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MED BGD Infectious diseases- Rheumatology

MED BGD Infectious diseases- Rheumatology. LeeChuy, Katherine Lee, Sidney Abert Lerma, Daniel Joseph Legaspi, Roberto Jose Li, Henry Winston Li, Kingbherly Lichauco, Rafael Lim, Imee Loren Lim, Jason Morven Lim, John Harold Lim, Mary Lim, Phoebe Ruth Lim, Syndel Raina

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MED BGD Infectious diseases- Rheumatology

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  1. MED BGDInfectious diseases- Rheumatology LeeChuy, Katherine Lee, Sidney Abert Lerma, Daniel Joseph Legaspi, Roberto Jose Li, Henry Winston Li, Kingbherly Lichauco, Rafael Lim, Imee Loren Lim, Jason Morven Lim, John Harold Lim, Mary Lim, Phoebe Ruth Lim, Syndel Raina Lipana, Kirk Andrew Liu, Johanna Llamas, Camilla Alay

  2. General Data • Name: T. R. • Age: 60 • Sex: M • Status: Married • Nationality: Filipino • Date of Birth: 12/10/1949 • Place of Birth: Leyte • Religion: Roman Catholic • Educational attainment: High School Graduate • Occupation: retired; Grass cutter of Military Shrines Service • Current Address: Bataan • Informant: Patient, Wife, Niece, Nephew • Reliability: 70%

  3. CHIEF COMPLAINT “Namamaga ang mga kasukasuan sa kamay, tuhod, at bukong-bukong hanggang paa(swelling of the hands, knees and ankle to feet)”

  4. 4 months PTA History of Present Illness • 10 years history of recurrent monoarthritis -No proper consult was done; self-medicated with paracetamol 500mg + ibuprofen 200mg (Alaxan) & paracetamol (Biogesic) 500mg -denied steroid intake and aspirin -pain free interval: 3 weeks initially, progressive shorter pain free intervals -frequency of drug intake 3 tabs/day: taken as needed, initially TID -efficacy: slight relief of pain • patient slipped and sustained an injury to the both hands and wrist in an attempt to break his fall • admitted at a local hospital in Bataan • confined and was given unrecalled medications • relieved from the pain

  5. 2 weeks PTA 1 week PTA -patient accidentally stepped on a sharp object and cleaned the wound site with guava leaves and betadine and then applied 500mg penicillin powder -recurrence of joint pain and swelling of both hands, knees, and feet; self-medicated with Mefenamic acid 500 mg and amoxicillin 500 mg which provided relief, taken as needed -progression of joint pain and swelling of both wrist to hands, knees, ankles to feet, graded 10/10 with limitation of movement these joints ADMISSION (August 24, 2010)

  6. Past Medical History • No major hospitalization, unrecalled immunizations • No allergy, no previous transfusion • (-) DM, PTB, Asthma, Cancer Family History • not clear to the patient Personal and Social History • Non-smoker • Alcoholic beverage drinker ( 2 bottles beer; 3x a week and occasional gin drinker 2-3 bottles/week) • Diet: mixed diet • Denies illicit drug use

  7. Review of Systems • General: no fever, no weight loss, (-) anorexia, (-) weakness, (-) insomnia • HEENT: no blurring of vision, no eye redness, pain, itchiness, no excessive lacrimation, no ear pain nor tinnitus, no ear discharge, no epistaxis, no nose discharge, no anosmia, no obstruction nor sinusitis, no mouth sores, fissures, bleeding, no dental carries, no throat irritation, • Pulmonary: no hemoptysis, no coughing, no dyspnea, no chest wall abnormality • Gastrointestinal: no abdominal pain, no melena nor hematochezia, no changes in bowel habits • Genitourinary: no hematuria, no dysuria, no urinary frequency, no hesitancy, no incomplete voiding • Endocrine: no heat or cold intolerance, no polyphagia, no polydipsia, no polyuria, no thyroid enlargement • Musculoskeletal: see HPI • Hematologic: no abnormal bleeding,easy bruising

  8. PHYSICAL EXAMINATION Admission (August 24, 2010) August General survey: conscious, coherent, ambulatory, not in cardiorespiratory distress, normal speech, appropriate thought process and content and well-oriented as to time, place and date. Vital Signs BP: (RUE) 170/100 (LUE) 170/100 PR: 74 beats/minute RR: 17 cycles/minute Temperature (axillary): 37.2oC Anthropometric measurement -Ht: 165.1 cm Wt: 65 kgs BMI: 23.9 General survey: Conscious, Coherent, stretcher-borne not in respiratory distress Vital signs: BP: 120/70 PR:88 regular RR:22 cpm Temp: 36.5 C Anthropometric mesaurement -Ht: 165.1 cm Wt: 65 kgs BMI: 23.9

