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Self-Assessment Questions

Rheumatology

Gout: Review Questions

Neil J. Gonter, MD

Dr. Gonter is an assistant clinical professor of medicine, Columbia University, New York, NY, and a practicing rheumatologist, Rheumatology Associates of North Jersey, Teaneck, NJ.



Choose the single best answer for each question.



Figure 1

Questions 1 to 3 refer to the following case.
An 88-year-old man presents to his primary care physician complaining of difficulty holding the phone with his right hand. He reports chronic morning stiffness that lasts 1 hour, but he has had no recent episodes of acute swelling. Examination of the patient’s right hand reveals swelling and several hard nodules across the third digit (Figure 1). His past medical history is notable for chronic kidney disease, with the most recent laboratory tests demonstrating a serum creatinine level of 2.9 mg/dL (normal, 0.6-1.2 mg/dL), and a long history of “rheumatism.”

1. Which of the following should be obtained to most accurately diagnose this patient’s condition?

  1. 24-Hour urine collection for uric acid
  2. Microscopic examination of tissue aspirate
  3. Radiographs of the patient’s hands
  4. Rheumatoid factor
  5. Serum uric acid level
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2. Once a diagnosis of gout is confirmed, goals of therapy should include which of the following?

  1. Decrease the serum uric acid level to less than 4.0 mg/dL
  2. Decrease the serum uric acid level to less than 6.0 mg/dL
  3. Decrease the serum uric acid level to less than 8.0 mg/dL
  4. Normalize the erythrocyte sedimentation rate
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3. What therapy should be used in the management of this patient?

  1. Allopurinol
  2. Indomethacin
  3. Intravenous (IV) colchicine
  4. Prednisone
  5. Probenecid
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Questions 4 and 5 refer to the following case.
A 63-year-old male construction worker presents to the primary care physician with difficulty using his left elbow over the past few days. He states that he is unable to bend it easily and it is hot to the touch and painful. On examination, the elbow is red, swollen, and tender to light touch (Figure 2). There are no other areas of swelling or erythema. He denies fever, recent trauma, or previous history of joint problems. He drinks a 6-pack of beer daily and smokes 1 pack of cigarettes per day. He states that his father and 2 brothers have gout.




Figure 2

4. What is the first step in the management of this patient?

  1. Aspirate the olecranon bursa
  2. Prescribe pain medication
  3. Radiography of the elbow
  4. Start antibiotics
  5. Start colchicine
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5. Aspiration reveals thick yellow fluid. Microscopic examination of the aspirate reveals many white blood cells, red blood cells, and thin, needle-shaped crystals that are both intracellular and extracellular. What is the next step in this patient’s management?

  1. Inject steroids
  2. Start allopurinol
  3. Start antibiotics
  4. Start oral colchicine
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6. A 55-year-old man presents to the medical residents’ clinic with a complaint of “the longest gout attack of my life.” Physical examination is notable for several hot, swollen, and tender metacarpophalangeal and metatarsophalangeal joints bilaterally. The patient was diagnosed with gout 10 years ago. He usually has 1 to 2 acute gout attacks per year, which are typically treated with indomethacin with resolution after 3 to 5 days. At his last clinic visit 3 weeks ago, the patient was noted to have tophi on both elbows as well as several on the peripheral and distal interphalangeal joints. Laboratory tests revealed a uric acid level of 7.6 mg/dL (normal, 4.0-8.0 mg/dL), and kidney function was normal. He was prescribed allopurinol 300 mg daily. How should this patient be managed at this time?

  1. Add acetaminophen to this patient’s current medication regimen
  2. Check the patient’s uric acid level and increase the dose of the allopurinol if the uric acid level is still high
  3. Start colchicine and indomethacin twice daily
  4. Stop the allopurinol because it should not be taken during an acute attack
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