MEDICAL HISTORY U.S. 28 year old male, catholic, married, born on May 6, 1981, works as a tricycle driver since 2001, residing in Caloocan City with wife. Chief Complaint:

History of Present Illness 7 Yrs PTA White scales of the scalp resembled dandruff when scratched (no consult) Few mos. later: pustules and papules that later coalesced to erythematous plaques topped with scales spread all over his body affecting his back, trunk, upper and lower extremities and his face  consult at UST Dermatology OPD; punch biopsy: Psoriasis – medications: PUVA therapy (once in 2002), Methotrexate 1 tab BID for 1 wk, Dermovate with Petroleum Jelly and LCD, Hydroxizine (Iterax) for pruritus 3x/day prn  resolution of Symptoms White scales of the scalp resembled dandruff when scratched (no consult) Few mos. later: pustules and papules that later coalesced to erythematous plaques topped with scales spread all over his body affecting his back, trunk, upper and lower extremities and his face  consult at UST Dermatology OPD; punch biopsy: Psoriasis – medications: PUVA therapy (once in 2002), Methotrexate 1 tab BID for 1 wk, Dermovate with Petroleum Jelly and LCD, Hydroxizine (Iterax) for pruritus 3x/day prn  resolution of Symptoms 2 Yrs PTA Reappearance of lesions Painful swelling of distal and proximal joints of the fingers of right and left hands and feet (self-medication: Naproxen  temporary relief) Gradual limitation of in the movement of digits Consult to Rheumatologist, prescribed with Celebrex and requested for further lab work-ups; but patient lost to follow-up Reappearance of lesions Painful swelling of distal and proximal joints of the fingers of right and left hands and feet (self-medication: Naproxen  temporary relief) Gradual limitation of in the movement of digits Consult to Rheumatologist, prescribed with Celebrex and requested for further lab work-ups; but patient lost to follow-up 1 Yr PTA Pain and swelling in both knees, noted to be limping, and pain when walking down the stairs Relieved by rest or sitting down Pain and swelling in both knees, noted to be limping, and pain when walking down the stairs Relieved by rest or sitting down

1 month PTA Swelling of both knees with increasing severity of pain (no consult) 1 week PTA Pain in the hips extending down to his ankles More difficulty in ambulating Pain in the hips extending down to his ankles More difficulty in ambulating 5 days PTA Consulted an Orthopedic Surgeon in Marikina; was told to have excess fluid in knee joints & advised arthrocentesis (pt. opted not to) 4 days PTA Fever [undocumented] (self-medication: Paracetamol  temporary lysis of fever) Persistence of pain and fever  consult at FEU Hospital (X-Ray of leg: soft tissue swelling); advised admission but refused due to financial constraints; referred to USTH for further evaluation & management Fever [undocumented] (self-medication: Paracetamol  temporary lysis of fever) Persistence of pain and fever  consult at FEU Hospital (X-Ray of leg: soft tissue swelling); advised admission but refused due to financial constraints; referred to USTH for further evaluation & management ADMISSION

Past Medical History (-) DM (-) HPN (-) Joint surgery (-) history of trauma (-) Allergy Diagnosed with dengue fever (2 nd year high school) Excision of cyst at the back (2007)

Family History (+) Myocardial Infarction – father (+) DM – father (-) HPN (-) stroke (-) Psoriasis (-) Cancer (-) Arthrides

Personal & Social History Smoker: y/o (1-2 sticks per day) Occasional Alcoholic Beverage Drinker Denies Illicit Drug Use 3 past sexual partners, all protected

Review of Systems No wt. loss, no loss of appetite No hearing loss, no nasal congestion, no cough No dyspnea, orthopnea, cyanosis No chest pain, palpitations No abdominal pain, diarrhea, constipation No dysuria, frequency, change in character of urine

PHYSICAL EXAMINATION General Survey Conscious, coherent, oriented as to time, place and person, not in cardio-respiratory distress Vital Signs BP 120/70 mmHg, PR 83 bpm, RR 20 cpm, T 36.6 °C Skin Warm moist skin, (+) erythematous plaques topped with scales all over the body, (+) hyperpigmented patches over the extremitie, (+) oil spots, (+) nail pitting, (+) onychodystrophy

HEENT Pink palpebral conjunctivae, anicteric sclerae, no naso- aural discharge, no tragal tenderness, moist buccal mucosa, nonhyperemic PPW, tonsils not enlarged Neck Supple neck, trachea midline, no palpable cervical lymph nodes, thyroid gland not enlarged Cardiovascular Adynamic precordium, AB at 5 th LICS, MCL; no murmurs All pulses full and equal Respiratory Symmetric chest expansion, no retractions, clear breath sounds on all lung fields, no crackles, no wheezes

Abdomen Flat abdomen, NABS, soft, nontender, no masses Musculoskeletal (+) sausage-shaped 4 th digit of the right hand (+) swelling and tenderness, both knees, DIP 4 th R digit of the hand, R ankle (+) flexed 5 th left digit and the 4 th R digit of the hand Cannot flex the PIP and DIP of the right 2 nd digit of the hand

Neurological Conscious, oriented to person, place and time, can follow commands GCS 15 E4V5M6; pupils 2-3 mm, isocoric ERTL, V1,V2,V3 intact; intact hearing, can swallow, (+) gag reflex, can shrug shoulders, tongue midline on protrusion Motor: MMT 5/5 on both UE; 4/5 on both LE, no atrophy Cerebellum: no deficits, can do FTNT, APST, HTST Sensory: no sensory deficits DTRs: 2+ on the UE, LE not assessed (-) Babinski; no nuchal rigidity

SALIENT FEATURES History of Psoriasis Painful swelling of distal and proximal joints of the fingers of right and left hands and feet Gradual limitation of in the movement of digits Pain and swelling in both knees (increasing severity of pain), limping, and pain when walking down the stairs (difficulty in ambulating); Relieved by rest or sitting down Pain in the hips extending down to ankle excess fluid in knee joints Persistence of pain and fever X-ray of leg: soft tissue swelling

SALIENT FEATURES (+) erythematous plaques topped with scales all over the body, (+) hyperpigmented patches over the extremitie, (+) oil spots, (+) nail pitting, (+) onychodystrophy (+) sausage-shaped 4 th digit of the right hand (+) swelling and tenderness, both knees, DIP 4 th R digit of the hand, R ankle (+) flexed 5 th left digit and the 4 th R digit of the hand Cannot flex the PIP and DIP of the right 2 nd digit of the hand