CHIEF COMPLAINT: Questionable gout, previously told he has pseudogout.
SUBJECTIVE: The patient was added acutely to my schedule today for history of gout. He actually states he saw Dr. John Doe a few weeks ago for this right knee discomfort. He states this began on MM/DD/YYYY without any precipitating factors. Dr. John Doe did an MRI and aspirated the joint and told the patient he had “pseudogout.”
The patient was given indomethacin, which he took for 11 days 3 times a day with ice. Improved dramatically but then returned about 5 or 6 days later.
He describes no exacerbating event at that time; although, he was active and was playing golf. He does note swelling at the anterior part of the knee. He wanted to know if there is anything else we can do for pseudogout.
OBJECTIVE:
VITAL SIGNS: Afebrile, pulse 66, blood pressure 128/72, and weight 250 pounds.
GENERAL: In no apparent distress. A pleasant, awake, alert, and oriented x3 white male.
HEENT: Normocephalic and atraumatic. Extraocular muscles are intact Oropharynx is clear with moist mucous membranes.
HEART: Regular rate and rhythm without murmurs, rubs, gallops or thrills. PMI normal.
LUNGS: Clear to auscultation. No wheeze, rales or rhonchi. Trachea is midline.
ABDOMEN: Soft, nontender and nondistended. No hepatosplenomegaly.
EXTREMITIES: No clubbing, cyanosis or edema.
MUSCULOSKELETAL: He has obvious swelling at the left infrapatellar area with some increased warmth there. He has 1+ effusion. Negative anterior and posterior drawer test. Negative varus or valgus stressing pain. Negative patellar grind to the right knee. Gait is nonantalgic. No joint abnormality to the ankle or hip. No pain with internal or external rotation of the right hip.
MRI was reviewed. He did have chondromalacia of the patella as well as small joint effusion and infrapatellar tendinosis without evidence of tear of the meniscus or ligaments.
ASSESSMENT:
1. Pseudogout.
2. Chondromalacia of the patella on the right.
PLAN: We will have the patient continue the indomethacin for the next 2 to 3 days and then after that we will give Celebrex 200 mg daily. Pathophysiology of pseudogout was explained to him. Continue exercises and strengthening as tolerated. We told we could not do another injection in that joint at least for a while. He is understanding of this.
