1. Gout History
Mono/ oligoarticular crystal arthropathy characterised by presence of negatively Joints monoarticular + - progressing to oligoarticular involvement
•
st
birefringent uric acid crystals in joints; associated with hyperuricemia 1 metatarsal
• knees, ankles
• inflammation believed to be due to WBCs phagocytosing urate crystals; WBCs acute onset
release inflammatory mediators • pain, swelling, warmth, decreased movement, loss of function
• 90% men, women mostly postmenopausal asymptomatic between attacks
• >30y To exclude Autoimmune/ CTD
other causes of • alopecia, malar rash, photosensitivity, oral ulcers
Clinical Manifestations (5) arthritis • nodules, conjunctivitis, keratitis
• asymptomatic hyperuricemia (technically not gout) • stretching of skin, dysphagia
• acute arthritis • systemic involvement – lungs, cardiac, renal
• chronic tophaceous gout IBD
• urate urolithiasis • chronic bloody mucoid diarrhea
• urate nephropathy • eye involvement
Gonococcal
DDx: • sexual history
• Septic Arthritis (can coexist with gout) • urethral discharge
• Pseudogout Reiters
• If oligoarticular, rheumatoid arthritis • genital ulcers, diarrhea, conjunctivitis
• other autoimmune conditions Reactive
•
st
history of diarrhea/ URTI 2 weeks before 1 episode
Skin Tophi (big toe, ears, hands, feet)
Causes of gout pruritis, desquamation of surrounding skin after attack
Renal Renal colic, loin to groin pain suggesting stones
Primary Hyperuricemia S/S CRF
Increased production of purine Idiopathic • decreased urine output
0
Genetic Enzyme Defects e.g. Lesch 2 causes Malignancies
Nyhan Syndrome • LOW/ LOA
Decreased renal clearance of uric acid Idiopathic • LNs
Anemia history
Secondary Hyperuricemia Long-standing renal disease
Increased turnover of purine Malignancies Drug history
• myeloproliferative disorder MTX/ aspirin/ diuretics
• lymphoproliferative disorder e.g. Gout • as follows
leukemia Medications
Chronic hemolytic anemias Associated • HTN
Cytotoxic drugs e.g. MTX
Metabolic • DM
Decreased renal clearance of uric acid Renal disease
conditions • Hyperlipidemia
Drug-induced • IHD
• low dose aspirin
• loops and thiazides

2. Physical Exam (Short Case Style) Between Attacks
Lifestyle changes lose weight
st
Feet palpate tophi - podagra seen on 1 metatarsal joint avoid alcohol
palpate metatarsal – warm/ tender? suggests acute attack avoid hyperuricemia medx
Other joints Ankles, knees avoid purine-rich foods – all
Tophi Olecranon bursa meats, yeasts, beans, seafood
Helix of ear Allopurinol avoid during acute attacks, rash -> SJS
Achilles tendons (xanthine oxidase exacerbates it hepatitis
Causes of • LNs and abdomen to suggest hemato malignancy inhibitor) good for
secondary gout • Signs of CRF – sallow skin, pruritus • chronic tophaceous gout
Complications • Signs of CRF – sallow skin, pruritus • urate renal stones
Associated mtb • BP – HTN • urate nephropathy
conditions • dipstick - glycosuria Uricosurics probenicid • ineffective in patients with
sulfinpyrazole renal insufficiency
• MUST encourage
drinking lots of water,
Investigations ensure urine output
• confirm diagnosis of gout
>2L/day, else crystals
• etiology of gout may form in GU tract
• complications of gout
• associated metabolic conditions
Bloods FBC+PBF
• raised WBC suggest septic arthritis
• grossly raised WBC + blasts suggest blood CA
Serum uric acid level
U/E/Cr for RF
Radio Xray affected joint
• soft tissue swelling
• punched-out erosions adjacent to tophi strongly suggests
gout
Joint aspiration send for culture
if acute attack send tor histopatholody
• neddle-shaped crystals, negatively birefringent
Associated • fasting plasma glucose
conditions • serum lipids
Management
Acute Episode
Bed Rest For 24h after pain subsides Digitally signed by DR WANA HLA SHWE
NSAIDS Indomethacin DN: cn=DR WANA HLA SHWE, c=MY, o=UCSI
University, School of Medicine, KT-Campus,
Colchicine Abdominal cramps Terengganu, ou=Internal Medicine Group,
D+V email=wunna.hlashwe@gmail.com
Reason: This document is for UCSI University, School
marrow suppression of Medicine students.
renal Date: 2009.02.26 15:04:08 +08'00'
Steroids if above don’t work