Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of chronic gouty arthritis of the left ankle. Reports recurrent episodes of localized pain, swelling, and erythema. Current flare duration is [X] days. Patient notes stiffness and decreased range of motion. Denies recent trauma, fever, or chills. Current medication adherence is [compliant/non-compliant].
Clinical Examination Findings
Left ankle examination: Visible swelling and mild erythema noted over the medial and lateral malleoli. Palpation reveals tenderness and warmth. Presence of palpable tophi noted at [location]. Range of motion is limited by pain, specifically in dorsiflexion and plantarflexion. No signs of cellulitis or skin breakdown. Neurovascular status intact distally.
Treatment Protocol
Plan: 1. Initiate/Adjust Urate-Lowering Therapy (ULT) with Allopurinol [dosage]. 2. Acute flare management: NSAIDs/Colchicine/Corticosteroids as indicated. 3. Lifestyle modification: Low-purine diet, hydration, and weight management. 4. Follow-up serum uric acid levels in 4-6 weeks. 5. Physical therapy referral for joint mobilization.