SOAP Note rewrite to get zero turnitin

SOAP Note – Acute Gout

United State University

Common illness Across the Lifespan-Clinical Practicum

SOAP Note – Acute Gout

SUBJECTIVE DATA

Patients ID: Mr. M.S, Age: 45 years old, Race: Caucasian, Gender: Male,

Date of Birth: February 14 1977. Marital Status: Married. The patient presents to the clinic unaccompanied though he seems a reliable historian.

CC: “I have been experiencing severe sharp pain on my big toe joint, which has now begun radiating to the leg’s upper part. The pain causes me sleepless nights since it worsens at night; thus, I ought to seek medical attention. The pain has been causing me chills.”

History of Present Illness: M.S, is 45 years old male patient who presents to the clinic with complaints of acute pain on the big toe joint in his right foot, which began six days ago. The patient reported that the attack began with signs of tenderness, swelling, and later severe pain at the big toe joint. He reported that the pain also radiates to the other leg parts, where the ankle and the foot are the most affected. The patient described the pain as severe, rating it 10/10 on a pain scale. The pain has been disturbing and bothering since it limits his locomotive abilities, thus affecting his work routine since he works as a machine operator at the port. His job requires both legs to be functional and effective. He reported that the pain worsens at night and is sensitive to touch; thus, he cannot wear shoes, socks, or even cover himself with a sheet. The pain had no relenting factors, and he used ibuprofen to control the pain, but it was no longer working.

Review of Systems

Constitutional: The patient is friendly and seems a reliable historian on account of his extant. He is in good shape with no significant medical issues tampering with his physique except the present issue. He reverts unaccounted weight loss or gain, nausea, vomiting, or increased weakness but is positive for fever and chills.

HEENT: Head; reports no headaches, dizziness or light headedness. Eyes; reports no double vision, sensitivities to light or occasional blindness. Ears; reports no tinnitus, epistaxis or ear wax. Nose; denies running nose, nasal congestion, or breathing difficulties. Mouth and Throat; reverts swollen glands, sores in the mouth, or throat. Also denied bleeding gums or difficulties with chewing or crashing.

Skin: Reverts skin rashes or changes in skin colour.

Pulmonary: Denies breathing difficulties, wheezing, persistent coughs, or nasal congestion.

Cardiovascular: Denies abnormal heartbeats, chest tightness, pain, laboured breathing, or heart murmurs.

Gastrointestinal: Denies abdominal pain, vomiting, constipation, diarrhea, loss of appetite or changes in bowel patterns.

Genitourinary: Denies changes in urinating patterns. Reverts pain upon urination or a burning sensation, foul smell, or difficulties initiating a pee.

Musculoskeletal: Reports pain on his feet in the big toe joint which makes his entire foot to be in pain. The patient reports that part of his toe is swollen and tender thus painful when touched. He reverts injuries or trauma, other joints weakness or stiffness, muscle cramps, swellings or pain in the extremities. Also denies back pain or discomforts.

Neurologic: Denies seizures or loss of memory.

Lymph/Hematologic: Denies the presence of swollen, enlarged, or painful lymph nodes. Excessive bleeding, bruising, and petechia are all denied by the patient.

Psychiatric: Reverts sadness, depression, suicidal ideation, or changes in his sleeping patterns.

Past Medical History: The patient reported having no significant health conditions bothering him at the present, and neither did he has one in his young life.

Surgical: Suggested to have undergone a tonsillectomy surgery at the age of 8.

Allergies: Allergic to dust and animals.

Medications: Been using ibuprofen 400mg to control the severe pain.

Immunization: Up to date with his immunizations. Received flu and yellow fever jabs on September while he was travelling to Congo for work.

Family History: His maternal grandparents are deceased due to old age-related health conditions. The grandfather was bothered by bipolar disorder, while the grandmother was bothered by hypertension and type two diabetes. Paternal grandmother at the age of 86 due to heart complications and was bothered by hypertension. Paternal grandfather is still alive aged 92, and he is bothered by chronic kidney disease and hyperuricemia. The father is alive, aged 70 years, and has hypertension. The mother is alive aged 69, and she is healthy free of any medical condition. The wife is alive, and two siblings who are all healthy and free from medical complications.

