HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who presents to the emergency department complaining of a three-day history of increasing pain and swelling at the left knee. It has been a bit stiff. Tonight, it has gotten bad enough that it has kept him from sleeping. The patient denies any injury to the area. The patient denies any fever, chills, nausea or vomiting.
PAST MEDICAL HISTORY:
1. Gout, that is affecting him mostly in the feet.
2. Diabetes.
3. Hypertension.
MEDICATIONS:
1. Ambien.
2. Lipitor.
3. Toprol.
4. Lasix.
5. Aldactone.
6. Plendil.
7. Atacand.
8. Lisinopril.
9. Amaryl.
10. Hydralazine.
11. Metformin.
12. Aspirin.
13. Multivitamin.
ALLERGIES: PENICILLIN.
PHYSICAL EXAMINATION:
GENERAL: The patient is awake, alert, and in no apparent respiratory distress.
VITAL SIGNS: Blood pressure 142/96, temperature 98.8, pulse 98, and respirations 20.
HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Pharynx is clear.
NECK: Supple and nontender.
LUNGS: Clear and equal.
HEART: S1 and S2, no murmur.
ABDOMEN: Soft and nontender to palpation. Bowel sounds are present in all quadrants.
EXTREMITIES: Pulses are equal.
SKIN: Warm and dry.
EXTREMITIES: Left knee examination shows palpable effusion. It is not warm to touch, no erythema. The patient does have decent range of motion of the knee; however, it is tender. Distal neurovascular examination is intact.
DIAGNOSTIC STUDIES: Left knee x-ray is negative for bony abnormality or fracture.
LABORATORY DATA: White count is 14.2, hemoglobin 14.4, hematocrit 42.6. Uric acid level is 9.2, and sedimentation rate is 27.
EMERGENCY DEPARTMENT COURSE: The patient is given Lortab for pain. Vital signs and examination remained stable.
FINAL DIAGNOSIS: Left knee effusion, probable gouty arthritis.
PLAN:
1. The patient is discharged.
2. Indocin and Lortab.
3. Follow up with family doctor in one week.
4. Return to the emergency department sooner if worse.
