CHIEF COMPLAINT: Left foot pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who complains of left foot pain for the past two days. The patient states he was playing soccer just before noticing the pain but does not recall any specific injury. The patient states the area has been erythematous and edematous, but he denies any numbness, tingling or weakness of his foot. He states the pain is not significantly worsened with walking. He states the pain is mostly over the first MTP joint. He has no previous history of gout.
PAST MEDICAL HISTORY: Chondromalacia.
MEDICATIONS: Ibuprofen and Tylenol.
ALLERGIES: None.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient denies tobacco or alcohol use.
REVIEW OF SYSTEMS: As above, otherwise negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 148/90, pulse 84, respirations 18, temperature 97.8 degrees, and O2 sat 99% on room air.
GENERAL: This is a well-developed, well-nourished male in no acute distress.
EXTREMITIES: The patient does have a warm, red, first MTP joint, which is more painful with dorsiflexion and plantarflexion of the toe. There is no other tenderness to palpation along the first metatarsal. There is no tenderness to palpation at the ankle. He has no other tenderness to palpation. There is no edema noted to the areas. He has full range of motion of the toes and ankle, 2+ pulses bilaterally.
NEUROLOGIC: The patient is oriented x4. Gross sensation is intact. Strength is 5/5 bilaterally.
EMERGENCY DEPARTMENT COURSE: The patient’s nursing notes and records were reviewed. The patient did receive 30 mg of Toradol IM for his pain.
MEDICAL DECISION MAKING: At this time, the patient does appear to have signs and symptoms of acute gouty arthritis. He does not have a history of gout, but the presentation of his first MTP is classic for podagra. Therefore, we will place the patient on a course of indomethacin and given him a list of clinics for followup.
DIAGNOSIS: Gout.
PLAN:
1. The patient was given indomethacin.
2. He is to rest, ice, and elevate.
3. Follow up with clinic of choice from the list provided.
4. Return to the ER for any increased pain, swelling, inability to walk or any other concerns.
DISPOSITION: The patient was discharged to home in good condition.
