Gout
Doctor Information
Mr Robert Kerring, 44 years old
Past Medical History:
Hypertension: last BP 135/78
BMI: 33
Drug History:
Bendroflumathiazide 2.5mg
Last Entry:
Seen by Practice Nurse for blood pressure check yesterday.
BP: 135/78, tolerating anti-hypertensives well. Patient Informed me that 2 days ago he had started with a painful big toe. He had taken ibuprofen, which had settled the pain over 48 hours, and is now almost gone. I advised him to go and see a GP to exclude gout.
Past Medical History:
Hypertension: last BP 135/78
BMI: 33
Drug History:
Bendroflumathiazide 2.5mg
Last Entry:
Seen by Practice Nurse for blood pressure check yesterday.
BP: 135/78, tolerating anti-hypertensives well. Patient Informed me that 2 days ago he had started with a painful big toe. He had taken ibuprofen, which had settled the pain over 48 hours, and is now almost gone. I advised him to go and see a GP to exclude gout.
Patient Information
Mr Robert Kerring,, 44 years old.
You will readily reveal the following:
Presenting Complaint: Pain in your right big toe
History of Presenting Complaint: This all started around 3 days ago, when you woke up in the middle of the night with terrible pain in your foot. When you looked down you noticed that your right big toe was swollen, red and incredibly tender. You tried to get out of bed to get some pain killers, but you couldn’t actually put your foot down, and had to hop to the bathroom to get some pain killers.
You had tot make the next day of work as you simply could not drive to work. Over the next 24 hours things did start to settle down, and now things are almost back to normal. Although you still have to take ibuprofen regularly otherwise you couldn’t walk around. You’ve never known pain like it, it was absolutely intense!
You went to see the practice nurse, who said that he should come to see a GP as she thought this may have been gout.
Reveal the following if asked:
You’ve not had any previous episodes like this, you’ve not had any injuries to that foot / toe, you’ve not had any falls nor any trauma to that area in the last few days. You’ve never had any problems in that joint before. You have no symptoms consistent with kidney problems nor diabetes. If asked specifically: you have noticed some whitish lumps on your ears, that have developed over the past few months, as they weren't causing you problems.
Social History: You know that your weight is a little on the high side, and you know your diet isn’t the best. You like eating seafood and red meats. You especially love anything with beef in it. Your alcohol intake is around 1-2 bottles of beer most evenings. Your exercise regime is best described as minimal, as you’re not keen on going to the gym, or jogging outside. You work as an accountant, and have done for several years. You live at home with your wife and your 8 year old son. You have never smoked.
Past Medical History: You have been diagnosed with high blood pressure for over 6 years. And you take one small water tablet a day to control it - Bendroflumathiazide. You have been on this tablet for 3 years without any problems. Your last BP check was excellent. Your last set of bloods were taken almost 2 years ago, and it was normal as far as you were aware. No known drug allergies.
Family history: No known kidney problems. No other known problems that run in your family.
Ideas: You don’t know what’s causing it, but you’re intrigued by this gout - what is it, and is this what you could have had?
Concerns: You are wired about what having gout may mean for you? is there anything you need to do about this?
Expectations: You would like the doctor to tell you about what gout is, is that what you had? Also, what do I need to do now to stop it from happening again
You are receptive to both diet advice and any medications offered.
You will readily reveal the following:
Presenting Complaint: Pain in your right big toe
History of Presenting Complaint: This all started around 3 days ago, when you woke up in the middle of the night with terrible pain in your foot. When you looked down you noticed that your right big toe was swollen, red and incredibly tender. You tried to get out of bed to get some pain killers, but you couldn’t actually put your foot down, and had to hop to the bathroom to get some pain killers.
You had tot make the next day of work as you simply could not drive to work. Over the next 24 hours things did start to settle down, and now things are almost back to normal. Although you still have to take ibuprofen regularly otherwise you couldn’t walk around. You’ve never known pain like it, it was absolutely intense!
You went to see the practice nurse, who said that he should come to see a GP as she thought this may have been gout.
Reveal the following if asked:
You’ve not had any previous episodes like this, you’ve not had any injuries to that foot / toe, you’ve not had any falls nor any trauma to that area in the last few days. You’ve never had any problems in that joint before. You have no symptoms consistent with kidney problems nor diabetes. If asked specifically: you have noticed some whitish lumps on your ears, that have developed over the past few months, as they weren't causing you problems.
