WBR0240

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. The diagnosis of acute gout is made by visualization of urate crystals in a sample of fluid aspirated from an affected joint (or bursa). The patient feels better after treatment with anti-inflammatory agents. What is the most appropriate line of management of the patient at this stage?]]
Answer A	AnswerA::Nutritional and lifestyle strategies
Answer A Explanation	[[AnswerAExp::Incorrect : In patients presenting with gouty arthritis and normal renal function but without visible or palpable tophaceous deposits or radiographic evidence of joint destruction or bony erosions, it should be possible to manage their disease successfully with life-style modifications, combined when necessary with pharmacologic therapy.]]
Answer B	AnswerB::Advice NSAIDs on every attack
Answer B Explanation	[[AnswerBExp::Incorrect : While prolonged use of colchicine and NSAIDs may prevent recurrent episodes of gouty arthritis, they do not prevent the development of silent bony erosions and tophaceous deposits.]]
Answer C	AnswerC::Start him on Allopurinol after 2 weeks
Answer C Explanation	[[AnswerCExp::Correct : More than two or three attacks annually are often quoted as an indication for urate-lowering treatment (Allopurinol). However, starting the patient on urate lowering drug would be the best management to prevent recurrent attack of gout and allopurinol can be used in any cause of hyperuricemia.]]
Answer D	AnswerD::Start him on Allopurinol immediately
Answer D Explanation	[[AnswerDExp::Incorrect : It has long been advocated that urate-lowering therapy should not be initiated until after an acute gout flare has resolved, and we wait at least two weeks after an acute flare has subsided to initiate urate-lowering medication.]]
Answer E	AnswerE::Start him on methotrexate
Answer E Explanation	[[AnswerEExp::Incorrect : Methotrexate has no role in the management of gout.]]
Right Answer	RightAnswer::C
Explanation	[[Explanation::Upon resolution of an acute gouty attack, the patient is said to have entered an intercritical (between attacks) period. Intervals between attacks of acute gouty arthritis are of variable duration. The majority of untreated patients with gout will experience a second episode within two years. The general goal of antihyperuricemic therapy is to maintain a serum urate concentration of <6 mg/dL (<357 micromol/L), which is substantially below the urate concentration (6.8 mg/dL [405 micromol/L]) at which monosodium urate is saturating in extracellular fluids. Educational Objective: References: ]]
Approved	Approved::Yes
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