History

Full Name: M.F.

Sex: Female

Age: 48 years

Date & Time: February 8, 2024

Location: Metropolitan Hospital

Source of Information: Self

Reliability: Reliable

Source of referral: Self

Mode of transportation: Walk-in

CC:

“My toe hurts” x 5 days.

HPI:

48 year old female with no known pmhx presents to the ED with complaints of pain in her R great toe x5 days. Pt describes the pain as a constant, sharp pain with a 7-8/10 rating in severity. The pain is localized to the IP joint with no radiation. Pt says the pain started out of nowhere and denies any trauma to the area. Pt does however admit to eating a lot of red meat recently. Pt states that walking exacerbates the pain. She admits that Motrin helps to improve the pain, however icy hot application provided no relief. Pt states that she had a similar episode over 10 years ago.

Denies fever, recent illness, other joint pain,  or numbness/tingling. 

Good HPI 

PMHx:

• No known pmhx, surgeries or hospitalizations 

Medications:

• No prescription medication use.
• Denies herbal supplement use.

Surgical History:

• No surgical history.

Allergies:

• No known drug/food/environmental allergies

Family History:

• Unknown
• No known family hx of HTN, diabetes, cancer.

Social History:

• Smoking: Denies
• Alcohol: Denies
• Illicit drug use: Denies past or current use
• Marital History: Single
• Language: English
• Occupational History: Works as a cashier
• Travel: No recent travel
• Home situation: Lives in an apartment in NYC with her sister
• Sleep: Endorses adequate sleep
• Exercise: None
• Diet: Reports to eat a lot of red meat, seafood and vegetables
• Caffeine: Drinks one cup of coffee daily

ROS:

• General: Denies fever, fatigue, chills, night sweats, weight loss/gain, changes in appetite.
• Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
• HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Breast: Denies lumps, nipple discharge, or pain.
• Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
• Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
• Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, rectal bleeding, hemorrhoids or blood in stool.
• Genitourinary: Denies urinary frequency, nocturia, dysuria, urgency, flank pain, oliguria, polyuria and incontinence.
• Menstrual/Obstetrical: G0P0000, LMP 1/25/24; denies postcoital bleeding, vaginal discharge, dyspareunia.
• Musculoskeletal: Admits to joint pain and slight joint swelling. Denies back pain, muscle pain and arthritis.
• Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular: Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
• Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
• Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating, or hirsutism.
• Psychiatric: Denies feelings of helplessness, hopelessness, lack of interest in usual activities, or suicidal ideations, anxiety, obsessive/compulsive disorder, or ever seeing a mental health professional.

Physical

General:

• Well developed, well-nourished, overweight female in no acute distress appears stated age of 48. Neatly groomed, alert and oriented x3. Dressed appropriately for the weather. Ambulates well without support, with slight limp.

Vitals:

• BP: 126/70 mm Hg
• RR: 18/min, regular rate and rhythm, unlabored
• P: 67 beats per minute, regular rate, rhythm and amplitude
• T: 98.1 degrees F (oral)
• O2 Sat : 100% room air
• Height: 69 inches Weight: 194 lbs BMI: 28.6

Skin and Head:

• Skin: Warm and moist, good turgor. Nonicteric, no lesions, scars, or tattoos noted.
• Nails: No clubbing, cyanosis, or lesions. Capillary refill < 2 seconds in upper and lower extremities.

Thorax and Lungs:

• Chest: Symmetrical, no deformities, no trauma. Respirations unlabored/ no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout.
• Lungs: Clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiac Exam:

• Heart: Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Musculoskeletal:

• Erythema observed over the R great toe. Minimal swelling noted externally. Decreased ROM of the R great toe. Tenderness elicited upon palpation of R great toe, particularly of the IP joint. Increased warmth appreciated over the affected area. Restricted flexion, extension, abduction and adduction of the R great toe due to pain and stiffness. All other joints appear normal, with no tenderness and complete ROM.

