Patient complains of severe joint pain Joint/s affected: Patient states they have a history of gout and this feels like that On Examination: The patient is afebrile Joint affected feel hot and very sensitive to movement Clinical Impression : Gout Plan: 1. Anti-inflammatory medication prescribed (indomethicin, Colchicine or Prednisone) 2. Apply hot compresses or ice to the joint involved 3. Bed Rest Discussed the usefulness of Allopurinol. Not prescribed at this time but if continued attacks the patient will represent for treatment Discussed the "Rules of Moderation" and these notes have been printed and provided to the patient Rules of moderation Do: • restrict intake of food high in purines, especially organ meats (liver, brain, kidneys, sweetbread), shellfish and tinned fish (sardines, anchovies, herrings), game, pork • reduce your intake of alcohol, especially beer and red wine • reduce or cease intake of sugary, fizzy soft drinks and frui...
Preventative Health Screen Height: Weight: BMI: BP Pap Smears: UTD Exericse: Exercises regularly Diet: Eating a good balanced diet Bowel Cancer Screening: completed and nil abnormalities Mood: Happy and no concerns about mood Mammograms: UTD and no issues Bloods: Completed in the last 2 years and no issues Smoking: Non smoker Alcohol: Social drinker with no concerns regarding alcohol consumption Actions:
Patient advises they have recently given up alcohol Heavy Drinker Usual daily consumption: Experiencing the following symptoms: - headaches - nausea - tremors - anxiety - hallucinations - seizures. - Insomnia On Examination Appears agitated / in a withdrawal State Vital signs noted Impression: Alcohol Withdrawal Management: 1. Valium 5mg qid 2. Maxolon 10mg tds prn 3. Thiamine 4. Given details to contact nearest detox centre for phone assessment and admission as soon as possible 5. Continue to try to maintain abstinence 6. Mental Health Plan prepared and referral psychologist arranged Present to ED or call ambulance if any seizures
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