CHIEF COMPLAINT: Right foot pain.
HISTORY OF PRESENT ILLNESS: The patient has a one day history of intense right foot pain, some degree of swelling and erythema. This has happened to him once before. He thought it might have been gout. He did see a physician and has been taking some over-the-counter anti-inflammatories up to this point with some relief of symptoms. At this time, it did not give him any relief of symptoms whatsoever. The foot pain is quite intense. He is unable to walk on his own. He had to be basically carried into the emergency room.
PAST MEDICAL HISTORY: Hypercholesterolemia, some degree of gastroesophageal reflux disease, and possibly uric acid gout.
MEDICATIONS: Prilosec, Lipitor, and aspirin.
SOCIAL HISTORY: The patient does not smoke. No alcohol or illicit drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As mentioned, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 106/76, pulse 88, respirations 12, temperature 97.2, and pulse ox 99%.
GENERAL: The patient is awake, alert, and oriented, in mild distress secondary to foot pain.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended with good bowel sounds with no organomegaly.
EXTREMITIES: The left foot is acutely tender to palpate along the first, second, and third metatarsals especially as well as the fourth and fifth. There is some tenderness to palpation in the first metatarsophalangeal joint. He does have good range of motion in his ankle. He does have limited range of motion in his first and second toes. His foot does feel warm to touch, not hot but warm.
NEUROLOGIC: Cranial nerves are intact. Reflexes are normal. Sensation is grossly intact.
EMERGENCY DEPARTMENT COURSE: The patient was treated in the emergency room for right foot pain. He was given Dilaudid for the pain. He was given a total of 4 mg on separate occasions. This did seem to relieve a lot of his symptoms. We did check a CBC, which showed a white count of 11.6. His uric acid was on the high side of normal at 8. His sed rate was 11. We discussed this case with Dr. John Doe who also evaluated the patient himself. It is an atypical presentation for gout. It is an atypical presentation for rheumatologic disease. The exact diagnosis is uncertain. He has seen a rheumatologist in the past and will pursue further diagnostic workup. He did leave the emergency room in stable condition with crutches on his own power though with much symptom relief.
DIAGNOSIS: Foot pain.
PLAN:
1. At this time, we will give him Vicodin 1-2 tablets to take as needed for the pain.
2. He can continue taking over-the-counter anti-inflammatories as necessary.
DISPOSITION: The patient was discharged to home in stable condition.
