1. Admission Conference Clk. Kirsten Diane Dy

2. General Data U.S. 28 y/o Male Married Filipino Tricycle driver Roman Catholic Quezon City Date of Admission: August 25, 2009

3. Chief Complaint Difficulty in ambulation

4. History of Present Illness 7 years PTA Few months later (+) pustules and papules on his face that later coalesced to form erythematous plaques topped with scales Consult :UST Dermatology OPD Punch biopsy Assessment: Psoriasis Medications: Methotrexate Dermovate with Petroleum Jelly LCD PUVA therapy patient noted white scales on his scalp

5. History of Present Illness (+) painful swelling of all the digits of his hands and feet (+) gradual limitation in the movement of his digits Consult: private physician (Rheumatologist) Medications: Celebrex Work-ups not done 2 years PTA (+) pain in both his knees (+) limping (+) pain when walking down the stairs Relieved by rest or sitting down No consult done Self-medicated with Naproxen 1 year PTA

6. History of Present Illness (+) swelling of both knees increasing severity of the pain No consult was done 1 month PTA 1 week PTA (+) pain in the hips extending down to ankles more difficulty in ambulating Consult: Orthopedic Surgeon Assessment: excess fluid in his knee joints Offered arthrocentesis but refused 5 days PTA

7. History of Present Illness (+) fever (undocumented) Self-medicated with Paracetamol 4 days PTA 3 days PTA Persistence of pain and fever Consult: FEU Hospital x-ray of left leg: soft tissue swelling Advised admission but refused Referred to our institution ADMISSION

8. Review of Systems No loss of appetite, no weight loss No hearing loss, no nasal congestion, no cough No dyspnea, orthopnea, cyanosis No chest pain, palpitations No abdominal pain, no diarrhea, no constipation No dysuria, no change in character of urine No polyuria, no polyphagia, no polydipsia

9. Past Medical History (-) Diabetes Mellitus (-) HPN (-) Allergy (-) Asthma (-) History of trauma (-) Joint surgery

10. Family History (+) DM – father (+) Myocardial Infarction- father (-) Psoriasis` (-) HPN (-) Stroke (-) Asthma (-) Cancer (-) Blood Dyscrasia (-) Arthrides

11. Personal and Social History Smoker- 16-21y/o (1-2 sticks per day) Occasional alcoholic beverage drinker Denies illicit drug use Had 3 sexual partners before his wife, protected

12. Physical Examination Conscious, coherent, wheel chair-borne, not in cardio- respiratory distress BP 120/70 mmHg PR 83 bpm, reg RR 20 cpm T 36.6 o C Height= 165cm Weight= 70kg BMI= 25 Warm moist skin, (+) erythematous plaques topped with scales all over the body, (+) hyperpigmented patches over the upper extremities, (+) oil spots, (+) horizontal ridging, (-) nail pitting Pink palpebral conjunctivae, anicteric sclera, no naso-aural discharge, no tragal tenderness, moist buccal mucosa, nonhyperemic PPW, tonsils not enlarged Supple neck, trachea midline, no palpable cervical lymph nodes, thyroid gland not enlarged

13. Physical Examination Adynamic precordium, AB at the 5 th LICS, MCL, no murmurs Symmetric chest expansion, no retractions, clear breath sounds on all lung fields, no crackles, no wheezes Flat abdomen, NABS, soft, nontender, no masses, (+) sausage-shaped right 4 th digit of the 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 right digit of the hand Cannot flex the PIP and DIP of the right 2 nd digit of the hand All pulses full and equal

19. Neurologic Examination Patient is conscious, oriented to person, place and time, can follow commands, GCS 15 E4V5M6 Pupils 2-3 mm, isocoric ERTL, V1,V2,V3 intact; (+) corneal reflex, 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 upper extremities, LE not assessed (-) Babinski; no nuchal rigidity

20. Salient Features 28 y/o Male Known Psoriatic since 2002 (+) erythematous plaques topped with scales all over the body (+) oil spots, (+) horizontal ridging (+) gradual limitation in the movement of his digits (+) fever (+) swelling and tenderness, both knees, (+) swelling and tenderness, DIP 4 th R digit of the hand (+) swelling and tenderness, R ankle (+) contraction, 2 nd R digit of the hand

21. Assessment Psoriatic Arthritis r/o Septic Arthritis

22. Diagnostic Plans Arthrocentesis Synovial fluid cell count Synovial fluid Gram stain Synovial fluid culture and sensitivity Sacroiliac x-ray X-ray of the hands CBC, ESR BUN, Creatinine SGOT, SGPT

23. Therapeutic Plans Dolcet tablet, q8 prn for pain Cefotaxime, 1g/IV q8 Etanercept 50mg/SC/week Methotrexate 25mg/week Frequent passive motion of the joints Avoid weight-bearing until signs of inflammation have subsided

24. Thank You