Social History: Mr. Martin is married to one wife, and together they have sired two children, a boy and a girl. He is employed by the Carolina ports serving as a machine operator. He and his family live in a rental apartment in North Carolina. He reported that he does not take recreational drugs, but he takes alcohol about two beers a day. Maintains a healthy diet. He is physically active, reporting that he does yoga, jogging, and weight lifting in his leisure time. The patient suggested being a Christian, though he does not attend church services always.

OBJECTIVE DATA

Vital Signs: Temperature: 99.2 ℉, Pulse: 84, Respiratory Rate: 20, Blood pressure 118/82, Oxygen saturation: R.A 96%, Height 5’.7’, Weight 130 lbs, BMI 20.4.

Physical Examination

General: The patient seems to be well-behaved, alert, and oriented X3. He is appropriately dressed and logically responds to queries where his responses are brief. He also maintains eye contact while in conversations. He reflects signs of acute physical distress; particularly on his right leg due to pain.

HEENT: Head; Atraumatic and Normocephalic. Eyes; PERRLA, conjunctiva pink with no scleral jaundice nor signs of discharge. No discharge. Visits an optician semi-annually. Ears: no pinna or tragus abnormalities, no tenderness or ear canal inflammation, no discharge. Nose: no sinus, moist and pink. Mouth and Throat: Moist mucosa, no lesions, inflammation, or exudate to the oral mucosa, tongue, or gum line. Good dentition with all his teeth. Sees a dentist semi-annually.

Neck: Trachea midline, with no lymphadenopathy or carotid bruits noted. supple to full range of motions and negative for thyromegaly.

Skin: Soft and warm to touch. Normal skin colour with no bruises or lesions.

Respiratory: Breath sounds were clear upon auscultation anteriorly and posteriorly.

Cardiovascular: S1 and S2 sounds were present upon auscultation and no gallops nor murmurs were noted. Normal heart rate with no edema.

Gastrointestinal: Soft and round, no guarding or rebound tenderness was noted, normal bowel sounds present in all the four quadrants. No masses or tenderness upon palpation of the CVA region.

Genitourinary: Bladder is non-distended. Negative for infections at the pelvic region. Reverts erectile dysfunction or challenges with sexual activities. Impalpable lymph nodes, upon inspection, his penis reflects a circumcised male with a normal growth of pubic hairs.

Musculoskeletal: On the big toe joint on his right-side leg, there was a palpable mass; it was warm and tender. The foot join of the leg was limited to range of motions due to the pain. Other joints in the body were upright with no swelling or tenderness, and their rage of motions was full.

Neurologic: Negative for sensory deformities. Speech was clear and logical backed by normal tone of an aging woman. negative for abnormal reflexes.

Psychological: Alert and oriented.

ASSESSMENT

Differential Diagnoses

Differential Dx: Acute gouty arthropathy (ICD-10-CM-274.01)

A gout is a form of arthritis characterized by severe pain, tenderness, heat, and swelling in the joints. The condition is painful, and it affects one joint at a time where the big toe joint is commonly affected. Its symptoms worsen with time. The most severe symptoms are flares, and when there are no symptoms at all, it is regarded as remission (Vaidya et al., 2018). The condition is triggered by hyperuricemia, a condition described by a build-up of excess uric acid in the body. Excess of this uric acid builds up in the joints. Males, obese patients, insulin resistance, and hypertension are among the situations which may make the condition easily manifest (Vaidya et al., 2018).

Differential Dx: Pseudogout (ICD-10-CM-M11.272)

Pseudogout is a form of arthritis characterized by sudden and painful swelling in one of the joints. These episodes of swelling and pain may persist for a while, and the most affected joint is the knee joint (Vaidya et al., 2018). The condition is also regarded as calcium pyrophosphate deposition disease or CPPD, and it correlates to gout, though their crystal deposits differ. The risks of the condition increase with age, and it manifests as warm swellings with severe pain (Vaidya et al., 2018). The condition is usually caused by calcium pyrophosphate dehydrate crystals in the affected joints.

Differential Dx: -Cellulitis (ICD-10-CM- L03.90)

The condition is triggered by a bacterial infection that affects the skin where it results in redness, pain, fever, red spots, swelling, and warmth to the touch (Sullivan & De Barra, 2018). The condition affects the skin on the lower legs, though it can also occur on the face, arms, and other body areas. The condition surfaces when your skin is cracked and allows bacteria to pass in (Sullivan & De Barra, 2018).

