Shellie Ray CRNP - Home



SUBJECTIVE:CHIEF COMPLAINT: “My left big toe is killing me”HISTORY OF PRESENT ILLNESS: 53 yom presents to the clinic with c/o pain in his left great toe. He is limping and has only a sock on stating that he is unable to wear a shoe. The pain started last night after he had been working all day climbing up and down a ladder. He did not remember doing anything unusual to injure his foot and had his work boots on while working. Last night pt unable to sleep due to the pain. States that just the weight of the sheet was unbearable. The pain is located in the left great toe and is described as a throbbing, sharp pain. It is severe in intensity, 10/10 with no relief from ibuprofen or rest. The timing is constant for the past 15 hours. PMH: HTN, DepressionSx: noneAllergies: NKDAMedications: Hydrochlorothiazide 12.5 mg PO QD, Ibuprofen 200 mg PO Q 6 hrs. PRN painAge/health status: 53 yom appearing to be in a good present state of healthPrevious Health Screening: Dyslipidemia, Diabetes, PSA Jan. 2009 ; Colonoscopy neverImmunizations: Tetanus 2009, Flu and Pneumonia does not takeFAMILY HISTORY:Father: Hypercholesterolemia, HTN, DepressionMother: HTN, DepressionSon: unremarkableSOCIAL HISTORY: Married for 28 years, lives with wife. One son who is married with a child. Works as an electrician with the same company for 30 years. Graduated high school, some technical school education. Current ? PPD smoker for 30 years. Drinks occasional beer while watching football on the weekends. Denies drug use. Sexual activity: monogamous relationship with wife who has been his only sexual partner, no birth control methods due to wife’s hysterectomy. REVIEW OF SYSTEMS:Constitutionals: Denies fever, change in weight or fatigue. Positive for difficulty sleeping last night due to pain. Musculoskeletal: Positive for left foot pain and joint pain. Denies history of broken bones, arthritis or gout. Denies back pain or stiffness.Cardiovascular: Denies chest pain, palpitations, dyspnea, orthopnea, edema. Denies varicose veins, claudication or history of DVT. Does not exercise. Denies dyslipidemia. Positive for HTN. Respiratory: Denies cough, sputum, hemoptysis, dyspnea, wheezing, pleurisy, unknown last chest x-ray. Denies history of asthma, bronchitis, emphysema, pneumonia or tuberculosis. Denies exposure to tuberculosis and last PPD unknown. Positive for current smoker ? PPD for 30 years.Integumentary: Pt denies skin disorders. No skin lesions, itching, nail deformity or open areas. Has several moles which he watches for changes. Tanned skin and denies use of sunscreen. Endocrine: No thyroid problems, no heat or cold intolerance, polydipsia, polyphagia, polyuria. Denies changes in skin, hair or nails, or unexplained hair growth. Hematologic/lymphatic: Denies blood disorders, fatigue, anemia, blood transfusions, swollen or tender glands. Denies lead exposure.Objective:Height: 70 in. Weight: 183 BMI: 26.3Vital Signs: T 98.9 P 74 R 16 BP 132/92 Constitutionals: Pleasant, appropriately dressed and groomed adult male. Alert and orientated to person, place and time and answers all questions appropriately.Cardiovascular: S1, S2 no S3 or S4. No gallops or murmurs. No presence of JVD. No carotid bruits. Calves are nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis and posterior tibial pulses are 2+ and symmetric.Respiratory: Clear to auscultation bilaterally, no rales, wheezes or rhonchi. Thorax symmetric with good excursion. Integument/Lymphatic: Skin pink, warm and dry. Edema noted only to the left MTP joint. Nails without clubbing or cyanosis. No varicosities or stasis changes. No palpable lymph nodes. Feet without open areas, blisters or callous.Musculoskeletal: Left first metatarsophalangeal joint extremely painful to touch, edema with erythema, warmth and decreased ROM. No presence of tophi. All other joints with full ROM, no edema, warmth or erythema noted to other joints.Hematologic/immunologic: no bruising noted ASSESSMENT:Differential Diagnosis:GoutBursitisCellulitisRheumatoid arthritisSeptic arthritisTraumaDiagnosis: Gout ICD 9- 274.00 HTN ICD9- 401.9PLAN:CBC, ESR, serum uric acidIndomethacin 50 mg PO Q 8 hours for 8 doses, then 25 mg PO Q 8 hours until pain free.Warm or cool compresses to affected areas for comfort 20 minutes 2-3 times a day.Activity: Avoid weight bearing of affected joint until symptoms improve. Resting and elevation of the joint is the best treatment.Diet: Drink 10-12 glasses water a day. Avoid foods high in purine such as organ meats (liver), meat extracts and gravies, yeast and yeast extracts (brewer’s and baker’s), beer and alcoholic beverages, beans, peas,lentils, oatmeal, spinach, asparagus, cauliflower, and mushrooms.Patient’s risk factors for gout include: overweight (BMI 26) and HTN. Advise to lose weight.Call clinic if symptoms worsen or do not improve in 3-4 days after starting therapy. Return to clinic for a follow-up in two weeks. Pt is on HCTZ which is a predisposing factor in gout, may need to evaluate the need to change medications if persistent gout attacks.Chronic gout: if patient has 3 or more attacks per year, consider long-term therapy.Routine Health Maintenance: Due for PSA, Diabetes and Cholesterol Screening ( labs for PSA, BMP and fasting lipid profile); Stool for occult blood; Recommend colonoscopy. ReferencesBecker M A Treatment of acute goutBecker, M. A. (n.d.). Treatment of acute gout. Retrieved September 3, 2012, from 20120903181705788035035Cash J C Glass C A 2011 Family practice guidelinesCash, J. C., & Glass, C. A. (2011). Family practice guidelines (2nd ed.). New York, NY: Springer Publishing Company. Dunphy L M Winland-Brown J E Porter B O Thomas D J 2011 Primary care: the art and science of advanced practice nursingDunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary care: the art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F.A. Davis Company. 2012082821040868339467020120828210601934854742012082821060193485474 ................
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