
1. Inj TRAMADOL 1 amp in 100ml NS over 30 min sos
2. Tab WYSOLONE 5mg po od
3. Tab COLCHICINE 0.5 mg po od
4. Tab OROFER XT po bd
5. GRBS 8th hrly
6. BP 8th hrly
SOAP NOTES
WARD CASE
DAY 3
S
Pain at the MP joint resolved
O
Pallor +
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 90/60 mmHg
RR 17 cpm
SpO2 99% at room air
PR 70 bpm
CVS S1 S2 +
RS NVBS +
P/A soft, non tender
CNS no FAD
A
GOUTY ARTHRITIS WITH MICROSCOPIC HYPOCHROMIC ANEMIA ? IDA
P
1. Inj TRAMADOL 1 amp in 100ml NS over 30 min sos
2. Tab WYSOLONE 5mg po od
3. Tab COLCHICINE 0.5 mg po od
4. Tab OROFER XT po bd
5. GRBS 8th hrly
6. BP 8th hrly
SOAP NOTES
WARD CASE
DAY 4
S
Pain at the MP joint resolved
O
Pallor +
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
Pedal edema -
Afebrile
BP 90/60 mmHg
RR 17 cpm
SpO2 99% at room air
PR 70 bpm
CVS S1 S2 +
RS NVBS +
P/A soft, non tender
CNS no FAD
A
GOUTY ARTHRITIS WITH MICROSCOPIC HYPOCHROMIC ANEMIA ? IDA
P
1. Inj TRAMADOL 1 amp in 100ml NS over 30 min sos
2. Tab WYSOLONE 5mg po od
3. Tab COLCHICINE 0.5 mg po od
4. Tab OROFER XT po bd
5. GRBS 8th hrly
6. BP 8th hrly
