Israel is a 45 year old man of Torres Strait Islander descent who presents with 1 day history of pain and swelling of his left 1st MTP. He admits to have been eating lots of “junk food” and drinking more alcohol than normal over his birthday festivities held recently.
What are the key additional features of history you would like to elicit in Israel? (List 8)
- Systemic Fever
- Joint heat
- Joint redness
- Presence of tophi
- History of previous attacks
- History of IVDU
- Recent surgery to area
- Recent trauma
- Family history of arthritis disorders
What is the most important initial investigation would you perform to differentiate between diagnoses? (List 1)
- Joint aspiration for Microscopy and Culture
Source – SpotonHealth, eTG
What is the most likely diagnosis? (List 1)
- Acute gout
What immediate pharmacological management options could you institute? (List 4)
- Local corticosteroid injection, stat
- Ibuprofen 400mg QID, oral, 5 days
- Prednisone 30mg daily , oral, days
- Colchicine 1 mg orally initially, then 500 micrograms 1 hour later
Source – eTG
NB options listed are at the upper end of the ranges in eTG.
What non-pharmacological management options could you present to Israel to reduce the likelihood of this presentation in future? (List 5)
- Improved dietary control with less purine-rich food
- Alcohol minimisation
- Adequate hydration
- Exercise 30 min daily
- Avoidance of sugary soft drinks
- Wearing comfortable shoes
- Weight reduction
GPCC Comment
Gout, acute and chronic management, gouty tophi, with all of the links to other associated diseases are deep within the core content for exams and questions on this topic probably appear frequently.
My opinion on the exams is that the College wants a firm commitment to a diagnosis based on patterns, with the occasional safety question, perhaps one or two per exam only, and the safety stuff is (hopefully) obvious. This is a clear commitment to acute gout in this question, then the features listed would be the features of gout. The hard bit is not repeating things that were listed in the stem already, and sometimes there are a lot of responses which tests the limits of knowledge, and sometimes not as many as you expected, which makes it hard to choose the highest priority ones.
RACGP Comment
This case featured a middle-aged Torres Strait Islander male patient presenting with signs of acute gout. Candidates were required to provide the specific pharmacological management of the initial acute presentation, as well as the longer-term non-pharmacological strategies to minimise further episodes.
The most common error in this case was not listing the range of management options, but focusing on three different nonsteroidal anti-inflammatory drugs (NSAIDs). The question requested specific management, namely the appropriate dosing regimen for acute management, not merely providing the drug name. While naming the drug would have gained marks, providing the appropriate regimen for each management option resulted in a higher score.
In the non-pharmacological management component of this case, candidates recommended that the patient quit smoking, when there was no history of smoking, or provided vague, non-specific answers, such as provide education or refer to various allied health professionals, without specifying the content of the education or the purpose of the referral. When referring to another health professional, candidates should consider outlining the nature and urgency of the referral.
Study References
- AFP – two articles on gout, here and here.
- eTG – lots of good info at the required level here.
- SpotonHealth – Gout
- Murtaghs p371 – note difference in details between eTG and Murtaghs’s, and err on side of eTG (IMO)
- https://www.gptrove.net/msk/ – good overview
