Information Sheet for Candidates

Your next patient as HMO in an emergency department is Mr. Miller, a 35 year old man
who presents with right knee pain, swelling and decreased range of movement for one
day.

Your tasks are to:

Take a focused history

Perform an examination and order appropriate investigations
Discuss your diagnosis and management with the examiner
Advise the patient regarding the management

HOPC:
Mr. Miller noticed some knee discomfort about 3 weeks ago. It started with a gradual
onset and has intermittently been aggravated by weight bearing movement. He works as a
moulder and yesterday he had to perform repetitive twisting movement in the same
direction during work. and noticed acute swelling and increased pain in his right knee
after work. Today, in the morning he couldnt move his knee joint and found it most
difficult to weight bearing on his right side.
He didnt notice any localized redness. No trauma, no other joints involvement.
PHx:
Mr Miller suffered from a single episode of non-traumatic right knee swelling 5 years
ago, which was treated with aspiration and antibiotics. But he was not told what the cause
was. In 2006 he was diagnosed with gout in his left ankle. This was successfully treated
with NSAID.
He was found to have an increased GGT and high cholesterol level due to his severe
alcohol drinking at the time.
No other significant PHx.
FHx: unremarkable
SHx:Mr. Miller lives with his wife and two children. He works in a factory as a
injection moulder. There is lots of physical labor, twisting and stepping up and down.
No kneeling.
He smokes 20-30 cigarettes for 10 years. He drinks 10 cans of beers every day. He eats
lots of meat, including liver and kidney and he also likes shell fish.
No allergies.
EXAMINATION: (LOOK, LISTEN, FEEL !!!!):
One examination, Mr Davis was resting in bed, right knee was elevated by inserting a
pillow underneath because that is the most comfortable position.
T 36.3, P 80, BP 120/75, R 15
On inspection there appears severe swelling in the right knee, especially superior to the
patella with fluctuation and a positive patella tap. The ROM is decreased, no findings of
ligament or meniscus injury.
The rest of the examination is normal.
INVESTIGATION:

GGT markedly elevated, CRP elevated , ESR elevated

Uric acid 0.58 mmol/L (0.2-0.45 mmol/L)
FBE,U+E normal

Knee X-ray: There is a large supra patellar pouch effusion, no fracture or

dislocation identified.
Joint fluid aspiration: cloudy yellow, no lymphocyte, no RBC, no organism, uric
acid crystals +ve.

WHAT IS THE MOST LIKELY DIAGNOSIS?: GOUT!!!

Gout is a recurrent acute arthritis of peripheral joints due to deposition of crystals of
monosodium urate in and around the joints and tendons. It is caused by an inherited
abnormality of the uric acid metabolism, hyperuricaemia (purines!).
In the majority of cases (60-70%) it is due to excessive purine synthesis (diet) or
sometimes due to diminished uric acid clearance via the kidneys.
Urate crystals can collect in joints (gouty arthritis), soft tissue (tophi and tenosynovitis) or
the urinary tract (urate stones!). Patients with gout often suffer from diabetes,
hypertension and dyslipidaemia.
Sypmtoms:
An acute attach often happens without any warning although usually triggered off by a
precipitating event like trauma, certain purine rich foods, alcohol, infections or drugs
(frusemide, thiazide). Typically it is the nocturnal onset of excruciating pain in a great toe
with throbbing, redness, swelling and shiny skin.
In chronic gout, tophi can occur in ear lobes, joints and tendons (Achilles).
Long term complications can be gouty arthritis,chronic tophaceous gout and
Diagnosis:

The diagnosis can usually be made from the history, the distinctive clinical
features and examination.
Elevated serum uric acid
Synovial fluid aspirate shows typical uric acid crystals
Therapeutic response to colchicines
In advanced cases X-rays show punched-out lesions in subchondral bone.

TREATMENT OPTIONS:
1. Acute Attack: termination by use of an anti-inflammatory drug like NSAIDs , e.g.
indomethacin 50 mg, orally tds (!indigestion and high BP) or colchicine 0.5 mg hourly
until pain relief (max. 8 mg).
Intra-articular or oral corticosteroids are useful.
2. Prophylaxis ( about 4 weeks after acute attack):
a) colchicine
b) allopurinol (blocks uric acid production, xanthine oxidase inhibitor!, contraindicated in
acute attack)
c) probenecid (uricosuric therapy, contraindicated in acute attack)
3. Adjuncts:
a) high fluid intake (prevents uric acid stones)
b) alkalinisation of urine to prevent chronic uric acid stone formation
c) weight reduction with a sensible and sustainable reduction in energy intake. Drastic
reduction in food intake may in fact precipitate an attack of gout as the resultant
ketosis may reduce urate excretion.
d) normal, well balanced diet (specific restriction of purine containing food probably not
necessary because of efficiency of medications) although it makes sense to avoid
purine rich foods like meat, particularly organ products like liver, kidney and offal,
shell fish etc. To avoid tomatoes is a myth probably based on the acid component of
the word uric acid and the thinking that any foods associated with acidity are linked
with gout. Eat lots of plant based foods and actually tomatoes are beneficial because of
their high Vit A and C content and antioxidant lycopene, which has been shown to be a
factor in preventing prostate cancer.
e) avoid certain medications like frusemide, thiazides, beta-blockers and aspirin, take
panadol for pain relief and ACE inhibitors for HPT!.
f) reduce alcohol intake!!! Alcohol causes a rise in blood lactate which inhibits urate
excretion