DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Joint pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with history of diabetes and history of methamphetamine-induced cardiomyopathy, who presented complaining of bilateral knee pain. The patient states that he has a history of gouty arthritis. He had been taking his allopurinol medication, but the pain had been worsened over the past several days. The patient states he has been bedridden secondary to pain. The patient denies fever or chills. He had no other complaint. The patient denies any fever. The patient states he is unable to walk secondary to the pain.
PAST MEDICAL HISTORY: Diabetes, history of methamphetamine-induced cardiomyopathy, diabetes, ulcer, and pacemaker placement.
MEDICATIONS: Please see nursing note.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Positive tobacco, occasional alcohol.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert, in no acute distress, nontoxic appearing, hemodynamically stable.
HEENT: Head is atraumatic and normocephalic. Pupils are equal, round, and reactive.
HEART: Regular rate.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, and nondistended.
EXTREMITIES: The patient moves all four extremities. He has tenderness to palpation of the knee, but there is no sign of joint effusion. No sign of septic arthritis bilaterally. He has good brisk capillary refill.
SKIN: No sign of bruising or ecchymosis.
ASSESSMENT:
1. Gouty arthritis.
2. History of methamphetamine abuse.
MEDICAL DECISION MAKING: The physical findings were discussed with the patient. Initially, the patient received Toradol 60 mg IM injection for pain control with some relief of his pain; however, the patient states he is unable to walk. The patient was then given two tablets of Vicodin, and basic labs initially included a CBC to rule out acute infectious disease. Hemoglobin, hematocrit, and platelets are normal, including his electrolytes. BUN was 58 with a creatinine of 2.0, which was mildly elevated compared to his level in the past. His sed rate was 104; however, his sed rate has always run in the level of around 100. The patient was given 1 mg Dilaudid for pain control after IV access was established. The patient was given ambulatory trial, which he was able to walk with the help of a walker. The plan at this time is to discharge the patient home. He was given a prescription of Vicodin for pain control. He was also given indomethacin for treatment of his gouty arthritis. Follow up with his primary care physician if any of worsening.
