Patient Chief Complaint

History of Present Illness

Past Medical History?

•Renal disease/kidney stones

•Hypertension

•Back pain

•Skin rash

•Diarrhea

•Diabetes,hyperlipidemia,obesity

Medications?

Social History

•Dietary intake beer, fructose, meat

•Lead exposure?

•How has illness affected lifestyle and work

Family History

•Parents, aunts, uncles and if pertinent cousins

Physical Examination

•Skin

•Joints

Patient Illness Script

•Epidemiology relevant to case

•Time course: acute, sub-acute, chronic,recurrent

•Syndrome Statement

•Mechanism of disease

exclude diagnosis by previous physicians

Disease Script

•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

compare and contrast

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??”