Left great toe pain

The patient is a very pleasant 87-year-old gentleman with left foot pain. He has a fairly extensive medical history which will be elaborated on later. He presents with his daughter today for evaluation. He states that this left foot pain in what appears to be the great toe metatarsophalangeal joint becomes episodic in the evenings with very sharp severe burst of pain, which lasts for several seconds and then abates. When questioned, it appears that this began after discontinuation of gout medication by his nephrologist due to his advanced kidney disease. It would appear that his primary concern here is gout-related pain of the joint. He has undergone x-rays of the foot as well as MRI of the foot and had injections from Dr. several months ago into this area, which was non-fluoroscopically guided. He ended up developing a rash, which may have been related to suspected glucocorticoid injection. He remains on Uloric at this time as his only anti-gout medication and presents today for evaluation.

Of note, he is status post stroke with a right vocal cord paralysis. He only has one kidney secondary to nephrectomy for cancer. A recent PET/CT preformed on May 10, 2013 shows a large hypermetabolic mass in the right lung unchanged as compared to the recent chest CT. He has a large right pleural effusion, small left pleural effusion, as well as possible esophagitis. He presents today for evaluation.

PAST SURGICAL HISTORY:
Back surgery, kidney surgery, colon surgery and prostates surgery.

CURRENT MEDICATIONS:
Lipitor, Protonix, Spiriva, Ultram, Neurontin, Proscar, Flomax, sodium bicarbonate, Uloric, PhosLo, Kayexalate, Levoxyl, amiodarone and Norvasc.

ALLERGIES:
Denies.

SOCIAL HISTORY:
The patient denies use of alcohol, tobacco, and recreational drugs. He is married, with two children and is a high school graduate.

DIAGNOSTIC STUDIES:
PET/CT scan on May 10, 2013 at Shrewsbury Diagnostic Imaging in Shrewsbury, New Jersey shows large irregular mildly hypermetabolic mass at the right lung unchanged as compared to the recent chest CT. There are additional subpleural patchy densities of the bilateral upper lobes with mild hypermetabolic activity along the right medial spinal border and in the posterior left upper lobe in the lingula. In addition, there is a hypermetabolic nodule of the right upper lobe with higher hypermetabolism. These findings are suspicious for multifocal bronchogenic carcinoma. Also, a large right pleural effusion and small left pleural effusion both slightly increased. Also possible esophagitis.

ASSESSMENT:
This is an 87-year-old gentleman with a primary complaint of left foot pain primarily in the left first digit metatarsophalangeal joint.

IMPRESSION:
1. Suspected gout pain; symptoms seems to increase significantly when the patient’s gout medications are discontinued due to renal disease.
2. Query osteoarthritis of the first digit MTP joint as there is obvious deformity in that joint upon visualization and upon x-ray.
3. History of stroke.
4. Suspected multifocal bronchogenic carcinoma.
5. Hard of hearing.
6. Polypharmacy.

PLAN:
I had a lengthy visit with Dominick and his daughter today. While he did have non-image guided injection in the area, this did not seem to help. He is obviously in a lot of pain. I did write a note to his nephrologist to see if it would be okay to place him back on colchicine or any other type of gout medicine to help decrease pain flares without the significantly increased risk to his kidney. The patient has declined to go on dialysis at the nephrologist’s request (per patient’s daughter). The best treatment I would offer him at this time is a fluoroscopically guided injection of the left first digit metatarsophalangeal joint in order to ensure proper placement of glucocorticoid (low dose) and local anesthetic. It may not even be necessary to use contrast, but one-tenth of a cc would give us an appropriate arthrogram to ensure proper placement. I then elected him to follow up in our office.

I would like him to follow up in our office in two to four weeks after the injection so that we can assess his progress.

Otherwise, this can be a very difficult case as he appears to respond well to his antigout medications, but we may just have to use other means of pain control rather than the antigout medications in order to provide him with the release he requests.

He seemed very happy with this visit today and I look forward to working with him.

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