  9. PHYSICAL EXAMINATION Admission (August 24, 2010) August 27, 2010 Skin: Warm, moist skin, no jaundice, no skin discoloration, (+) tophi on the right wrist, right dorsum of the hand, right elbow, both feet, (+) ruptured tophi on dorsum on the right foot and sole of the left foot. (+) ulcer on the medial calcaneal area of the left foot No rashes, petechiae, No palmar erythema, no spider angioma Nails without clubbing or cyanosis. Skin Warm, dry skin, (+) scaling on the right foot and ulcers on the sole of the left foot

  10. PHYSICAL EXAMINATION Admission (August 24, 2010) August 27, 2010 HEENT Pale palpebral conjunctivae, anicteric sclera, pupils ERTL 2-3mm, no exophthalmos, no tragal tenderness, no aural discharge, supple neck, no distended neck veins, no palpable cervical lymph nodes, thyroid gland not enlarged HEENT Pale palpebral conjunctiva, slightly icteric sclera, 3-4 mm ERTL No tragal tenderness, No nasoaural discharge, nasal septum midline, no hoarseness Supple neck, no palpable cervical lymph nodes, trachea is midline thyroid not enlarged

  11. PHYSICAL EXAMINATION Admission (August 24, 2010) August 27,2010 Respiratory Symmetrical chest expansion, no subcostal retractions, unimpaired tactile and vocal fremiti , resonant upon percussion,(-) crackles on both lower lung bases, no wheezes, no rhonchi Respiratory Symmetrical chest expansion No retractions Equal vocal and tactile fremiti Resonant on percussion (+) crackles on both lower lung fields

  12. PHYSICAL EXAMINATION Admission (August 24, 2010) August 27,2010 Cardiovascular Adynamic precordium, AB at 5th LICS MCL, no heaves, no lifts, no thrills, S1>S2 apex,S2>S1 base; Pulses were full and equal in all extremities, no cyanosis and clubbing Cardiovascular Adynamic precordium Apex beat at 5th LICS MCS No heaves and thrills S1 > S2 at the apex, S2> S1 at the base No murmurs

  13. PHYSICAL EXAMINATION Admission (August 24, 2010) August 27, 2010 Gastrointestinal Inspection: Globular and symmetrical abdomen, No caput medusae, inverted umbilicus, no visible peristalsis, pulsation or mass Auscultation: Normoactive bowel sound , No bruits Percussion: tympanitic, Liver span 10 cm along the Right MCL, Traube’s space not obliterated, (-) shifting dullness Palpation: Liver edge not palpable. No mass, (-) succusion splash, (-) fluid wave Genitourinary (-) CVA tenderness, kidneys not palpable Gastrointestinal Flabby abdomen, Abdominal circumference: 98 cm, (+) shifting dullness, (+) venous collaterals, normoactive bowel sounds, no palpable mass, no tenderness, tympanitic all over, liver span 10 cm MCL, Traubes space not obliterated, (-) Murphy’s sign , DRE: smooth rectal vault, no perianal tenderness, tight sphincteric tone, no masses, prostate not enlarge and greenish brown on examining finger Genitourinary (-) CVA tenderness DRE: greenish brown on examining finger

  14. PHYSICAL EXAMINATION Admission (August 24, 2010) August 27, 2010 Musculoskeletal (+) swelling on both wrists and hands, ankles and feet, warm to touch The patient can move his head, shoulders, elbows and knees with ease. Can perform flexion, extensions and supination of the hands and elbows without difficulty. No tenderness upon palpation. Musculoskeletal Pulses full and equal, no cyanosis, (+) bipedal edema, (+) swelling on wrist to hands and ankle to foot, warm to touch, (+) draining abscess measuring 1 X 1 cm on the sole of the left foot

  15. PHYSICAL EXAMINATION Admission (August 24,2010) August 27, 2010 Neurologic Exam Mental status: Conscious, awake, alert GCS 15 Pupils 2-3mm, isocoric ERTL, EOMs full and equal, no ptosis, no nystagmus No facial asymmetry, can shrug shoulders, can turn head against resistance MMT: 5/5 all extremities No sensory deficits Can do FTNT, APST Reflexes: Superficial: (+) Gag and corneal reflex Deep Tendon: (++) on all extremities No Babinski, nuchal rigidity, Brudzinski, Kernig’s Neurologic Exam GCS 15 (E4V5M6) Alert, oriented in three spheres Intact cranial nerves Cerebellar – can do FTNT and APST with ease MMT- 5/5 on all extremities No sensory deficits Refelexes: ++ on all extremities, (-) Babinsky, nuchal rigidity, Brudzinki’s and Kernig’s

  16. Physical Examination

  17. Physical Examination

  18. Physical Examination

  19. Physical Examination

  20. Physical Examination

  21. Physical Examination

  22. SALIENT FEATURES

  23. Clinical Impression: 1. XXXXXXXXXX 2. Acute Gouty Arthritis on top of Chronic Tophaceous Gout 3. Anemia prob secondary to NSAID gastropathy (chronic NSAID use)4. Stage 2 hypertension