Social History: You know that your weight is a little on the high side, and you know your diet isn’t the best. You like eating seafood and red meats. You especially love anything with beef in it. Your alcohol intake is around 1-2 bottles of beer most evenings. Your exercise regime is best described as minimal, as you’re not keen on going to the gym, or jogging outside. You work as an accountant, and have done for several years. You live at home with your wife and your 8 year old son. You have never smoked.
Past Medical History: You have been diagnosed with high blood pressure for over 6 years. And you take one small water tablet a day to control it - Bendroflumathiazide. You have been on this tablet for 3 years without any problems. Your last BP check was excellent. Your last set of bloods were taken almost 2 years ago, and it was normal as far as you were aware. No known drug allergies.
Family history: No known kidney problems. No other known problems that run in your family.
Ideas: You don’t know what’s causing it, but you’re intrigued by this gout - what is it, and is this what you could have had?
Concerns: You are wired about what having gout may mean for you? is there anything you need to do about this?
Expectations: You would like the doctor to tell you about what gout is, is that what you had? Also, what do I need to do now to stop it from happening again
You are receptive to both diet advice and any medications offered.
Examination Findings
Examination
Pulse 70 regular, BP 135/78,
BMI 33: waist 39cm.
Right 1st MTP: swollen, slightly erythematous and tender to press.
Ears: tophi seen on both ears.
Urine dip: NAD
Pulse 70 regular, BP 135/78,
BMI 33: waist 39cm.
Right 1st MTP: swollen, slightly erythematous and tender to press.
Ears: tophi seen on both ears.
Urine dip: NAD
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Clarifies the problem & nature of decision required Gathers information from history taking, examination and investigation in a systematic and efficient manner. Is appropriately selective in the choice of enquiries, examinations & investigations Identifies abnormal findings or results & makes appropriate interpretations |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them |
Clinical Management Skills
|
POSITIVE INDICATORS
Recognises presentations of common physical, psychological & social problems. Offers appropriate and feasible management options Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions Manages risk effectively, safety netting appropriately Simultaneously manages multiple health problems, both acute & chronic Encourages improvement, rehabilitation, and, where appropriate, recovery. Encourages the patient to participate in appropriate health promotion and disease prevention strategies |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Follow-up arrangements are absent or disjointed Fails to take account of related issues or of co-morbidity Unable to construct a problem list and prioritise Unable to enhance patient’s health perceptions and coping strategies. |
Inter Personal Skills
|
POSITIVE INDICATORS
Explores patient’s agenda, health beliefs & preferences. Shows responsiveness to the patient's preferences, feelings and expectations Enhances patient autonomy Provides explanations that are relevant and understandable to the patient Responds to needs & concerns with interest & understanding Backs own judgment appropriately Does not allow own views/values to inappropriately influence dialogue |
NEGATIVE INDICATORS
Does not inquire sufficiently about the patient’s perspective / health understanding. Pays insufficient attention to the patient's verbal and nonverbal communication. Fails to explore how the patient's life is affected by the problem. Instructs the patient rather than seeking common ground Fails to empower the patient or encourage self-sufficiency Uses inappropriate (e.g. technical) language Inappropriately influences patient interaction through own views/values Treats issues as problems rather than challenges Appears patronising or inappropriately paternalistic |
Management
Explanation:
Gout is a type of arthritis caused by uric acid crystals forms in and around joints. The most commonly affected joints include the big toe and knees. An anti inflammatory pain killer usually eases the symptoms quickly. Lifestyle factors may reduce the risk of having gout attacks. If gout attacks recur then taking daily medication may be an option.
Assessment:
Enquire about possible risk factors for developing gout:
Exclude alternative diagnosis:
Gout can be diagnosed on history and examination alone, however there are some Investigations that might be worth doing. These include:
Management:
Acute Gout:
Acute gout can be managed by using any of the following:
Self Care: For mild attacks, rest and elevate the limb, use ice packs on the affected joint and avoid any further trauma
Medications:
NSAIDS are considered 1st line in management.
If NSAIDS are contra-indicated then consider using low dose colchicine (500mcg BD - QDS up to max of 6mg in one dose)
Oral Steroids are an option if the above are contra-indicated.
Intra-muscular steroids can be very effective, as can Intra-articular steroid injection if the expertise is present to perform such a procedure.
DON'T stop Allopurinol during an acute attack.
