Level 4 Visit
A 62-year-old male patient returns to the office for a follow-up visit for gout in his left foot. The patient’s present uric acid level is at 4.0. He is now taking allopurinol 450 mg per day. He was taken off indapamide because it was increasing his uric acid. His left foot has pain on a severity level of 6 out of 10 and some swelling. There is mild tenderness to the left ankle and foot. He is taking only colchicine, with acute flare attacks. The patient is now on a low-purine diet and is under treatment for squamous cell cancer on his nose. He has a tattoo on his right arm. He will not receive chemotherapy until September of this year. He still takes gabapentin for facial neuropathy.
Past Family History
Father deceased, but also had gout.
Pt has squamous cell cancer.
Systems Review
Constitutional: Negative for chills, pallor, fatigue, fever, weight gain/loss
Neurologic: Negative for weakness
Endo: Negative for malaise, night sweats
Respiratory: Negative for cough, dyspnea, chest pain (respiratory), wheezing
Gastrointestinal: Negative for anorexia, nausea, emesis, hematemesis, diarrhea, constipation, melena, abdominal pain, dysphagia, reflux, indigestion/heartburn
Musculoskeletal: Negative for rheumatologic manifestations, back pain, myalgias. Positive for joint and bone symptoms—left ankle pain, c/o swelling, severity mild
Physical Exam General/Constitutional: Vital signs—BP Systolic 122, BP Diastolic 80, Weight LB 216.00, Temp F 97.2, pain score 6/10. Well nourished, well developed
Respiratory: Chest symmetric, lungs clear to auscultation, no cough
Psych: Patient’s mood is good, no acute distress
Musculoskeletal: Left ankle is positive for swelling, decreased ROM. Left foot has mild swelling, some pain, mildly reduced ROM. There are zero tender joints. There is one swollen joint. No tenderness or warmth. Patient cannot bear full weight without pain.
Medical Decision Making
Radiologic Procedures: Reviewed left foot X-ray heel spur, soft tissue swelling from prior visit
Laboratory Studies: Review urinalysis complete, uric acid, C-reactive protein, Sed Rate by Mod Wet, CMP, CBC (includes DIFF/PLT) from the previous visit
Assessment/Plan
The patient’s gouty arthropathy is chronic. Patient’s present uric acid is 4.0. Allopurinol OD and will continue to take colchicine 0.6 OD/BID with acute flare. I will have patient follow up in three weeks prior to leaving for Florida. Emphasized the importance of daily adequate hydration and maintaining a low-purine diet. I discussed with the patient different options for a diet and exercise plan. I will order new labs. Also, stressed the importance of patient calling for an appointment if he has an acute flare so fluid can be aspirated from the joint for a crystal analysis. The total time for the visit was 33 minutes, and more than 50% of the visit was spent on counseling the patient on diet and an exercise plan.