WBR0239

Author	[[PageAuthor::Mugilan Poongkunran M.B.B.S [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Musculoskeletal/Rheumatology
Prompt	[[Prompt::A 56 year old man comes to the emergency department with severe pain in the right great toe. He says that this is the first time he is experiencing such a severe pain and it started suddenly when he woke up from his bed this morning. He is a chronic alcoholic and smokes 2 packs of cigarette a day. He denies any trauma to his leg. On examination, his right toe is swollen, erythematous and he did not allow touching because of severe pain. What is the most appropriate line of management?]]
Answer A	AnswerA::Arthrocentesis
Answer A Explanation	AnswerAExp::'''Incorrect''' : The diagnosis of acute gout is most secure when supported by visualization of urate crystals by experienced examiners in a sample of fluid aspirated from an affected joint (or bursa).
Answer B	AnswerB::Serum uric acid levels
Answer B Explanation	[[AnswerBExp::Incorrect : Serum uric acid (sUA) levels can be difficult to interpret during an acute gout flare. For example, in the early months of urate-lowering drug therapy, gout attacks often occur with normal or even low serum urate concentrations at the time of the acute event. Lower urate levels have also been proposed to result from effects of cytokines during flares.]]
Answer C	AnswerC::X ray of the great toe
Answer C Explanation	[[AnswerCExp::Incorrect : Subcortical bone cysts apparent on plain radiograph or magnetic resonance imaging (MRI) examination identifying gouty tophi or erosions. Changes of these types seen in imaging procedures are not usually detectable at the time of the first acute attack of gouty arthritis]]
Answer D	AnswerD::Cochicine
Answer D Explanation	[[AnswerDExp::Incorrect : In patients with NSAID intolerance or with an absolute (or often relative) contraindication to NSAIDs, we suggest the use of oral colchicine. Oral colchicine is most likely to be effective if treatment is started within 12 to 24 hours of symptom onset, and incipient attacks may frequently be aborted by using low-dose oral colchicine as soon as the patient perceives the first sign of an attack. We generally do not use colchicine for acute attacks that have been ongoing for more than 72 to 96 hours because of the diminished likelihood of benefit.]]
Answer E	AnswerE::NSAIDs
Answer E Explanation	[[AnswerEExp::Correct : NSAIDs is the correct option as they are most effective if treatment is initiated within 48 hours of the onset of symptoms. The dose may be reduced after a significant reduction in symptoms has occurred, but the frequency of dosing should be maintained for several more days for optimal anti-inflammatory effect.]]
Right Answer	RightAnswer::E
Explanation	[[Explanation::Acute gout (or a gout flare) is an intensely painful and disabling inflammatory arthritis usually involving a single joint but occasionally involving two or more joints. Clinical diagnosis of gout can be made with the following: • A classic history of one or more episodes of monoarticular arthritis followed by intercritical period(s) completely free of symptoms • Maximum inflammation (with the features described above) within 24 hours • Unilateral first metatarsophalangeal joint attack (podagra) • Presence of a visible or palpable lesion, which by location or appearance is likely to be a tophus. Once after making the diagnosis, treatment should be initiated. The goal of therapy in an acute gout attack is prompt and safe termination of pain and disability. Treatment should start as soon as possible after the patient perceives the beginning of an attack, preferably within several hours of symptom onset. More rapid and complete resolution of symptoms occurs the earlier that treatment is introduced, especially if treatment is initiated at the full recommended dose of the chosen antiinflammatory agent. Educational Objective: References: ]]
Approved	Approved::Yes
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