Case Study of diagnosis and treatment of Gout

Case Study of diagnosis and treatment of Gout A 50 year-old male presented for an evaluation of rapid onset of pain and swelling in his right toe. The patient reported that he had two similar previous episodes with the same symptoms lasting four to five days and was treated by emergency physicians. The patientà ¢Ã¢â€š ¬Ã¢â€ž ¢s past medical history is significant for hypertension and treated with Hydrochlorothiazide. The review of systems was negative for headache, fever, chills, rash, earache, sore throat, cough, rhinorrhea, vision changes, weight loss, or change in appetite or disposition. The patient was afebrile, and this blood pressure was slightly elevated. PHYSICAL EXAMINATION: General: The patient is a pleasant male who appears to be in no apparent distress. Vital Signs: blood pressure 123/48, heart rate 76, Temperature 38.3 and 98% on room air. HEENT: Extraocular muscles are intact. Pupils are equal, round, and reactive to light and accommodation. Neck: Supple. No jugular vein distention noted. No carotid bruits noted . Lungs: Clear to auscultation bilaterally. No wheezes, rubs or rhonchi. Heart: Regular rate and rhythm. Normal S1, S2. A 2/6 to 3/6 systolic ejection murmur at the right upper sternal border. PMI is nondisplaced. Abdomen: Notable for laparoscopy surgical wound. Positive bowel sounds. Extremities: MTP is red, hot and swollen. Neurologic: The patient is alert and oriented x3. No focal neurologic deficits noted. Pathophysiology Gout is an inflammatory disease characterized by the deposition of uric acid crystals in and around joints, subcutaneous tissues, and kidneys. Although men and women are equally affected by gout, men are six times more likely to have serum concentrations above 7 mg per dL. Gout typically occurs during middle age and is uncommon before the age 30 years old. Women rarely have gouty arthritis attacks before menopause 1. Clinical Presentation Gout attacks are usually associated with precipitated events. Patients usually present with rapid onset of severe pain, swel ling, redness, and warmth in one or tow joints. This pain and inflammation are caused by inflammatory response. Acute attack untreated attacks usually last two to 21 days depending on cases. There are four clinical stages of gout according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). The first stage is known as asymptomatic hyperurecemia. During this stage, the patients can have an elevation of uric acid in the blood but they do not have any symptoms yet. After more and more urate deposits around a joint and if any trauma triggers the release of crystal into the joint space, patients will suffer acute attacks of gout. This second stage is known as acute gouty arthritis. The third stage, known as interval or intercritical gout, involves the interval between acute flare gout attacks with persist crystals in the joints. When crystals deposits continue to accumulate, patients are likely to develop chronically stiff and swollen joints. This stage is called chronic tophceous gout. Some permanent damage to affected joints and sometimes to kidneys can be seen. This advanced stage is relatively uncommon if patients receive proper treatment. Differential Diagnosis Gout in the elderly is often polyarticular and involves upper extremity joints (especially proximal interphalangeal joints and distal interphalangeal joints). Women present 70% of the time with polyarticular disease rather than the classic monoarticular arthritis seen in men. Gout can be mistaken for rheumatoid arthritis because tophi may resemble rheumatoid nodules and rheumatoid factors often become weakly positive as people age. It may be difficult to differentiate cellulitis or septic arthritis from gout, particularly when a fever, leukocytosis, redness, or desquamation is present. The term pseudogout, for calcium pyrophosphate deposition disease, belies the difficulty in clinically differentiating it from gout. For definitive diagnosis, joint fluid must be aspirate d for culture and a search for urate crystals.