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Gout is a monoarthropathy caused by deposition of monosodium urate crystals in hyperuricaemia. 

Hyperuricaemia risk factors

  • Male gender
  • Chronic kidney disease
  • Diuretics
  • Purine rich diet: alcohol, meat, seafood
  • Obesity

Clinical features

  • Tender, inflamed joint
    • Usually a monoarthritis
    • Commonly affects first metatarsophalangeal joint
    • Other joints include ankles, knees, wrists, finger joints
    • Arthralgia worse at night
  • Acute episodes last around 2 weeks 
  • Other features of hyperuricaemia
    • Gouty tophi
    • Renal nephrolithiasis

Investigations

  • Bloods: uric acid level (hyperuricaemia seen in gout, but uric acid level may be falsely low or normal during attack)
  • Needle aspiration of synovial fluid – gold standard 
    • Send for polarising microscopy 
    • Send for microbiology: to rule out septic arthritis
  • X-Ray

Management

  • Treat cause
    • Lifestyle: keep hydrated, avoid purine rich food/drink, avoid fasting, lose weight
    • Medication review: thiazides and loop diuretics can trigger gout
  • Acute management: NSAIDs, colchicine or corticosteroids
  • Prevention: allopurinol (NB: starting allopurinol can trigger an acute episode of gout so wait 2 weeks for symptoms to subside and offer NSAID/colchicine cover for first 1-3 months); febuxostat may be used if there is a contraindication to allopurinol

Questions

What are the classical features of gout on an X-ray?

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What is pseudogout?

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What are the findings of gout and pseudogout on polarising microscopy?

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Try some OSCE stations

  1. Tophaceous gout exam
  2. Gout history and spotter
  3. Foot and ankle exam
  4. Find lots more here!
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