  24. Course in the Ward

  25. Upon admission • Given Clindamycin 300mg q 6h • Cold compress on affected areas, colchicine (0.5 mg bid) • Send wound discharge for Gram’s stain and culture

  26. Other Ancillary procedures: • Fecal occult blood test – (+) • ECG – Sinus rhythm with left ventricular hypertrophy • Urinalysis: albumin- negative, sugar – negative, RBC-0-2/hpf, Pus cell-1-4/hpf

  27. X-ray of the left foot September 1, 2010

  28. X-ray of the right foot September 1, 2010

  29. X-ray of the left foot September 1, 2010

  30. Official X-ray findings Both feet • Multiple erosive and lytic changes involving the tarsal, metatarsal, and phalangeal bones in both sides, with evidence of narrowing of the joint spaces. • Calcaneal spurs are noted. • One notes evidence of soft tissue swelling, with soft tissue lucencies, which may be due to abscess formation. . • Sclerotic changes are also noted involving the tarsocalcaneal articulating surfaces on the right side. • One notes of decreased bone density. • Impression:  • Above findings consider the possibility of Osteomyelitis. • The possibility of Gouty arthritis is not entirely ruled out.

  31. Chest X-ray

  32. Official X-ray findings • Lung fields are clear. • There is increase in the transverse diameter of the heart. • Aorta is calcified. • Diaphragm & sinuses are intact. • Impression: Cardiomegaly Atheromatous aorta

  33. Anemia due to: Hawkey CJ. Non-steroidal anti-inflammatory drug gastropathy: causes and treatment. Scand J Gastroenterol Suppl. 1996;220:124-7. CATHERINE S. SNIVELY, M.D.,et.al. Chronic Kidney Disease: Prevention and Treatment of Common Complications. Am Fam Physician. 2004 Nov 15;70(10):1921-1928.

  34. ADA Criteria for the diagnosis of diabetes Table 3—Criteria for the diagnosis of diabetes 1. A1C ≥ 6.5%. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.* OR 2. FPG ≥ 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.* OR 3. 2-h plasma glucose ≥200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.* OR 4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥ 200 mg/dl (11.1 mmol/l). *In the absence of unequivocal hyperglycemia, criteria 1–3 should be confirmed by repeat testing. American Diabetes Association Diagnosis and Classification of Diabetes Mellitus, DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010

  35. In the setting of an elevated Hba1C but “nondiabetic” FPG, the likelihood of greater postprandial glucose levels or increased glycation rates for a given degree of hyperglycemia may be present. American Diabetes Association Diagnosis and Classification of Diabetes Mellitus, DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010

  36. Pending procedures • Wound CS -to determine etiology of the lesion as well as the sensitivity or susceptibility of the pathogen to antibiotics

  37. Polarized light microscopy of specimen collected September 2, 2010

  38. Final Diagnosis Ruptured tophi on the right foot with secondary bacterial infection with osteomyelitis Acute gouty arthritis on top of chronic tophaceous gout Anemia secondary to occult GI bleeding probably due to NSAID gastropathy Chronic kidney disease secondary to gouty nephropathy and hypertensive nephrosc lerosis

  39. Management

  40. Febuxostat: the evidence for its usein the treatment of hyperuricemia and gout Angelo L Gaffo Kenneth G Saag Core Evidence 2009:4;25–36

  41. Objective • Review the clinical evidence of effectiveness of febuxostat (TEI-3420, or TMX-67) on outcomes and its potential for clinical management of hyperuricemia and gout.

  42. Phases II and III evidence Literature searches PubMed Cochrane database American College of Rheumatology European League Against Rheumatism (?) Inclusion exclusion criteria not mentioned Methods

  43. Febuxostat • Orally administered, nonpurine selective inhibitor of xanthine oxidase. • Binds to a channel in the molybdenum center of the enzyme, leading to a very stable and long-lived enzyme-inhibitor interactions with both oxidized and reduced forms of the enzyme

  44. Phase II data • 28-day, multicenter, double-blind, placebo-controlled, dose response clinical trial • Determine safety and efficacy of once daily febuxostat • 40, 80, 120 mg • Inclusion: patients with American College of Rheumatology criteria-defined gout aged 23-80y/o • Exclusion: absence of kidney dysfunction or taking drugs known to affect serum urate (aspirin or diuretics)

  45. Phase II data • Cases of reduction seen in as early as 7 days after start of treatment • Dose-dependent effect • Incidence of gout flares, due to sudden removal and mobilization of uric acid crystals from the tissues • Despite pretreatment with colchicine • Diarrhea, abdominal pain • Abnormal liver function tests • 40mg (14%), 80mg (8%), 120mg (8%)

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