COMPREHENSIVE CLINICAL WRITEUP
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Clinical Write-up: Comprehensive Health History II
Advanced Health Assessment and Measurement Course
Roshan Jan Muhammad
The Johns Hopkins University School of Nursing
“On my honor, I pledge that I have neither given or nor received any unauthorized assistance on
this assignment”. RJM
COMPREHENSIVE CLINICAL WRITEUP
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Comprehensive Health History
BIOGRAPHIC DATA
Name: JR
Date of Birth/Age: Dec 6th, 1928
Date of visit: 6th Nov, 2012 (1300) was in ER till 7th Nov
History Number: One
Gender: Male
Birthplace: USA
Social Security Number: 000-01-1111
Address: Baltimore
Home phone: 410-002-9898
Employer: Retired Navy officer
Religion: Christian
Marital Status: Married
Insurance (name and #): Medicare
Primary Clinician: YR
Date of Last Visit: One month ago
SOURCE/RELIABILITY: Patient, who is reliable.
CHIEF COMPLAINT: Patient is presented with the complaint of “knee pain”.
HISTORY OF PRESENT ILLNESS:
Patient arrived in ER at 1300, with the complaint of non-traumatic origin of throbbing
pain in rt knee for 3 days. The intensity of pain gradually increased to 9/10 over 3 days, it
radiates to the foot, is aggravated while weight bearing and flexion of the limb, and is associated
with heavy feeling of the limb, swelling, and restricted motion of rt knee, took Tylenol 2 tablets
twice a day for 3 days but did not significantly relieve the pain and is now seriously affecting his
walking ability. Uses cane to walk. Had similar type of pain in Oct 2011 as well, which
improved after colchanice. Denies joint stiffness, tingling, numbness, clumsiness, weakness,
crepitation, bone deformity, cyanosis, pallor, hypothermia/hyperthermia, decreased sensation,
ulceration, edema, calf tenderness, varicosities, and abnormal pigmentation. Pain at the time of
assessment was 2/10 after administration of cap acetaminophen 650 mg, oxycodone 5 mg PO,
and prednisolone 40 mg PO OD. Knee x-ray (Dec 6th, 2012) reveals joint effusion with anterior
displacement of patella (ballotable).
PAST MEDICAL HISTORY
General health: According to patient he had a very healthy life upto age of 60 and despite
current medical ailments he considers himself in a good state for his age.
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Childhood illnesses: Patient had measles and pertussis in his childhood. Age and course of
illness could not be recalled. (-) chickenpox, mumps, rheumatic fever, otitis media, sinusitis,
tonsillitis, asthma, congenital conditions.
Adult Medical illnesses and hospitalizations: Known case of HTN since 15 years, Gout
(diagnosed in Oct 2011). Was hospitalized for coronary artery bypass grafting (CABG) in
(1995). Prostat Ca was diagnosed in (1987), he was admitted then to receive radiation and
Lupron, is in remission ever since, PSA and testicular exam done in April 2012 which is normal
as per patient (official report not available). Patient had also been hospitalized for non-traumatic
severe epistaxis x 1, dehydration x 2 , GI bleed x1, urinary tract infection x1, appendectomy.
Data gap (year and course of treatment). Reports intermittent breathing problem for last 3 years
with wheeze and dry cough but denies asthma, COPD or bronchitis (Refer respiratory system
review of system for details). Denies diabetes, tuberculosis and hepatitis.
Immunization: Childhood immunization status is not known. Had Influenza shot last week,
pneumococcal pneumonia (2011), denies any reaction to the immunization. Had several
vaccination during navy service but do not know the names. (-) Hep A & B, varicella,
meningococcal meningitis, herpes zoster, cholera, typhus, typhoid.
Psychiatric illnesses: (-) for depression, anxiety, attention/hyperactivity disorder, schizophrenia
and suicide attempt, has never received any related emergent treatment or psychotherapy.
Medications
Patient is on following prescribed medications.
 Metoprolol, Norvasc, cozar for HTN, compliance is inconsistent. (data gap) year of start
and dose.
 Aspirin 81 mg OD was started post CABG, takes it regularly.
 Protonix PRN. (Data gap) dose.
 Combivent (INH) and albuterol (INH) was prescribed 3 years back when he had acute
breathing problem. He was prescribed to take it routinely, but he only takes in case of
acute wheeze and breathing problem. (Data gap) dose.
 Procit shot once a week for anemia. Takes is regularly.
 Colchicine was started last year with onset of joint pain but he does not take it regularly.
