46 y/o, male
C.C : admitted for resecting tophi of right elbow joint
The patient had history of (1)Chronic tophi gouty arthritis (2)Essential hypertension
for 4~5 years (3)hyperlipidemia. He had gout for 10+years without regular medication.
In his thirties, he had swelling and warmed right ankle and progressed to left ankle,
bilateral big toe, PIP of hand and knee. So he went to LMD for help. At LMD, the
gout was diagnosed and antigouty agents were prescripted. But he took medication
just while he had gouty pain. Because of the poor medication compliance, the tophi
developed and pain progressed. So he went to our OPD for help about 2 years ago
and Colchicine and Allopurinol were given. Pain was relievied and the tophi stopped
progression. He drank socially 20 bottles of Taiwan beer(20*375ml) and 3 bottles of
紹興(3*360ml) every night when he was in his twenties, but he quit 8 years ago.This
time, he came to for resecting the tophi of right elbow joint. The size about 5*5cm,
and skin had erythmatous change. In addition, he also complained of left heel pain
with radiating to left buttock area for 1 day. The left heel and buttock pain became
more aggressive while walking. He also complained of rhinorrhea, nasal congestion
and mild cough for 1 day, but he denied fever , joint swelling and pain. So admission
for surgical intervention was suggested.
Dr Buttrey’s rewrite:
CC: 46 y/o male admitted for resection of tophi
HPI: The patient has had chronic tophaceous gouty arthritis for 10+ years. In his thirties, he
had swelling and heat [and pain?] of the right ankle that then progressed to the left ankle, both
big toes, PIP of hand [exactly which joint(s)?] and [L or R?]knee. An LMD diagnosed gout and
antigout agents were prescribed. He took the medication only when he had acute attacks
[frequency of recurrent attacks?]. However, tophi developed [when?] and the pain progressed.
He was first seen at our OPD about 2 years ago and was found to have [PE findings at that
time?]. Colchicine and allopurinol were prescribed, which relieved the pain and stopped
progression of the tophi. He drank 20 bottles of Taiwan beer (20 x 375ml) and 3 bottles of 紹
興(3 x 360ml) every night when he was in his twenties, but he quit 8 years ago. He also has a
history of essential HTN diagnosed 4 or 5 years ago and hyperlipidemia (see PMH) [TG and/or
cholesterol?]. He was admitted this time for resection of a tophus of the right elbow joint
[reason for resection?]. In addition, he also complained of left heel pain radiating to the left
buttock for 1 day, exacerbated by walking [Recent back injury? Numbness or weakness of L
foot?]. He denies recent joint swelling or pain, or fever.
Missing data: Exact description of the pain—in acute gout, the pain is usually intense. Exact
joints involved in toes, fingers, which knee, etc. Over what period of time did it progress to all
these joints? How was the initial diagnosis of gout made? How frequently did his recurrent
attacks occur and what joints were usually involved? What was the extent of the tophi when
he first presented to our OPD? Did his hyperlipidemia involve TG or cholesterol? What has his
serum uric acid usually been in our OPD? Was there any change in the frequency or severity
of the gout when he stopped drinking? Why does the tophus of the R elbow require resection?
Is it interfering with joint mobility, causing skin erosion, etc? Who described the size and
erythema? (I deleted that information because I thought it was your PE, but if it was either the
patient himself or an OPD note, add it back in, but be sure to state who described it that way.)
Did the L lower extremity pain definitely begin in the heel or might it have begun in the buttock
and radiated to the foot?
Comments
Content:
This history is quite clear in terms of the basic illness, chronic tophaceous gout. The reason for asking
for further details of the earlier attacks is not because it would change the diagnosis in this case but
because it’s important to understand the natural history of gout and inquire carefully about the nature of
the pain, joints involved, frequency, etc. in every patient in whom you suspect gout. (A diagnosis of
gout should not be made just on the basis of hyperuricemia + a painful joint.) A clear description of his
physical findings when he first presented to our OPD would serve as a good baseline for comparison
with the present findings. (Unfortunately, there’s rarely time in the OPD for careful PE and recording of
exact findings.)
HTN is associated with gout, although the exact nature of the interaction between hyperuricemia isn’t
clear. Hypertriglyceridemia (but not increased cholesterol) is also common in patients with gout. These
other problems should be noted because of the association with gout, but they should not be written at
the beginning of the HPI. (They both require clear descriptions in the PMH. How are they being treated?
Degree of control? Complications?) The amount of alcohol ingested is well recorded! “Socially” is
somewhat irrelevant. It isn’t a measure of alcohol consumption.
Be careful about attributing complications to poor compliance when recording the history. This is an
important interpretation of what the patient says. However, it’s not always the patient’s fault. Again, it’s
important to understand the natural history of the disease. Not all patients with acute gouty arthritis go
on to develop chronic gout. We need to know more about the instructions he was given about how to
take the medicine, how frequent his attacks were, etc. It may well be that, had he taken medicine
regularly, he would not have developed tophi. But the information given in the history is inadequate to
make such a judgment. Simply state that he only took the medicine with acute attacks.
What is it about the R elbow tophus that makes surgical resection necessary? We need to understand the
indications for surgical resection in such a case, both to make sure the patient really has those
indications and also so that we will be alert for other such patients in our practice who might benefit
from resection.
The L leg pain needs further description. It’s unusual (but not impossible) for pain to begin in the foot
and radiate up to the buttock. But is it possible that this in fact represents sciatic pain and is actually
radiating down the leg? In that case, we need to consider other causes for the problem and also evaluate
(by history and by PE) for the presence of neurologic deficits in the distribution of the sciatic nerve.
I don’t think the upper respiratory symptoms are relevant to this HPI (unless they might affect the
timing of surgery). They should be noted in the ROS and problem list.
English:
warmed right ankle: “had a hot R ankle” or “R ankle was warm.”
prescripted: Even though the noun is “prescription,” the correct verb is “prescribe.” There is no verb
“prescript” in the English language. (There is a noun in that form, but it has a different meaning.)
tophi stopped progression: The correct grammar would be “tophi stopped progressing.” I would state
it differently, as I did in my rewrite.
for resecting the tophi: “for resection of the tophus.” I assume there is only one tophus to be resected.
“Tophus” is singular, “tophi” is plural. (This is Latin, not English!)
skin had erythematous change: “skin was erythematous.” When stating pathological appearances,
you don’t usually need to add the word “change.” Your description does indicate a change from normal,
but we assume that without using the word change.
left heel pain with radiating to left buttock area: “left heel pain radiating to the left buttock” or “left
heel pain with radiation to the left buttock.” Area is an unnecessary word.
the pain became more aggressive: We say “ the pain was exacerbated” or “the pain became more
severe.”