Patient profile as of 25 July 2011 Male 22 74.1Kg 168cm South East Asian Case Description *Inflammation (ususal not always) of either foot with severe pain (7) Inflammation sites: ankles ventral arch (often) dorsal arch *Would start as bearable/tolerable discomfort on day 1 *wound progress on days 2-4 *usu on days 4-5 Pt would not be able to walk in the morning due to pain and inflammation *Pt describes pain as throbbing, sometimes painful even by merely switching positions of foot inflamed or tapping the leg, pt describes pain as “sometimes it feels like I am stepping on a small ball.” *pain migrates/shifts (point of greatest pain, or point that triggers greatest pain) *usu painful in mid/arch area lower pain towards heels and ankles *usual pain points/triggers: Metatarsophalangeal joint compression (pressure exerted on medial MPjoint opposing pressure exerted on lateral MPjoint) 60-90% of times Pressure exerted on the three most lateral dorsal part of MPjont Pressure exerted on medial metatarsal opposing pressure exerted on lateral metatarsal Pain is relieved with NSAID *First instances (type I; with light to moderate pain) were relieved by Mefenamic acid 500 tid onset: May 08 pain duration two to three days *After several instances (type II) a moderately severe to severe pain which resulted to difficulty in walking with the affected foot was relieved by Celecoxib onset: late 08 pain duration two to four days *After several more instances (type III) a severe to very severe pain resulting to inability to move and grimaced face was somehow relieved by Etoricoxib and Tramadol+Paracetamol onset: late 09 case severity varies usu Pt would exp type I then after 2-6 weeks type I and after 4-12 weeks would be either type usu II and III. Pt was unable to attend Med classes for two days to a week for about 12 instances from Oct 08 to July 10 Early moderate pains and late decreasing pains are decreased by cold pack Pt tried hot packs several times but pt describes “it would get really red and it feels like I have edema inflammation with less pain, it is better with cold baths/packs” Medical History Pt is at 82.6Kg on May 2008 Thought to be caused by increased weight pt reduced weight over time May 08 lab results serum uric acid 0.45 mmol/L blood urea nitrogen 3.93 mmol/L Creatinine 88.40 mmol/L WBC 6.8k/cu mm RBC 4.6/cu mm Hemoglobin 14.0g/dL Hematocrit .42 Sept 08 lab results serum uric acid 0.40 mmol/L blood urea nitrogen 3.24 mmol/L Creatinine 112.67 mmol/L WBC 8.2k/cu mm RBC 4.7/cu mm Hemoglobin 14.4g/dL Hematocrit .44 Nov 09 lab results serum uric acid 0.65 mmol/L blood urea nitrogen 2.86 mmol/L Creatinine 70.72 mmol/L WBC 10.5k/cu mm RBC 4.5/cu mm Hemoglobin 13.6g/dL Hematocrit .41 Jan 10 lab results Fam Med serum uric acid 0.62 mmol/L blood urea nitrogen 3.21 mmol/L Creatinine 79.56 mmol/L WBC 7.5k/cu mm RBC 4.8/cu mm Hemoglobin 14.6g/dL Hematocrit .44 Jan 10 lab results OrthoSur serum uric acid 0.60 mmol/L blood urea nitrogen 3.29 mmol/L Creatinine 79.44 mmol/L WBC 7.6k/cu mm RBC 4.4/cu mm Hemoglobin 14.5g/dL Hematocrit .42 Dx of diff MDs Hospital A May 08 Family Med 1 plantar fascitis Sept 08 Fam Med 2 plantar fascitis (based on May 08) Sept 08 rehab 1 plantar fascitis (based on May 08) Feb 09 Fam Med 3 plantar fascitis (based on May 08) Nov 09 Rehab 2 plantar fascitis Jan 10 Fam Med 4 plantar fascitis (did differential dx on osteoarthritis-xray clear; rheumatiod arthritis-RF negative, no fevers, no malaise; did thorough diff on gouty arthritis-very young, xray clear, no specific night pains, no pronounced redness, no to relatively least pain on big toe, blood uric acid level not high enough) Institute B May 09 OrthoSurgeon 1 plantar fascitis Jan 10 OrthoSur 2 plantar fascitis (did xray and re run labs, not osteo, not rheuma, not gouty) Nov 10 OrthoSur 3 planter fascitis (based on orthosur/fam med 10) July 11 Ortho Sur 4 (no dx yet wants pt to take colchicine every 2 hrs max 10 tabs/day for 2 days and allopurinol 300mg once a day for 15 days; referred to rheumatologist) pt not at rest w/ this approach asks me to help research Hosp C July Ortho Sur 1 Sprain (LOLs, after 4days wants to run new lab tests thinks arthritis) please please help I saw several differentials on fibroma posterior tibial tendon dysfunction DIMCS radiculopathy nerve entrapment PTTD tear on plantar fascia tarsal tunnel pls advise what other tests are better done possible dx for particular result several confirmatory tests possibility of comorbid I am a 2nd year med student not very knowledgable yet pls help me and my friend thanx

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Differential: plantar fascitis, gouty arthritis, others pls help…

