Joint Pain OSCE - Gout

Diagnosis: Gout

Case Overview

  • Age/Sex: 47-year-old male
  • Occupation: Office-based IT worker (sedentary)
  • Setting: Emergency department / urgent clinic
  • Chief complaint: "Painful joints" (acute severe pain in the right big toe)

Patient Script

Who I Am

I am a 47-year-old man who works at a desk all day and I smoke about a pack a week.

What Brings Me In

My right big toe is extremely painful, swollen and red — I can barely put my shoe on or walk.

My Story

About 48 hours ago my right big toe started to ache, and overnight it got much worse — now it is very swollen, hot, and extremely painful, so I woke up this morning and couldn’t put any weight on it. I have had a couple of milder episodes in the past year where my toe hurt for a day or two and then settled, but nothing this bad. I had a kidney stone about 3 years ago which needed treatment. I drink alcohol most weekends and often have several beers and sometimes red meat with my meals. I take a tablet for blood pressure that I started a few years ago. I also cut the toe on the side of the nail about 10 days ago while trimming my toenail, but it healed and didn’t look infected. I tried ibuprofen and paracetamol at home but the pain didn’t improve.

My Medical Background

  • Past medical history: hypertension (diagnosed 3 years ago), history of one kidney stone 3 years ago
  • Medications: hydrochlorothiazide 25 mg daily (for blood pressure), occasional simvastatin for cholesterol
  • Allergies: none known
  • Social: current smoker (about 7–10 cigarettes/day), drinks alcohol most weekends (4–6 beers typical), sedentary job, BMI around 31
  • Family: father had "arthritis" in older age (not sure what type), no known autoimmune disease in family

What I Think & Worry About

  • I think this might be an infection in my toe because it is so hot and painful.
  • I worry I might need my foot operated on or a long course of antibiotics if it’s infected.
  • I want to be able to walk and get back to work; I don’t want this to keep coming back.

If You Ask Me About Other Symptoms...

  • Fever/chills: I felt a bit warm last night but I didn’t have shaking chills.
  • Other joints: my other joints are fine right now, though I had brief aches in this toe before.
  • Recent travel/contact exposures: I haven’t traveled recently and haven’t been around anyone with joint infections.
  • Urinary symptoms: no pain passing urine, no blood in urine now.
  • Recent medications/antibiotics: I took a single antibiotic tablet a month ago for a sore throat (not a full course).
  • Trauma: I mentioned I clipped the side of the toe 10 days ago; it healed.
  • Skin rashes: none elsewhere.

Clinical Summary

Examination

  • General: alert, uncomfortable due to pain, BMI ~31
  • Vitals: Temperature 38.2°C, HR 98 bpm, BP 145/88 mmHg, RR 16/min, SpO2 98% on air
  • Right foot: first metatarsophalangeal (MTP) joint markedly swollen, tense, erythematous, warm and exquisitely tender to touch; patient refuses full weight bearing
  • Other joints: no synovitis of wrists, knees, or other small joints on brief exam
  • Skin: no spreading cellulitis, no draining sinus at the clipped nail site
  • Cardiovascular / respiratory / abdominal: unremarkable

Investigations

  • Full blood count: WBC 13.5 x10^9/L (neutrophils 11.0 x10^9/L) (mild leukocytosis)
  • CRP: 120 mg/L (elevated)
  • ESR: 55 mm/hr (elevated)
  • Serum uric acid: 9.6 mg/dL (570 µmol/L) (elevated)
  • Urea & electrolytes: creatinine 1.4 mg/dL (124 µmol/L) (mildly reduced eGFR ~60 mL/min/1.73m2)
  • Blood cultures: sent (pending)
  • X-ray right foot: soft tissue swelling around 1st MTP; no acute fracture; small marginal erosion at first MTP consistent with chronic gout changes
  • Joint aspiration (right 1st MTP) performed:
    • Appearance: turbid
    • Synovial fluid WBC: 60,000 cells/µL, neutrophil predominant
    • Polarising microscopy: needle-shaped, negatively birefringent crystals consistent with monosodium urate (MSU)
    • Gram stain: no organisms seen
    • Fluid culture: sent (pending)

Diagnosis

Primary diagnosis:

  • Acute gout (podagra) — severe acute monoarthritis of the right first MTP with rapid onset of severe pain, erythema and swelling, hyperuricaemia, and demonstration of intracellular needle-shaped, negatively birefringent monosodium urate crystals in synovial fluid.

Differential diagnoses to consider and reasoning:

  • Septic arthritis: important to exclude because of similar presentation and high synovial WBC; gram stain negative and no organisms seen, but culture pending — aspiration required to rule out and patient should be treated based on clinical risk if culture positive.
  • Cellulitis: would usually have more diffuse skin involvement and less discrete joint swelling; no spreading erythema or lymphangitic streaking and focal joint effusion present.
  • Pseudogout (calcium pyrophosphate deposition): tends to affect larger joints (knee, wrist) and crystals are positively birefringent, rhomboid-shaped — not consistent with current crystal findings.
  • Trauma or fracture: x-ray shows no acute bony injury; history of minor nail cut is unlikely to explain acute severe joint inflammation.

Management

  • Immediate/acute steps:

    • Confirm aspiration results and continue to treat as gout while awaiting cultures; maintain high suspicion for septic arthritis until cultures confirm absence of bacteria.
    • Analgesia: consider NSAID (e.g., naproxen/indomethacin) if no contraindication and renal function acceptable; if NSAIDs contraindicated consider colchicine (dose-adjusted for renal function) or oral corticosteroids (e.g., prednisone 30–40 mg daily) or intra-articular corticosteroid after aspiration.
    • Local care: rest, elevation of foot, ice packs, avoid weight-bearing
    • Stop hydrochlorothiazide (thiazide diuretics can raise uric acid); discuss switch with primary care/GP (e.g., consider ACE inhibitor) — do not abruptly stop other essential meds without plan.

  • Follow-up and longer-term management:

    • Do not start allopurinol (urate-lowering therapy) during the acute attack; consider initiating after 2–4 weeks once attack has settled.
    • If recurrent attacks or tophi: start allopurinol (dose adjusted for renal function) with prophylaxis (low-dose colchicine 0.5 mg once or twice daily or low-dose NSAID) for at least 3–6 months when initiating ULT.
    • Lifestyle advice: reduce alcohol intake (especially beer), reduce intake of red meat and shellfish, encourage weight loss and increased hydration.
    • Arrange follow-up with primary care and consider rheumatology referral if recurrent attacks, tophi, or difficulty with management.
    • Ensure wound over nail is clean and not source of infection; review antibiotic therapy only if cultures indicate infection.

Key Learning Points

  • Gout often presents as a very sudden, severe monoarthritis, classically of the first MTP (podagra); aspiration of the joint is essential to confirm diagnosis and to exclude septic arthritis.

  • Risk factors include male sex, hyperuricaemia, diuretics (thiazides), alcohol and high-purine diet; avoid starting urate-lowering therapy during an acute flare — treat the acute inflammation first and plan long-term urate-lowering after resolution.

  • Always consider septic arthritis in an acute monoarthritis: joint aspiration for cell count, gram stain and culture is mandatory when there is significant effusion and systemic inflammation.

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