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Admission Conference

Admission Conference. Clk. Kirsten Diane Dy. General Data. U.S. 28 y/o Male Married Filipino Tricycle driver Roman Catholic Quezon City Date of Admission: August 25, 2009. Chief Complaint. Difficulty in ambulation. History of Present Illness. patient noted white scales on his scalp.

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Admission Conference

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  1. Admission Conference Clk. Kirsten Diane Dy

  2. General Data • U.S. • 28 y/o Male • Married • Filipino • Tricycle driver • Roman Catholic • Quezon City • Date of Admission: August 25, 2009

  3. Chief Complaint Difficulty in ambulation

  4. History of Present Illness patient noted white scales on his scalp 7 years PTA (+) pustules and papules on his face that later coalesced to form erythematous plaques topped with scales Consult :UST Dermatology OPD Punch biopsy Assessment: Psoriasis Medications: Methotrexate Dermovate with Petroleum Jelly LCD PUVA therapy Few months later

  5. History of Present Illness (+) painful swelling of all the digits of his hands and feet (+) gradual limitation in the movement of his digits Consult: private physician (Rheumatologist) Medications: Celebrex Work-ups not done 2 years PTA (+) pain in both his knees (+) limping (+) pain when walking down the stairs Relieved by rest or sitting down No consult done Self-medicated with Naproxen 1 year PTA

  6. History of Present Illness (+) swelling of both knees increasing severity of the pain No consult was done 1 month PTA (+) pain in the hips extending down to ankles more difficulty in ambulating 1 week PTA Consult: Orthopedic Surgeon Assessment: excess fluid in his knee joints Offered arthrocentesisbut refused 5 days PTA

  7. History of Present Illness (+) fever (undocumented) Self-medicated with Paracetamol 4 days PTA Persistence of pain and fever Consult: FEU Hospital x-ray of left leg: soft tissue swelling Advised admission but refused Referred to our institution 3 days PTA ADMISSION

  8. Review of Systems • No loss of appetite, no weight loss • No hearing loss, no nasal congestion, no cough • No dyspnea, orthopnea, cyanosis • No chest pain, palpitations • No abdominal pain, no diarrhea, no constipation • No dysuria, no change in character of urine • No polyuria, no polyphagia, no polydipsia

  9. Past Medical History • (-) Diabetes Mellitus • (-) HPN • (-) Allergy • (-) Asthma • (-) History of trauma • (-) Joint surgery

  10. Family History • (+) DM – father • (+) Myocardial Infarction- father • (-) Psoriasis ` • (-) HPN • (-) Stroke • (-) Asthma • (-) Cancer • (-) Blood Dyscrasia • (-) Arthrides

  11. Personal and Social History • Smoker- 16-21y/o (1-2 sticks per day) • Occasional alcoholic beverage drinker • Denies illicit drug use • Had 3 sexual partners before his wife, protected

  12. Physical Examination • Conscious, coherent, wheel chair-borne, not in cardio-respiratory distress • BP 120/70 mmHg PR 83 bpm, reg RR 20 cpm T 36.6 oC • Height= 165cm Weight= 70kg BMI= 25 • Warm moist skin, (+) erythematous plaques topped with scales all over the body, (+) hyperpigmented patches over the upper extremities, (+) oil spots, (+) horizontal ridging, (-) nail pitting • Pink palpebral conjunctivae, anicteric sclera, no naso-aural discharge, no tragal tenderness, moist buccal mucosa, nonhyperemic PPW, tonsils not enlarged • Supple neck, trachea midline, no palpable cervical lymph nodes, thyroid gland not enlarged

  13. Physical Examination • Adynamicprecordium, AB at the 5th LICS, MCL, no murmurs • Symmetric chest expansion, no retractions, clear breath sounds on all lung fields, no crackles, no wheezes • Flat abdomen, NABS, soft, nontender, no masses, • (+) sausage-shaped right 4th digit of the hand • (+) swelling and tenderness, both knees, DIP 4th R digit of the hand, R ankle • (+) flexed 5th left digit and the 4th right digit of the hand • Cannot flex the PIP and DIP of the right 2nd digit of the hand • All pulses full and equal

  14. Neurologic Examination • Patient is conscious, oriented to person, place and time, can follow commands, GCS 15 E4V5M6 • Pupils 2-3 mm, isocoric ERTL, V1,V2,V3 intact; (+) corneal reflex, intact hearing, can swallow, (+) gag reflex, can shrug shoulders, tongue midline on protrusion • MOTOR: MMT 5/5 on both UE; 4/5 on both LE, no atrophy • CEREBELLUM: no deficits, can do FTNT, APST, HTST • SENSORY: no sensory deficits • DTRs: 2+ on the upper extremities, LE not assessed • (-) Babinski; no nuchalrigidity

  15. Salient Features • 28 y/o Male • Known Psoriatic since 2002 • (+) erythematous plaques topped with scales all over the body • (+) oil spots, (+) horizontal ridging • (+) gradual limitation in the movement of his digits • (+) fever • (+) swelling and tenderness, both knees, • (+) swelling and tenderness, DIP 4th R digit of the hand • (+) swelling and tenderness, R ankle • (+) contraction, 2nd R digit of the hand

  16. Assessment Psoriatic Arthritis r/o Septic Arthritis

  17. Diagnostic Plans • Arthrocentesis • Synovial fluid cell count • Synovial fluid Gram stain • Synovial fluid culture and sensitivity • Sacroiliac x-ray • X-ray of the hands • CBC, ESR • BUN, Creatinine • SGOT, SGPT

  18. Therapeutic Plans • Dolcet tablet, q8 prn for pain • Cefotaxime, 1g/IV q8 • Etanercept 50mg/SC/week • Methotrexate 25mg/week • Frequent passive motion of the joints • Avoid weight-bearing until signs of inflammation have subsided

  19. Thank You

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