Patient profile as of 25 July 2011 Male 22 74.1Kg 168cm South East Asian Case Description *Inflammation (ususal not always) of either foot with severe pain (7) Inflammation sites: ankles ventral arch (often) dorsal arch *Would start as bearable/tolerable discomfort on day 1 *wound progress on days 2-4 *usu on days 4-5 Pt would not be able to walk in the morning due to pain and inflammation *Pt describes pain as throbbing, sometimes painful even by merely switching positions of foot inflamed or tapping the leg, pt describes pain as “sometimes it feels like I am stepping on a small ball.” *pain migrates/shifts (point of greatest pain, or point that triggers greatest pain) *usu painful in mid/arch area lower pain towards heels and ankles *usual pain points/triggers: Metatarsophalangeal joint compression (pressure exerted on medial MPjoint opposing pressure exerted on lateral MPjoint) 60-90% of times Pressure exerted on the three most lateral dorsal part of MPjont Pressure exerted on medial metatarsal opposing pressure exerted on lateral metatarsal Pain is relieved with NSAID *First instances (type I; with light to moderate pain) were relieved by Mefenamic acid 500 tid onset: May 08 pain duration two to three days *After several instances (type II) a moderately severe to severe pain which resulted to difficulty in walking with the affected foot was relieved by Celecoxib onset: late 08 pain duration two to four days *After several more instances (type III) a severe to very severe pain resulting to inability to move and grimaced face was somehow relieved by Etoricoxib and Tramadol+Paracetamol onset: late 09 case severity varies usu Pt would exp type I then after 2-6 weeks type I and after 4-12 weeks would be either type usu II and III. Pt was unable to attend Med classes for two days to a week for about 12 instances from Oct 08 to July 10 Early moderate pains and late decreasing pains are decreased by cold pack Pt tried hot packs several times but pt describes “it would get really red and it feels like I have edema inflammation with less pain, it is better with cold baths/packs” Medical History Pt is at 82.6Kg on May 2008 Thought to be caused by increased weight pt reduced weight over time May 08 lab results serum uric acid 0.45 mmol/L blood urea nitrogen 3.93 mmol/L Creatinine 88.40 mmol/L WBC 6.8k/cu mm RBC 4.6/cu mm Hemoglobin 14.0g/dL Hematocrit .42 Sept 08 lab results serum uric acid 0.40 mmol/L blood urea nitrogen 3.24 mmol/L Creatinine 112.67 mmol/L WBC 8.2k/cu mm RBC 4.7/cu mm Hemoglobin 14.4g/dL Hematocrit .44 Nov 09 lab results serum uric acid 0.65 mmol/L blood urea nitrogen 2.86 mmol/L Creatinine 70.72 mmol/L WBC 10.5k/cu mm RBC 4.5/cu mm Hemoglobin 13.6g/dL Hematocrit .41 Jan 10 lab results Fam Med serum uric acid 0.62 mmol/L blood urea nitrogen 3.21 mmol/L Creatinine 79.56 mmol/L WBC 7.5k/cu mm RBC 4.8/cu mm Hemoglobin 14.6g/dL Hematocrit .44 Jan 10 lab results OrthoSur serum uric acid 0.60 mmol/L blood urea nitrogen 3.29 mmol/L Creatinine 79.44 mmol/L WBC 7.6k/cu mm RBC 4.4/cu mm Hemoglobin 14.5g/dL Hematocrit .42 Dx of diff MDs Hospital A May 08 Family Med 1 plantar fascitis Sept 08 Fam Med 2 plantar fascitis (based on May 08) Sept 08 rehab 1 plantar fascitis (based on May 08) Feb 09 Fam Med 3 plantar fascitis (based on May 08) Nov 09 Rehab 2 plantar fascitis Jan 10 Fam Med 4 plantar fascitis (did differential dx on osteoarthritis-xray clear; rheumatiod arthritis-RF negative, no fevers, no malaise; did thorough diff on gouty arthritis-very young, xray clear, no specific night pains, no pronounced redness, no to relatively least pain on big toe, blood uric acid level not high enough) Institute B May 09 OrthoSurgeon 1 plantar fascitis Jan 10 OrthoSur 2 plantar fascitis (did xray and re run labs, not osteo, not rheuma, not gouty) Nov 10 OrthoSur 3 planter fascitis (based on orthosur/fam med 10) July 11 Ortho Sur 4 (no dx yet wants pt to take colchicine every 2 hrs max 10 tabs/day for 2 days and allopurinol 300mg once a day for 15 days; referred to rheumatologist) pt not at rest w/ this approach asks me to help research Hosp C July Ortho Sur 1 Sprain (LOLs, after 4days wants to run new lab tests thinks arthritis) please please help I saw several differentials on fibroma posterior tibial tendon dysfunction DIMCS radiculopathy nerve entrapment PTTD tear on plantar fascia tarsal tunnel pls advise what other tests are better done possible dx for particular result several confirmatory tests possibility of comorbid I am a 2nd year med student not very knowledgable yet pls help me and my friend thanx

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Differential: plantar fascitis, gouty arthritis, others pls help…