MED BGD Infectious diseases- Rheumatology

1. MED BGDInfectious diseases- Rheumatology LeeChuy, Katherine Lee, Sidney Abert Lerma, Daniel Joseph Legaspi, Roberto Jose Li, Henry Winston Li, Kingbherly Lichauco, Rafael Lim, Imee Loren Lim, Jason Morven Lim, John Harold Lim, Mary Lim, Phoebe Ruth Lim, SyndelRaina Lipana, Kirk Andrew Liu, Johanna Llamas, Camilla Alay

2. General Data • Name: T. R. • Age: 60 • Sex: M • Status: Married • Nationality: Filipino • Date of Birth: 12/10/1949 • Place of Birth: Leyte • Religion: Roman Catholic • Eduacational attainment: High School Graduate • Occupation: retired; Grass cutter of Military Shrines Service • Current Address: Bataan • Informant: Patient, Wife, Niece, Nephew • Reliability: 70%

3. CHIEF COMPLAINT “Namamagaangmgakasukasuhansakamay, tuhod, at hinlalakisapaa (swelling of the hands, knees and big toe of R/L foot)”

4. 4 months PTA History of Present Illness • 10 years history of recurrent monoarthritis • No proper consult was done; self-medicated with paracetamol 500mg + ibuprofen 200mg (Alaxan), paracetamol (Biogesic) 500mg, Amoxicillin 500mg (duration of symptoms, interval between onset of symptoms, duration of intake, frequency of intake #tabs/day, frequency of attack, efficacy/ duration of relief from symptoms, compliance-if every how many hrs) • patient slipped and sustained an injury to the R/L hand or wrist in an attempt to break his fall • admitted at a local hospital in Bataan • confined and was given unrecalled medications • relieved from the pain (from medications or through massaging “hilot”? Was swelling also relieved)

5. 2 weeks PTA 1 week PTA -patient accidentally stepped on a sharp object and cleaned the wound site with guava leaves and betadine and then applied hydrogen peroxide with penicillin -recurrence of joint pain and swelling; self-medicated with Mefenamic acid 500 mg and amoxicillin 500 mg which provided relief (duration blah… blah…) -progression of joint pain and swelling, graded 10/10 with limitation of movement ADMISSION (August 24, 2010)

6. Past Medical History • No major hospitalization, unrecalled immunizations • No allergy, no previous transfusion • (-) DM, PTB, Asthma, Cancer Family History • not clear to the patient Personal and Social History • Cigarette smoker since 10 years old (unrecalled number of sticks) • Alcoholic beverage drinker ( 2 bottles; 3x a week and occasional gin drinker 2-3 bottles/week) • Diet: mixed and prefers meat and vegetables • Denies illicit drug use

7. Review of Systems • General: no fever, no weight loss, (-)anorexia, (-) weakness, (-) insomnia • HEENT: no blurring of vision, no eye redness, pain, itchiness, no excessive lacrimation, no ear pain nor tinnitus, no ear discharge, no epistaxis, no nose discharge, no anosmia, no obstruction nor sinusitis, no mouth sores, fissures, bleeding, no dental carries, no throat irritation, • Pulmonary: no hemoptysis, no coughing, no dyspnea, no chest wall abnormality • Gastrointestinal: (+) abdominal distention, no abdominal pain, no melena nor hematochezia, no changes in bowel habits • Genitourinary: no hematuria, no dysuria, no urinary frequency, no hesitancy, no incomplete voiding • Endocrine: no heat or cold intolerance, no polyphagia, no polydipsia, no polyuria, no thyroid enlargement • Musculoskeletal: see HPI, (+) ulcers on the medial side of the left foot • Hematologic: no abnormal bleeding, easy bruising

8. Physical Examination • General Survey: conscious, coherent, ambulatory, not in cardiorespiratory distress, normal speech, appropriate thought process and content and well-oriented as to time, place and date • Vital Signs • Systemic BP: (RUE) 170/100 (LUE) 170/100 • PR: 74 beats/minute • RR: 17 cycles/minute • Temperature (axillary): 37.2oC • Anthropometric mesaurement -Ht: 5’1” Wt kg 71 kgs BMI: 29.9

9. Physical Examination • Skin: Warm, moist skin, no active dermatoses, no jaundice • HEENT: Pale palpebral conjunctivae, anicteric sclera, pupils ERTL 2-3mm, no exophthalmos, no tragal tenderness, no aural discharge, supple neck, no distended neck veins, no palpable cervical lymph nodes, thyroid gland not enlarged • Pulmonary: Symmetrical chest expansion, no subcostal retractions, unimpaired tactile and vocal fremiti ,(+) crackles on both lower lung bases, no wheezes, no rhonchi, resonant, clear breath sounds

10. Physical Examination • Cardiovascular: Adynamic precordium, AB at 5th LICS MCL, no heaves, no lifts, no thrills, S1>S2 apex,S2>S1 base; Pulses were full and equal in all extremities, (+) bipedal edema, no cyanosis and clubbing • Gastrointestinal: flabby abdomen, normoactive bowel sounds, tympanitic upon percussion, no masses palpated, (+) fluid wave, Traube’s space not obliterated, Liver span: 10cm, , (-) murphy’s sign • Genitourinary: (-) CVA tenderness