Final Diagnosis: Acute gouty arthropathy (ICD-10-CM-274.01)

The patient is likely suffering from acute gouty since the symptoms that manifested in the patient most matched the condition signs and symptoms. The Pseudogout diagnosis will be disregarded since the condition affects the knees in most cases. Cellulitis diagnosis will also not be considered since the condition is caused by bacteria that affect the skin rather than joints. The signs and symptoms described also do not match most of the conditions. Acute gouty will also be affirmed by lab tests, where it will be affirmed with a serum uric acid level greater than six (:>6.0) (Cash et al.,2020).

PLAN

Diagnostic Lab

· A uric acid test would be significant test for the amount of normal waste product in the blood. The test is applied while testing for gout or kidney stones.

· The gold standard for diagnosing gout is joint fluid aspiration for urate crystals. Using polarized light microscopy, examine the fluid for uric acid crystals. Using polarized light microscopy, examine the fluid for uric acid crystals (Cash et al., 2020).

· Uric acid blood test would be done to test whether the patient has high levels of uric acid in his blood where high uric acid levels would indicate possibility of having gout (Cash, Glass, & Mullen, 2020).

· Uric acid level in the blood: uric acid >6.8 mg/dl. During acute attacks, the amount of serum uric acid may be normal (Cash et al., 2020).

· CBC: White blood cell count is high.

· Erythrocyte Sedimentation rate (ESR) is elevated

· Imaging studies such as, X-ray, and MRI would also be done to test the states of patients joint at the foot such as dislocation, joint swelling, fracture, or to identify if there is a bone cysts/gout tophi (Cash et al., 2020).

TREATMENT PLAN AND EDUCTION

The patient should rest the joint area: The patient should avoid heavy lifting and weight-bearing exercise. It is not recommended to use aspirin products. The patient will be administered Indocin 50mg three times a day for the first eight doses, and then the prescription should be reduced to 25mg three times a day until the pain frees. The normal course is 5 to 7 days (Cash et al., 2020). Naproxen 750 mg at first, then 500 mg every 12 hours. The patient should also be administered Colchicine 1.2mg as the starting dose, which should be later reduced to 0.6 mg two times a day until the symptoms stabilize. Colchicine works best when taken within 12 to 24 hours of the onset of symptoms and stopped after the patient is free from the symptoms after 2 to 3 days. Colchicine is another option for preventing attacks (Cash et al.,2020).

Colchicine warning: Contraindications should be understood by the patient, Colchicine has unpleasant side effects such as nausea, vomiting, and diarrhea, thus be cautious about drug interactions. If a patient has kidney or liver disease, use with caution (Cash et al., 2020). The patient should also be prescribed Allopurinol 100mg daily, which should help regulate the high levels of uric acid and prevent future flares (Cicero et al., 2021).

The patient should drink at least eight glasses of water every day. The patient should be counselled to embark on diets that would help him lose weight since he is obese. He should also avoid his alcohol consumption for effective recovery. He should also refrain from meals rich in purine such as organ meat and bacon or rather control their intake since they are among the factors that contribute to exacerbating the condition (Cicero et al., 2021).

Follow-up

The patient should be asked to report to the clinic in two weeks to evaluate treatment effectiveness, and serum urate should be monitored every 2 to 5 weeks during medication titration to achieve the objective goal of a uric acid level of less than 6.0 (Cash et al., 2020).

Referral: Refer to a physician or rheumatologist for joint fluid aspiration and newer treatment options (Cash et al., 2020).

References

Cash, J. C., Glass, C. A., & Mullen, J. (2020). Family practice guidelines. Springer Publishing Company. https://doi.org/10.1891/9780826153425.0018b

Cicero, A. F., Fogacci, F., Kuwabara, M., & Borghi, C. (2021). Therapeutic strategies for the treatment of chronic hyperuricemia: An evidence-based update. Medicina, 57(1), 58. https://doi.org/10.3390/medicina57010058

Sidari, A., & Hill, E. (2018). Diagnosis and treatment of gout and pseudogout for everyday practice. Primary Care: Clinics in Office Practice, 45(2), 213-236. https://doi.org/10.1016/j.pop.2018.02.004

Sullivan, T., & De Barra, E. (2018). Diagnosis and management of cellulitis. Clinical Medicine, 18(2), 160-163. https://doi.org/10.7861/clinmedicine.18-2-160

Vaidya, B., Bhochhibhoya, M., & Nakarmi, S. (2018). Synovial fluid uric acid level aids diagnosis of gout. Biomedical Reports. https://doi.org/10.3892/br.2018.1097