(Data gap) dose.
Allergies: No known allergies to medications, chemicals, environmental factors and food.
Transfusion: Received blood product during CABG, type of product not known. (-) transfusion
reaction.
Health maintenance screening:
Hb (see lab results section), lipid profile, testicular exam and PSA done in April 2012;
colonoscopy (2010); dental and ear exam (data gap, year); eye exam (2010). (Data gap) official
results are not available. (-) HIV, Chlamydia, Syphilis, Gonorrhea, PPD.
FAMILY HISTORY
Mother had diabetes and his brother has HTH and had a stroke He does not know the
cause of death of his parents and most of the family members. Family history (-) asthma;
allergies; tuberculosis; hepatitis; kidney or respiratory diseases; blood dyscrasias;
rheumatologic, or autoimmune illnesses; thyroid problem; cancer; addiction; violence.
PERSONAL/SOCIAL HISTORY
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Cultural and family constellation: Was born and raised in Baltimore. He is eldest among 4
siblings. Is married, has 2 sons and three daughters, all healthy and alive, live outside Baltimore.
He lives with her wife in Baltimore. Reports satisfied relationship with her family. (Data gap)
(hobbies, interest, proscriptions concerning medical care).
Education and occupation: Worked in navy service for 30 years, is now retired for last 28 years.
(-) exposure to infectious diseases and industrial toxins in recent years.
Economic condition and Environment: He is financially dependent on his children and on
Medicare benefit. Lives with his wife in his own house in Baltimore. House is equipped with
smoke detectors and has fluoridated water source.
Stress and Abuse: Reports that navy service was stressful but current abuse screen is negative.
Does not report major stressors in life at present that is beyond his ability to manage. (Data gap)
coping strategies.
Travel history: Negative travel history in last 10 years.
CURRENT HEALTH HABITS AND RISKS FACTORS
Exercise/activity: Stays home most of the time, does not exercise but goes for a walk every day
for 30-45 minutes accompanied by his friend or a wife, with an exception when he has acute
joint pain. Cannot do brisk walk, uses cane and takes at least 1-2 breaks in between due to
fatigue. Seldom develops shortness of breath that is relieved with 2 puffs of albuterol.
Diet/nutrition: Negative eating disorder screening. Reports good appetite; and denies recent
weight changes, use of supplementary pills and is not on restricted diet. (Data gap) dietary intake
for last 24 to 48 hours and typical fluid consumption.
Sleep: Easily falls into sleep and takes 6-7 hours and takes 1hour afternoon nap. Pain never
interfered with sleeping until last 3 days.
Substance Abuse: Occasionally drinks beer that is less than a glass with seafood only. Smoked
cigarette for 40 years (1-2 packs per week), quit in 1987 after diagnosis of prostat cancer. (Data
gap) coffee use.
Safety measures: Uses cane and glasses. (Data gap) seatbelts, and other safety measures based
on sensory impairment.
Typical day: (Data gap) usual daily activities.
REVIEW OF SYSTEMS (ROS)
General constitutional symptoms: (-) fever, chills, malaise, fatigability (other than while daily
walk), weakness or night sweats.
Diet: Appetite good. (-) anorexia, hyporexia, hyperexia.
Skin, hair and nails: Takes bath every 2 days and maintains good hygiene of hair and nails. (-)
rash, itching, pigmentation, cyanosis, abnormal hair or nail growth or loss (other than age
related)
Head and neck: (-) headache, dizziness, syncope, head trauma, period of loss of consciousness.
Eyes: Reports blurred vision bilateral (more in rt eyes) for 6 years to the extend that he cannot
read or recognize features of individuals, uses glasses but is not helpful for lt eye in particular. (-)
diplopia, photophobia, pain, discharge, floaters, strabismus, glaucoma, history of trauma or eye
infection. Data gap (date and report of eye exam)
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Ears: Reports slightly diminished hearing in both ears for 5years but does not use any hearing
aids. (-) pain, discharge, vertigo, tinnitus. (Data gap) hearing test and results.
Nose (-) sense of smell, frequency of colds, obstruction, congestion, epistaxis, post nasal
discharge, sinus pain and snoring.
Throat and mouth: wears removable upper and lower jaw dentures, cleans it daily. Denies
frequent sore throat, hoarseness or change in voice; halitosis, bleeding or swelling of gums;
soreness of tongue of buccal mucosa, ulcer, disturbance of taste.