11. Physical Examination • Musculoskeletal: deformed joints on the wrist, (+) swelling on the wrists to hands, ankles to feet, warm to touch • Neurologic Exam • Mental status: Conscious, awake, alert GCS 15 • Pupils 2-3mm, isocoric ERTL, EOMs full and equal, no ptosis, no nystagmus • No facial asymmetry, can shrug shoulders, can turn head against resistance • MMT: 5/5 all extremities • No sensory deficits • Can do FTNT, APST • Reflexes: • Superficial: (+) Gag and corneal reflex • Deep Tendon: (++) on all extremities • No Babinski, nuchal rigidity, Brudzinski, Kernig’s

12. Physical Examination

13. Physical Examination

14. Physical Examination

15. Physical Examination

16. Physical Examination

17. Initial Ancillary Tests

18. *Peripheral smear : Hypochromic with anisocytosis and poikilocytosis

21. Other Ancillary procedures: • Fecal occult blood test – (+) • ECG – Sinus rhythm with left ventricular hypertrophy • Urinalysis: albumin- negative, sugar – negative, RBC-0-2/hpf, Pus cell-1-4/hpf • X-ray of the foot – suggestive of osteomyelitis

22. SALIENT FEATURES

23. Clinical Impression: Chronic Tophaceous Gout w/ anemia and chronic kidney disease

24. Differential Diagnosis

25. Differential Diagnosis

26. Anemia due to: Hawkey CJ. Non-steroidal anti-inflammatory drug gastropathy: causes and treatment. Scand J Gastroenterol Suppl. 1996;220:124-7. CATHERINE S. SNIVELY, M.D.,et.al. Chronic Kidney Disease: Prevention and Treatment of Common Complications. Am Fam Physician. 2004 Nov 15;70(10):1921-1928.

27. Main Diagnosis Acute gouty arthritis on top of chronic tophaceous gout Ruptured tophi with secondary bacterial infection of the foot with osteomyelitis Anemia secondary to occult GI bleeding probably due to NSAID gastropathy Chronic kidney disease secondary to gout

28. Differential Diagnosis

29. Differential Diagnosis

30. Anemia due to: Hawkey CJ. Non-steroidal anti-inflammatory drug gastropathy: causes and treatment. Scand J Gastroenterol Suppl. 1996;220:124-7. CATHERINE S. SNIVELY, M.D.,et.al. Chronic Kidney Disease: Prevention and Treatment of Common Complications. Am Fam Physician. 2004 Nov 15;70(10):1921-1928.

31. Main Diagnosis Acute gouty arthritis on top of chronic tophaceous gout Ruptured tophi with secondary bacterial infection of the foot with osteomyelitis Anemia secondary to occult GI bleeding probably due to NSAID gastropathy Chronic kidney disease secondary to gout

32. Present Medications • Omeprazole 40 mg tab OD • Amlodipine 10 mg tab OD • Clindamycin 300 mg cap q 6 • Ciprofloxacin 250 mg tab BID • Given Colchicine as follows to treat acute gout: 2 tabs now then 1 tablet after 6 hours • Cold compress x 10-15 mins TID on inflamed joints

33. Pathophysiology of Gout

34. Gout • Metabolic or renal disease • Middle-aged to elderly men and postmenopausal women • Results from hyperuricemia • Characterized by episodes of inflammatory arthritis due to deposition of Monosodium urate (MSU) crystals in and around joints

35. Hyperuricemia • Serum urate concentration >6.8 mg/dl (men >7 mg/dl, women >6 mg/dl) • Causes • Increased urate production • Decreased uric acid excretion • Combination of the two

36. Purine metabolism

37. Uric acid elimination

38. Risk factors of Gout Group C1 • Obesity • Alcohol use • Family Hx • History of Kidney Disease • Diet • Others • Medications (low dose Aspirin, Pyrazinamide, Ethambutol) • Lead exposure • Hypertension • Diabetes • Hyperlipidemia • Arterioslcerosis

39. Pathogenesis of Hyperuricemia and Gout Group C1

40. Stages of Gout • Asymptomatic Hyperuricemia: • (-) symptoms, • uric acid levels are high and it needs to be taken care of so that the uric acid does not precipitate out of blood and then become crystallized in kidneys or the joints. • Acute gout or acute gouty arthritis: • Uric acid begins to crystallize and deposits in joint spaces • (+) pain and swelling

41. Intercritical gout: • attack of gout has subsided • no symptoms but it is because the body's immune system is stabilizing itself for more attacks on the uric acid crystals which form because of the high concentration of blood • chronic gout: • worst and most destructive stage of the disease • permanent damage to the joints • kidney damage

42. Complications:

43. Tophi: Join deformities Carpal tunnel syndrome (flexor tendons of hands and wrist) Compression of spinal cord and peripheral nerves

44. Gouty Nephropathy Severity correlates with the duration and magnitude of the elevation of the serum uric acid concentration presence of crystalline deposits of uric acid and monosodium urate salts in kidney parenchyma obstruction and inflammation to lymphocytic infiltration, foreign-body giant cell reaction,fibrosis

45. Nephrolithiasis In gout - urine pH is usually <5.4 In acidic urine, the protonated form of uric acid predominates and is soluble in urine only in concentrations of 100 mg/L. >100mg supersaturation stones

46. NSAID Gastropathy

47. NSAIDS Weak organic acids that inhibit biosynthesis of prostaglandins Anti-inflammatory, analgesic, antipyretic, antiplatelet effects Ex: Aspirin, Ibuprofen

49. Prostaglandin Regulate the release of mucosal bicarbonate and mucus Inhibit parietal cell secretion Important in maintaining mucosal blood flow Epithelial cell restitution