Preventing Gout:
Gout is a type of arthritis caused by uric acid crystals forms in and around joints. The most commonly affected joints include the big toe and knees. An anti inflammatory pain killer usually eases the symptoms quickly. Lifestyle factors may reduce the risk of having gout attacks. If gout attacks recur then taking daily medication may be an option.
Assessment:
Enquire about possible risk factors for developing gout:
- Alcohol intake.
- Dietary intake of purines (red meat and seafood).
- Drugs that raise plasma urate levels: Aspirin, Diuretics (thiazide and loop), Ciclosoprin, Cytotoxic drugs
- Family history.
- Known kidney problems.
Exclude alternative diagnosis:
- Septic arthritis, (admit if suspected)
- Pseudogout
- Oseteo arthritis
- Psoriatic arthritis
- Rheumatoid or reactive arthritis
Gout can be diagnosed on history and examination alone, however there are some Investigations that might be worth doing. These include:
- Uric Acid: Not the most accurate test, with a sensitivity around 60%, but a high specificity or over 90%. This means that a normal result does not exclude the diagnosis of gout, but a high result is likely to mean gout. Do not test immediately, as an acute attack of gout can lower uric acid levels within the first few weeks, so check after 4-6 weeks.
- Renal Function: Reduced renal function is a possible cause of gout.
- Diabetic screen, and cholesterol testing: The diagnosis of gout is heavily associated with other co-morbidities, such as hypertension, diabetes and cardiovascular disease. Therefore any diagnosis should include a screen for these conditions.
Management:
Acute Gout:
Acute gout can be managed by using any of the following:
Self Care: For mild attacks, rest and elevate the limb, use ice packs on the affected joint and avoid any further trauma
Medications:
NSAIDS are considered 1st line in management.
If NSAIDS are contra-indicated then consider using low dose colchicine (500mcg BD - QDS up to max of 6mg in one dose)
Oral Steroids are an option if the above are contra-indicated.
Intra-muscular steroids can be very effective, as can Intra-articular steroid injection if the expertise is present to perform such a procedure.
DON'T stop Allopurinol during an acute attack.
Preventing Gout:
Taken from NICE CKS - lifestyle advice for those with gout:
◦ Aim for an ideal body weight — but avoid crash dieting and high protein/low carbohydrate diets.
◦ Eat sensibly — by restricting the amount of red meat and avoiding a high protein intake. Avoid excessive consumption of foods rich in purines (such as liver, kidneys, and seafood).
◦ Drink alcohol sensibly — by avoiding binge drinking and restricting alcohol consumption to 21 units per week for men and 14 units per week for women, with at least two alcohol-free days a week.
◦ Avoid dehydration by drinking water (up to 2 litres/day unless there is a medical contraindication)
◦ Drink skimmed milk or consume low-fat dairy products (up to 2 servings daily).
◦ Limit consumption of sugary drinks and snacks.
◦ Take regular exercise — but avoid intense muscular exercise and trauma to joints.
◦ Stop smoking — see CKS topic on Smoking cessation.
◦ Consider taking vitamin C supplements.
Drug treatment:
Start after >1 attack in 12 months, or after the first attack if has tophi, gouty arthritis, joint damage, renal impairment (EGFR<60), uric acid stones or on long term diuretics.
1st line: Allopurinol
2nd line: Feboxustat
Start medication 1–2 weeks after the attack has settled, titrating the dose every few weeks until the serum uric acid level is below 300 micromol/L. When starting allopurinol, co-prescribe a low dose of Colchicine or an anti-inflammatory to prevent precipitating an acute attack:
Inform the patient that treatment is usually life long, and that repeat uric acid levels will be taken every 12 months.
Start after >1 attack in 12 months, or after the first attack if has tophi, gouty arthritis, joint damage, renal impairment (EGFR<60), uric acid stones or on long term diuretics.
1st line: Allopurinol
2nd line: Feboxustat
Start medication 1–2 weeks after the attack has settled, titrating the dose every few weeks until the serum uric acid level is below 300 micromol/L. When starting allopurinol, co-prescribe a low dose of Colchicine or an anti-inflammatory to prevent precipitating an acute attack:
- Prescribe Colchicine for up to 6 months (usually 3 months).
- Prescribe NSAIDs for up to 6 weeks and consider the need for gastro-protective medication.
- If NSAIDs and colchicine are contraindicated, consider low-dose oral prednisolone once a day for 4 to 12 weeks.
Inform the patient that treatment is usually life long, and that repeat uric acid levels will be taken every 12 months.