Endocrine: (-) thyroid enlargement or tenderness; heat or cold intolerance; unexplained weight
change; lethargy; polydipsia or polyuria, changes in facial or body hair, increased glove size or
skin striae.
Chest and Lung: Reports sporadic onset of breathing difficulty that is usually provoked by
exertion while walking and is associated with dry cough and wheezing and is relieved with
albuterol inhaler (2 puffs) and rest.(-) pleurisy, hiccups, exposure to TB. Chest x-ray, PFT done
few years back (report not available)
Heart: (-) chest pain or distress, palpitations, orthopnea at rest or exertion. CABG details, ECG,
ECHO, blood cholesterol and other lab report findings are not available.
Peripheral vascular: Refer HPI.
Hematologic: Reports to have low hemoglobin for a long time. Denies tendency to bruise or
bleed easily, thromboses, thrombophlebitis.
Lymph nodes: Denies palpable nodular swelling of glands at any part of the body.
Gastrointestinal: Passes normal stool every 1-2 days. Reports infrequent sporadic heart burn that
usually relieves with Protonix. Denies dysphagia, odynophagia, reflux, nausea, vomiting,
hematemesis, melena, constipation, diarrhea, jaundice, dark urine, abdominal fullness,
distension, swelling and pain. (Data gap) hemorrhoids. Colonoscopy report not available, no
other GI related studies performed.
Urinary: Denies dysuria, flanks or suprapubic pain, urgency, frequency, nocturia, hematuria,
polyuria, hesitancy, dribbling, passage of stone, edema of face, incontinence, hernia. (Data gap)
loss in force of stream.
Male GU: Denies STI and pain in scrotum or testes. (Data gap) age @ puberty; sexual function/
sexual orientation; penis: circumcised; adhesions, lesions, ulcerations, discharge from penis;
pain, edema, rashes, emissions; ejaculation painful/incapacity. Number of lifetime partners.
Musculoskeletal: Refer HPI.
Neurologic: Reports forgetfulness (senile). (-) syncope, seizures, weakness, paralysis, loss of
sphincter control, abnormalities of sensation or coordination, tremors, behavior change.
Psychiatric: Reports difficulty in concentrating. (-) mood changes, sadness, nervousness,
tension, irritability, change in social interactions or personality, depression/mania,
suicidal/homicidal thoughts.
PHYSICIAL EXAMINATION
Vital signs: Temperature 35.8C; Pulse 63/min; Respiration 18/min; Blood pressure trend in the
ER was systolic blood pressure (206-180), diastolic blood pressure (81-69), last blood pressure
in supine position 180/69 post hydralazine 50mg OD in ER; O2 saturation 98% on room air.
Growth and measurement: (Data gap) Height, weight and BMI. However, inspection does not
reveal truncal or abdominal obesity or muscle wasting.
General survey: 84 years old African American male, lying comfortably on bed without any
distress.
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Skin: Skin is smooth, dry (particularly in lower limb), warm to touch, no signs of central or
peripheral cyanosis, turgor normal. Onychogryphotic nails of lower extremities. Upper
extremities have thick pale nails with irregular surface but no clubbing. (-) capillary refill,
excessive perspiration.
Head: Normocephalic head, facial expressions relaxed and symmetrical. Scalp clean; black and
grey, hair with male pattern baldness. (-) edema or puffiness.
Ears: Whisper negative in rt ear, could hear me ok otherwise in both ears. Ears normally
aligned. (Data gap) weber and rinne’s test, assessment of ear cannal, tympanic membrane and
other landmarks deferred because of nonfunctional otoscope at bedside.
Eyes: Eye brows symmetrical, mild bilateral ptosis, conjunctiva pink and moist, sclera white, has
bilateral senile arcus, extraoccular movement smooth in all direction except nystagmus during
extreme lateral movement. Pupils rt 3.0 lt 4.0, round and reactive to light and accommodation,
corneal reflex positive. (-) orbital edema, crusting, discharge from eyes. Peripheral vision loss
both sides. (Data gap) visual acuity, visual field, cover uncover test. Fundoscopic and retinal
examination deferred because of non functional opthalmoscope.
Nose: Septum midline, no discharge or flaring, maxillary or frontal sinus tenderness, nostril
patent. (Data gap) turbinate examination deferred because equipment at bed side not working.
Mouth and throat: Tongue, gums, oral and buccal mucosa moist, clean and light pick in color.
