1. Patient Chief Complaint

2. History of Present Illness

3. Past Medical History? Renal disease/kidney stones Hypertension
Back pain
Skin rash
Diarrhea
Diabetes,hyperlipidemia,obesity

4. Medications?

5. Social History Dietary intake beer, fructose, meat Lead exposure?
How has illness affected lifestyle and work

6. Family History
Parents, aunts, uncles and if pertinent cousins

7. Physical Examination
Skin
Joints

8. Patient Illness Script
Epidemiology relevant to case
Time course: acute, sub-acute, chronic,recurrent
Syndrome Statement
Mechanism of disease
exclude diagnosis by previous physicians

9. Disease Script compare and contrast
Epidemiology-Septic ( TB or fungal if chronic), Rheumatoid Arthritis, Seronegative arthritis (reactive arthritis, inflammatory bowel disease,psoriatic arthritis),hepatitis
Clinical presentation
Time course
Mechanism disease

10. Why did it take seven years to make diagnosis?
Right history but patient too young??
Lack of knowledge?
Cognition bias?
Every person you see with tophi, ask yourself: “Why??”