Commonly gout patients will present with hyperesthesia to the area in which lightly brushing the area will lead to severe pain, which distinguishes it from other DDx.

Mental status exam:

• Patient is well appearing, has good hygiene and is neatly groomed. Patient is alert and oriented to name, date, time and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Patient denies changes to mood. Conversation progresses logically. Insight, judgment, cognition, memory and attention intact.

Neurologic Exam:

• Sensation: Sensation is intact bilaterally to pain and light touch. Two-point discrimination is intact.
• Motor: Good muscle tone. Strength is 5/5 bilaterally at the quadriceps, hamstrings, calves and ankles.

Peripheral Vascular System:

• Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and nontender.

Differential diagnosis:

• Gout
  • Gout is a type of arthritis in which uric acid crystals accumulate in the joint space and cause pain. Uric acid is a waste product of purine metabolism. Foods such as red meat and shellfish are high in purine content. Therefore, this pt who admits to eating a lot of red meat is at risk for gout. Additionally, gout typically occurs in the great toe, just as this pt is experiencing. Also, the fact that the pain responded to motrin and not icy hot also points to this diagnosis, as NSAIDs is the first line treatment for gout. This pt also had a similar experience about 10 years ago, which is typical in gout- it is characterized by recurrent attacks. The fact that walking makes the pain worse is also typical of gout. For all of those reasons, this is my primary diagnosis.
• Pseudogout
  • Pseudogout is similar to gout in that it is a type of arthritis caused by calcium pyrophosphate crystals in the joints. This is slightly less likely than gout in this pt because the most common site of pseudogout is actually the knee. However these 2 diagnoses are very similar and an arthrocentesis would need to be done to definitively know the diagnosis.
• Septic arthritis
  • The fact that pt has a warm and swollen joint that is tender and has decreased ROM made me think of septic arthritis. However, the pt does not have any fever and has no risk factors (such as surgery to the area, IVDA or immunosuppression). Also the fact that the pt had a similar episode 10 years ago makes gout or pseudogout a more likely diagnosis.
• Osteoarthritis
  • Osteoarthritis also presents with a tender joint that experiences decreased ROM. Also this pt’s history of being a cashier and standing for large portions of the day puts her at risk for developing osteoarthritis. However, this diagnosis is less likely for a few reasons. Firstly, the acute nature of this complaint makes this diagnosis less likely as this is usually a chronic issue. Also, osteoarthritis typically affects large joints like knees or hips or the joints in the hands first. Finally, osteoarthritis typically affects multiple joints which makes it a bilateral issue.
• Fracture
  • A fracture would lead to acute pain and decreased ROM, with warmth and swelling as this pt is experiencing. The point tenderness is also typical of a fracture. However, a history of trauma is usually present in the case of a fracture. Also with a fracture I would expect the pain to be rated higher and for there to be more visible deformity of the joint.

Great DDx

Assessment:

• 48 year old female with no known pmhx presents to the ED with complaints of pain in her R great toe x5 days. No known trauma prior to the onset of pain. Pt does admit to eating a lot of red meat the past few days. Pt had a similar occurrence about 10 years ago. On exam, pt has a tender, erythematous, warm, slightly swollen R great toe with decreased ROM. Tenderness is particularly located over the IP joint. All other exam findings are within normal limits. There are no labs or imaging to review at this point. Current concern for gout flare.

Plan:

• Pain control:
  • 800 mg ibuprofen Q6-8H PRN pain
• X-ray of the foot/toe- to r/o fracture
• Arthrocentesis
• Labs:
  • CBC
  • Serum uric acid levels
  • ESR, CRP
• Refer to PCP for further care
• Educate patient regarding the importance of remaining hydrated (to help clear the uric acid crystals) and abstaining from purine rich foods and alcohol.
• Discharge with instructions to return if symptoms worsen

Great plan, not a case for arthrocentesis, NSAIDs are a good first line, can also use steroids in non-diabetics, can consider putting in cam walker for increased support and comfort.