Posterior hard palate has painless, white, linear oral thrush measuring 1x 0.25 inches, rest of the
palate was pale. Posterior pharynx light pink, tonsils grade 1 bilateral, uvula rises on phonation,
tonsils grade I (-) erythema, petechiae, exudate.
Neck: Neck supple, trachea centered, thyroid non-palpable, carotid artery +2 bilateral.
Chest: Anterior posterior to transverse diameter is 1:2. Breathing regularly and comfortably at
rate of 18 breaths/min without using accessory muscles. Thoracic expansion and tactile fremitus
equal bilateral had resonance all over lung field. Breath sounds equal bilateral, bronchial sound
over trachea, bronchovesicular sound between 2nd and 3rd ICS, vesicular sound on rest of the
lung field, mild expiratory wheeze in rt lower lobe. (-) friction rub. (Data gap) diaphragmatic
excursion. Voice sounds not indicated.
Heart: Regular sinus rhythm (63/min); PMI, around 1 cm at 5th ICS mid clavicular line. No
abnormal pulsation, thrills, heaves or lift. S1 and S2 heard in all precordial areas. S2 louder in
aortic and pulmonic area, S1 louder in tricuspid and bicuspid area. No split sound, murmurs,
clicks, snaps, S3 and S4 gallop heard.
Blood vessels:. JVP 2cm at approximately 30 head of bed. Temporal, posterior tibial and
dorsalis pedis (+1 bliteral), radial and brachial pulse (+2 bilateral), femoral (+2 bilateral). Grade I
pitting edema on rt foot and swelling on rt knee. (-) venous distension or tenderness in lower
extremities, bruit over temporal or carotid artery. (Data gap) popliteal pulse.
Abdomen: Round, symmetrical abdomen, umbilicus centered, no abnormal pulsation, peristalsis
or bulges. Gurgling bowel sounds +ve in all 4 quadrants no bruit over renal, iliac and femoral
artery. Tympany heard over stomach, dullness on liver. Abdomen soft on palpation, spleen and
kidneys non-palpable. Liver span 6 cm at mid clavicular line. (-) guarding, direct or indirect
rebound tenderness. Femoral lymph nodes non-palpable, no CVA tenderness.
Genitalia, anus and rectum: Examination deferred.
Lymphatic: (-) lt femoral, inguinal, occipital, pre auricular, post auricular, superficial, anterior
and posterior cervical, tonsillar, parotid, submental, submandibular, supraclavicular and
epitrochlear nodes. (Data gap) axillary nodes.
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Musculoskeletal: Body parts normally alignment, muscle mass symmetrical, tone normal and
equal bilateral. Rt knee is swollen, warm and tender to touch with restricted knee flexion upto
120 and strength 3/5. Knee circumference rt 17.5 inches lt 16 inches. (-) deformity and crepitus
over joints; unrestricted and pain free active ROM of neck, upper and lower extremities (except
rt knee joint) against gravity and full resistance, strength 5/5.
Neurological: Oriented to time, place and person (GCS 15/15), coherent mood and affect,
speech fluent and clear, good comprehension and appropriate judgment.
Light touch, pain, point localization equal bilateral. Thumb to finger and finger to nose
movement was sluggish but to the point. Cranial nerve (CN) III, IV, V, VI (refer eyes section).
Cranial nerve VII, IX, X, XI, XII intact. CN XIII (refer ear exam). Biceps, triceps reflex,
brachioradialis and Achilles reflex +1 bilateral; planter reflex normal. (Data gap) vibration,
position sense, two point discrimination patella reflex, rennies and weber’s test, CN I and II, gait
and balance, graphesthesia, stereognosis, extinction.
LAB TEST
Lab test
WBC
RBC
HB/HCT
MCV
MCHC
RDW
PLT
Neutrophils %
Lymphocyte %
Monocyte %
Basophil %
Eosinophil %
Absolute Neutrophil
count
Monocytes
Lymphocyte
Eosinophil
Nov 6th, 2012
7970
2.94 (Low)
8.7/27.5 (Low)
93.5
31.6
20.5 (High)
203
51.7%
23.6 (Low)
23.2 (High)
0.1
1.1
4120
Lab test
Na
K
CL
CO2
Urea
Cr
Glucose
Ca
Mg
CRP
ESR
Lab test
Uric acid
Nov 6th, 2012
142
4.2
108
20
17
1.2
120 (High)
8.0 (Low)
1.2 (Low)
8.2 (High)
123 (High)
Feb, 2012
7.0 mg/dl (High)
1850 (High)
1880
90 (Low)
DIAGNOSIS/PROBLEM LIST
Potential problems from chief complain
Based on clinical presentation and history, following are the differentials diagnosis for this
patient.
