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A 60-year-old man presents to the emergency department after a syncopal episode. He had been drinking at a bar when he fell off the bar stool, striking his head on the ground. He denied any chest discomfort, shortness of breath, dizziness, palpitations or headache prior to the incident. He came to the hospital only because EMS was called.

His past medical history was significant for “arthritis”. He self medicates with Motrin and other anti-inflammatory medications, but does not follow with a physician for his medical care. He has never been officially diagnosed with any specific type of arthritis and “just deals with it.” He denies allergies. He is a long standing smoker, drinks alcohol regularly, and denies illicit drug use.

On physical exam, his vital signs were unremarkable. Examination shows an elderly male in no distress. He has multiple nodules on different parts of his body and deformities of his fingers. The nodules are in clusters and have a yellow appearance. Other nodules were located on his external ears fingers, elbows and Achilles tendons. There were neither open areas nor signs of secondary infection. The lesions were firm to the touch, non-tender and not fluctuant or vesicular. The patient’s finger and hands were deformed with ulnar deviation of the fingers bilaterally and the nodules were so large over the joints that his flexion was severely limited. Watching him put on his shoes, he has adapted to using his hands in a pincer mechanism with his thumb. The remainder of his exam, including heart, lung and neurologic exams are normal.

Pertinent studies for the patient included renal failure with creatinine greater than 4, uric acid of 8.5 and a lung mass found on chest x-ray. ECG demonstrated no acute ischemic changes or arrhythmia. He was admitted for further work up for his syncope, renal failure and lung mass.

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