GOUT

·          Location: Office

·          Vitals: Temp:fever; PR:N/minute; B.P: N; R.R: N /min.   

·          C.C: Pain and swelling of the first metatarsophalangeal joint. 

·          HPI:

·          A 43-year-old, previously healthy, white male presented to your office with a two-day history of excruciating pain in the right metatarsophalangeal joint.  The pain was sudden in onset, stated overnight, 8-9/10 in severity, and was aggravated by moving the joint.  Today he noticed some swelling and pain in the right knee. The patient denies any trauma. The patient also has a mild fever, and body aches.

1.        Order examination:   

2.       Focus the physical examination on the:

3.       Look for 

4.       The extremities reveal a warm, tender, erythematous joint with extensive soft tissue swelling; erythema extending to the knee and below the first metatarsophalangeal joint.

5.       CBC with, diff, stat   WBC count and bands

6.       BUN, stat

7.       Creatinine, stat

8.       PT, stat

9.       PTT, stat

10.    Uric acid, serum, routine 

11.    X-ray of the joint  

12.    Indomethacin, oral, continuous  

13.    If you have a patient with a history of gastrointestinal bleeding, acid peptic disease, or peptic ulcer disease, you can start Cox 2 inhibitors like celecoxib or rofecoxib instead of nonsteroidal anti-inflammatory drugs like indomethacin. 

14.    Aspiration of the joint, stat

15.    Fluid should be sent for gram stain, culture and sensitivity, crystals, and cell count.

16.    look for

17.    Synovial fluid analysis did not reveal any organisms. The WBC count is 10,000 per micro liter and most of the cells are polymorphs. Microscopy reveals negative birefringent monosodium urate crystals. 

18.    Based on these investigations, the most probable diagnosis of this patient is acute gouty arthritis.

19.     Counseling:

20.     Low protein diet

21.     Patient counseling

22.     No smoking

23.     No alcohol

24.     Medication compliance

25.     No illegal drugs

26.     Seat belt use