Event 1: Meet Mr. Clark

History of Present Illness

Mr. Clark, an 80-year-old Caucasian man wearing glasses. — Mr. Clark

Mr. Clark is an 80 year old, moderately overweight Caucasian male who awoke two nights ago with severe pain in his left foot. He has tried elevating his foot and has taken ibuprofen, with minimal pain relief. His wife states that he has some problems with his memory. She states that he has not been able to sleep, and asks the urgent care staff to give him something for the pain as well as something to help him sleep.

Past Medical History

Mild congestive heart failure (CHF), states has “a little swelling in legs”; wife states he has been told to lose weight as he is “borderline diabetic”; wife states he had a similar episode of painful “arthritis” 8 years ago; has had short term memory loss for about 2 years.

Past Surgical History

Appendectomy at age 40

Fall History

Negative

Current Medications

Hydrochlorthiazide 25 mg daily
Baby aspirin (81 mg) daily
Memantine 10 mg bid
Multivitamin one daily
Vitamin D 2,000 IU daily

Allergies

No known drug allergies

Family History

Mr. Clark’s mother died at age 85 after a hip fracture; she had “arthritis” for years, especially in her elbow; his father died at age 75, stroke; one sibling, brother, 82, has had “attacks of gout” for 10 years.

Social History

Mr. Clark has been married for 60 years; he lives with his wife in a 3-bedroom, one-story home. He is a retired high school teacher (agricultural science), and was a part time rancher until his memory problems began. He has 2 grown sons & 7 grandchildren (all live out of state).

His wife states he drank 2-3 beers per day until 6 months ago; now occasionally has 1-2 beers once or twice a month (which he had at dinner the evening the pain began; dinner was steak, baked potato with butter and sour cream, asparagus, and lettuce salad with ranch dressing)

History of smoking – 30 year pack history; quit 5 years ago.

Physical Examination

Height

5’10”

Weight

195 pounds

Vital Signs

BP 170/96 P 110 R 20, shallow; O2 sat = 94% on room air

Pain Faces Scale (IASP): 6/10

General Appearance

Overweight (BMI 28) white male, minimal weight bearing left leg due to painful foot; appears to be in more pain than what he indicated on the Pain Faces Scale

Head, ears, eyes, nose, throat and mouth exam

Pale, dry oral mucosa

Neck

Normal range of motion

Lungs

Decreased breath sounds bilaterally, otherwise clear

Heart

Tachycardic, regular rhythm, no murmurs

Abdomen

Soft, no masses, some tenderness with palpation, barely visible scar right lower quadrant

Extremities

No cyanosis or edema of right foot; facial grimacing when moving left foot; left great toe is red, swollen, hot to touch

Skin

Except for left great toe, skin is warm, dry; no rashes

Musculoskeletal

Pt. refused due to pain

Neurological

Alert, 80 year old man; oriented to person; MOCA score of 25 (note: he has a college degree)

Lab Results

Test	Value	Value range
Sodium	142 meq/l	135–145
Potassium	3.6 meq/l	3.5–4.9
Chloride	110 meq/l	96–110
CO2	27 mmol/l	20–30
BUN	22 mg/dl	6.0–23.0
Creatinine	1.4 mg/dl	0.6–1.4
Total protein	6.0 g/dl	6.0–8.0
Albumin	3.8 g/dl	3.6–5.0
Magnesium	1.8 meq/l	1.3–2.2
Phosphorus	3.6 mg/dl	2.5–4.5
Calcium	8.0 mg/dl	8.0–10.5
White blood count	11,700/mm3	4–12
Hemoglobin	11.9 g/dl	12.6–16.5
Platelet count	144 000/mm3	150–400
Uric acid	9.5 mg/dL	3.4–7.0

Imaging After Repeated Occurrences of Gout

Uric acid crystals and joint destruction of the base of the joint of the big toe.

Predisposing Factors for Gout Seen in Mr. Clark

Genetics
Mild obesity
High blood pressure (needs follow up)
Abnormal blood sugars (needs follow up)
Hyperlipidemia
History of smoking
Alcohol use
Low dose aspirin
Diuretic use

Issues with Polypharmacy

Upon further questioning, Mrs. Clark admits that on the day the pain started, she gave her husband one of the “pain pills” she had left over from her hip surgery 2 years earlier. A call to the pharmacy revealed the pain pill prescription was hydrocodone 10/325. Mrs. Clark said she got worried because the pill made her husband more confused.

Mrs. Clarl gave Mr. Clark a couple of ibuprofen on the second day of his pain before bringing him to urgent care. He complained to his wife of a “stomach ache” after having the ibuprofen, but that seemed to get better after having lunch. She wants something to help his pain and to help him sleep.