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

7 years PTA

Few months later

(+) pustules and papules on his face that later coalesced to form erythematous plaques topped with scalesConsult :UST Dermatology OPD Punch biopsy Assessment: Psoriasis Medications:

Methotrexate Dermovate with Petroleum JellyLCDPUVA therapy

patient noted white scales on his scalp

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 stairsRelieved by rest or sitting downNo consult doneSelf-medicated with Naproxen

1 year PTA

History of Present Illness

(+) swelling of both knees increasing severity of the painNo consult was done

1 month PTA

1 week PTA (+) pain in the hips extending down to anklesmore difficulty in ambulating

Consult: Orthopedic SurgeonAssessment: excess fluid in his knee joints Offered arthrocentesis but refused

5 days PTA

History of Present Illness

(+) fever (undocumented)Self-medicated with Paracetamol

4 days PTA

3 days PTA Persistence of pain and fever Consult: FEU Hospitalx-ray of left leg: soft tissue swellingAdvised admission but refusedReferred to our institution

ADMISSION

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

Past Medical History

• (-) Diabetes Mellitus• (-) HPN• (-) Allergy• (-) Asthma• (-) History of trauma• (-) Joint surgery

Family History

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

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

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

Physical Examination

• Adynamic precordium, 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

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 nuchal rigidity

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

Assessment

Psoriatic Arthritisr/o Septic Arthritis

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

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

Thank You