my notes for 10 minutes ))) History : 26 yof c/o on L knee pain for 2 dasy ehich is not relieved by tylenol, pain is 7?10 in severity, decreased motion in this joint; fever ( ) hs of inflammed big toe, sometimes pain in joint on her wrist and fingers, fatigue, loss of energy,(-) for headache, mouth ulcer, recent camping, diarrhea, constipation abdominal, cheat pain.\ROS:(-) except all abovePMH: gonorhea (1 Y ago treted with a/b)Allergy: noneMeds; tylenolOb/gym G@ P@ c-section; LMP 2 ws ago, normal flow, regularSH: works as waitress, Smoke 1 ppd -15 ys; drink 2-3 beers during the week and binge drinking on weekends (CAGE_0/4)FH: ( ) for RA at mother Physical Examination : PR is in no acute distress but on moderate painExtremities: rred ,swollen L knee, warmth, decreased all motion in L knee; other joints normal in full range of motion not painful; normal snsatin to pinprick Head: 9-0lymphadenopathyChest: normal breathing in both lu DATA INTERPRETATION: Diagnosis 1 : RA History Finding(s) : 1.pain in L knee 2.fatigue 3.pain in wrist joints Physical Exam Finding(s) : 1.swelling, redness in L knee 2.decreased motion in L kneee 3. Diagnosis 2 : septic artritis History Finding(s) : 1.pain in L knee 2. 3. Physical Exam Finding(s) : 1.swelling, redness in L knee 2.decreased motion in L kneee 3. Diagnosis 3 : GOUT History Finding(s) : 1.pain in L knee 2. hs of inflammed of big toe 3.binge drinker Physical Exam Finding(s) : 1.swelling, redness in L knee 2.decreased motion in L kneee 3. Diagnostic Study/Studies : 1.CBC with count 2.arthrocenresis with culture 3. pelvic exam 4.uric acid level 5.RA factor 6.HIV a/b
Posted on: Mon, 05 Aug 2013 17:11:17 +0000
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