1.
Crystal arthritis (Gout)
According to Burrows et al (2012) hot swollen knee with acute non-traumatic knee effusion
is common manifestation of crystal arthritis. It is an acute inflammation due to
crystallization in the joint, and is associated with erythematous, warm, tender, swollen joint.
Even minimal range of motion is exquisitely painful. It also involves fever, malaise,
COMPREHENSIVE CLINICAL WRITEUP
2.
3.
4.
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elevated WBC, CRP and other inflammatory reactants. And is usually common in patients
with gout.
Osteoarthritis
According to Calmbach (2007), osteoarthritis is non-inflammatory condition in which
patient presents with knee pain and swelling that is aggravated by weight-bearing activities
and relieved by rest. The patient has no systemic symptoms but usually awakens with
morning stiffness that dissipates somewhat with activity. In addition to chronic joint
stiffness and pain, the patient may report episodes of acute synovitis and effusion.
Subcutaneous Prepatellar Bursitis
Aoron, (2011) and Allen (2012) reports that pre patellar bursitis is one of the causes of knee
pain. It is the inflammation of subcutaneous prepatellar bursa and the superficial
infrapatellar bursa that is manifested as knee swelling and pain, erythema, warmth, local
tenderness to palpation, pain with flexion, crepitation and bursal effusion. Pain is usually
relieved with rest. The etiologies mainly include inoculation of organism, particularly
staphylococcus and streptococcus species; and due to noninfectious etiologies like trauma,
repeated motion of joint, gout.
Septic arthritis (infectious arthritis or bacterial arthritis)
PubMed Health (2011) defines it as an inflammation of a joint that's caused by infection that
is spread from another areas of the body or wound. Typically, septic arthritis affects one
large joint in the body, such as the knee or hip. It is presented with chills fatigue and
generalized weakness, fever, inability to move the limb with the infected joint, severe pain
in the affected joint, especially with movement, swelling (increased fluid within the joint),
warmth (the joint is red and warm to touch because of increased blood flow.
COMPREHENSIVE CLINICAL WRITEUP
Differential
Crystal arthritis (Gout
arthritis)
Supporting evidence
 Hot, swollen knee
 Knee pain that worsens
with movement
 Elevated CRP , ESR
 High serum uric acid
 Knee effusion
 Patient is known case of
gout
Osteoarthritis (noninflammatory arthritis)



Knee pain
Swelling
Joint effusion
Pre patellar bursitis




Knee swelling
Pain and local tenderness
Warmth
Pain with flexion
Septic arthritis

Severe pain in joint,
especially with movement
Swelling
Warmth
Effusion



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Negating evidence
 Malaise
 Fever
 Erythema
 Patient’s pain was same
throughout the day unlike
osteoarthritis pain that is
worse in the morning.
 Elevated CRP and ESR
does not support this
diagnose because
osteoarthritis is noninflammatory condition.
 Patient did not have joint
stiffness.
 Patients’ pain worsens with
activity whereas,
osteoarthritis pain
dissipates with activity.
 Negative history of
repetitive motion or
kneeling, trauma.
 Erythema
 Crepitation
 Pain did not relieved with
rest
 Bursal effusion
 Chills
 Fatigue and generalized
weakness
 Fever
PLAN
Diagnostic studies:
Synovial fluid aspirate and analysis
Burrows (2012) reports that as per orthopedic association guidelines, synovial aspirate does not
only help diagnosis in patient with knee pain but it also reduces the pain caused by joint
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swelling. According to Courtney (2009) identification of monosodium urate (MSU) crystals in
synovial fluid or in an aspirate of a tophus is considered the gold standard for definitive
diagnosis of crystal (gout) arthritis. According to ClinLab, following are the key findings
pertinent to different types of effusion to guide the diagnosis.
Test
Non inflammatory
Septic arthritis
Crystal arthritis
(Osteoarthritis)
(Gout)
Color
Yellow
Gray-green
Yellow-milky
WBC
0-2000
50,000-200,000
50-10,000
Crystal
Absent
Absent
Present
Culture
Sterile
Positive
Sterile
Uric acid levels
According to ClinLab, elevated serum urate level > 6.8mg/dl is associated with gouty arthritis. In
lieu of patient’s inconsistent compliance to colchicine, I would like to repeat the uric acid level
as the last level was done in Feb 2012.
