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 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

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??”