Audio_Rheu_Hp_19

CONSULTATION NOTE

HISTORY: This is a pleasant 42-year-old African-American male with no past medical history, referred for possible gout. He has a history of Podagra in the right MTP as well as the left MTP in the past. He has also had episodes of pain and swelling in the left knee, which resolved after treating with colchicine and NSAIDs. He denies any history of renal insufficiency. He does admit to alcohol use, having few beers twice a week. He does also have a family history of gout. He denies any history of uric acid kidney stones. He has not had x-rays of the feet. Currently, he does not complain of any joint pain or swelling.

PAST MEDICAL HISTORY: None.

MEDICATIONS: None.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: History of ETOH use, denies smoking.

FAMILY HISTORY: Mother with gout.

PHYSICAL EXAMINATION:
Vital Signs: On exam, his blood pressure is 122/72 mm Hg. He is a well-developed male in no apparent distress.
HEENT: Throat is clear. There are no tophi in the ears. There is no lymphadenopathy.
Lungs: Clear to auscultation bilaterally.
Heart: Normal S1, S2.
Extremities x 4: There are no tophi. No evidence of synovitis or rashes.

LABORATORY DATA: Uric acid equals 8.0.

ASSESSMENT: This is a 44-year-old male with probable gout.

PLAN:
1. At this time, I have given him a prescription for colchicine and Indocin only to take during an acute flare. He is also going to call me during an acute flare so that we may see him and possible aspirate synovial fluid to confirm the diagnosis of gout.
2. I have recommended that he get x-rays of bilateral feet to see if there is any evidence of erosive disease. If erosions are present, he would likely be a candidate for allopurinol therapy.
3. I have also instructed him to maintain a low-purine diet and to avoid alcohol.
4. He is to followup with me in three months or sooner if he is to have an acute gouty flare.