Treatment:
Following treatment regimen is proposed on the basis of strong clinical presumption of gout
arthritis. However, if synovial fluid analysis results and serum uric acid level redirects the
medical attention to any other differential diagnoses listed above, treatment plan would be
modified accordingly.
Acute management
 According to Gonzalez (2012), during the acute attack, nonsteroidal anti-inflammatory
drugs (NSAIDs) and colchicine are considered as first-line treatment for relief of acute
pain. Among the NSAIDs, indomethacin and naproxen (1,000–1,500 mg/day) have been
approved for acute gouty arthritis. However, considering the gastroenterological effects
(bleeding) of NSAIDs and the risk of renal dysfunction in elderly, Gonzalez (2012)
proposes that that the use of nonselective NSAIDs in patients over the age of 65 years be
avoided. Thus, colchicine would be prescribed to the patient with dose ranging from 1.8
mg to 4.8 mg/24hours in divided doses every 6 hourly.
 He also suggests that systemic corticosteroid (eg., prednisolone) is a treatment option for
patients who have contraindications to NSAIDs and colchicine. Initial dose of 50–60
mg/day is advised which can be readjusted later to maintain satisfactory response.
 Intraarticular injection of a long acting steroid is another potential therapeutic approach
that may be effective at alleviating pain associated with an acute monoarticular attack.
Chronic management
Long term management is also critical in these patients to prevent the reoccurrence of acute
symptoms. Allopurinol, probenecid or febuxostat have been recommended for chronic gouty
arthritis. Allopurinol, a xanthine oxidase inhibitor acts by blocking the production of uric acid
through a reduction in purine catabolism. (Gonzalvez, 2012)
Patient education
 Patient would be educated to reduce the intake of foods that are high in purine, such as
animal products, which helps control your body's production of uric acid. Fluid intake
would be also encouraged to help flush uric acid from your body (Mayoclinic).
 Patient education would also include the effects, purpose and side effects of the
medications and the procedure “synovial fluid aspirate”.
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Follow-up:
The patient would be kept in ER till the synovial fluid analysis and serum uric acid results are
back and patient’s acute pain is settled. Thereafter, patient would be discharged on the treatment
plan listed above. Follow up with primary doctor would only be needed if symptoms aggravate
to affect other joints, pain is refractory to the prescribed regimen, quality of life is affected due to
pain or restricted joint movement, and/or patient develops adverse effects to the treatment.
However, patient would be advised to see the primary physician as soon as possible for his blood
pressure concern.
Problems from preexisting medical conditions and signs and symptoms
 Uncontrolled systolic HTN (Unresolved)
 Hyperglycemia (Unresolved)
 Dyspnea and wheeze
 Vision and hearing impairment (Unresolved)
 Anemia (Unresolved)
 Electrolyte imbalance (hypomagnesemia). Treated in ER
 Oral thrush (Unresolved)
 Follow up for prostat (On going )
Reference
Aaron, D.L., Patel, A., Kayiaros, S.,& Ryan Calfee, R. (2011). Four Common Types of
Bursitis:Diagnosis and Management. Journal of the American Academy of Orthopaedic
Surgeons, Vol 19 (6),pp. 359-367
Allen, K.L. (2012). Prepatellar Bursitis Clinical Presentation. Retrieved from
http://emedicine.medscape.com/article/309014-clinical#a0217
Burrow, V., Murray, J.R., Smitham, P., et. Al (2012). Are we managing acute knee effusion
well? British Journal of Medical Practitioners, vol 5(1).
Calmbach, W. L.,& Hutchens, M. (2007). Evaluation of Patients Presenting with Knee Pain: Part
II. Differential Diagnosis. American Family Physician, 68(5), pp 917-922.
Courtney, P.,& Doherty, M. (2009). Joint aspiration and injection and synovial fluid analysis.
Best Practice & Research Clinical Rheumatology , 23, 161–192
ClinLab Navigator. Test interpretation. Retrieved from: http://www.clinlabnavigator.com/testInterpretations.html.
Gonzalez, E. (2012). An update on the pathology and clinical management
of gouty arthritis. Clinical Rheumatol, vol 31:13–21, DOI 10.1007/s10067-011-1877-0
COMPREHENSIVE CLINICAL WRITEUP
Mayoclinic. Gout diet. What’s allowed and what is not?. Retrieved from
http://www.mayoclinic.com/health/gout-diet/MY01137
PubMed health. (2011). Septic arthritis. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001466/
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