R. is a 33-year-old man who presents to the ED complaining of right knee pain x 3 days.

History elements:

• Constant right knee pain x 3 days
• 7/10 pain
• Worse with movement
• Took Tylenol yesterday for mild relief, but the pain was back in a few hours
• Admits to swelling and warmth to touch
• Difficulty walking and straightening out his leg; feels stiff
• Has never had these symptoms before
• Denies any trauma to the knee that he can remember
• Denies pain radiation
• Works as an accountant, so he spends most of the day sitting. He tries to go running at least 3 days per week in the mornings.
• No significant past medical history
• Does not take any daily medications, vitamins, or herbal supplements
• Tonsillectomy at age 11; no other surgeries, injuries, or blood transfusions
• Sexually active with his girlfriend of 2 years
  • Engages in penis in vagina and oral sex – always with a condom
  • No history of STIs
• Denies tobacco or illicit drug use
• Has “a couple of beers” on the weekends, but admits that he drank much more than he usually does this past weekend (5 days ago)
  • Was celebrating his best friend’s bachelor party and doesn’t remember how much he drank
• Tries to eat healthy foods, but admits to eating mostly red meat at dinner
• Denies fever, chills, body aches, nausea, vomiting, chest pain, SOB, or any other symptoms
• Denies recent travel, outdoor activities, and significant family history

Physical exam:

• Vitals:
  • BP: 138/86 (right arm, sitting)
  • HR: 73 bpm (regular)
  • RR: 18 bpm (nonlabored)
  • Temperature: 98.3 F (oral)
  • Height: 5’11”
  • Weight: 171 lbs
• General:
  • A&O x 3; well developed and well groomed. In no acute distress, but appeared to be in pain as he ambulated with a limp
• Cardiac:
  • RRR; S1 and S2 present with no murmurs, rubs, or gallops
• Lungs:
  • Clear to auscultation bilaterally with no adventitious lung sounds
• Musculoskeletal:
  • Skin overlaying right knee intact. Right knee appears swollen compared to the right and slightly erythematous. No swelling noted in the popliteal fossa. Tenderness to palpation of the right knee (more significant medially) and popliteal fossa. Patient initially resistant to passive motion of the right knee, but allowed extension to 15 degrees and flexion to 120 degrees with significant pain. Negative anterior/posterior drawer, Lachman, McMurray, and valgus/varus stress tests. FROM in all other joints without deformity or abnormality. 5/5 muscle strength throughout bilaterally
• Extremities:
  • Peripheral pulses 2+ throughout. Sensation intact throughout
• Differential Diagnosis:
  • Gout – monoarticular pain and swelling without known trauma following heavy drinking and excessive consumption of red meat
  • Pseudogout – similar presentation to gout; monoarticular pain and swelling without trauma; knee most commonly affected
  • Baker’s cyst – pain, swelling, and stiffness in knee and tenderness to palpation of popliteal fossa
  • Knee ligament injury – pain and swelling; history of running several times per week and recent alcohol consumption
  • Fracture – pain and swelling; recent alcohol consumption
  • Septic arthritis – pain and swelling in joint; slightly warm to touch
• Tests:
  • Right knee x-ray – to rule out fracture or other bony abnormality (especially with recent alcohol consumption before onset of pain that might suggest trauma)
    • Negative for fracture or other bony abnormality. Evidence of soft tissue swelling
  • CBC – to rule out infection (septic arthritis)
    • Within normal limits
  • Serum uric acid level – suggestive of gout if elevated
    • 2 mg/dL
  • Synovial fluid analysis – to confirm gout and rule out pseudogout and septic arthritis
    • Cloudy yellow fluid; WBC 20,145 cells/mm^3 (70% neutrophils); needle-shaped negatively birefringent monosodium urate crystals on polarized light microscopy
  • Treatment:
    • NSAIDs
    • Naproxen 500 mg BID x 10 days
      • Take as needed; typically, only 5-7 days of treatment necessary
    • Patient Counseling
      • Educate on risk factors for gout flares and encourage diet and lifestyle modification
      • Cut down on red meat and other high-purine foods (seafood, spinach, soft drinks, etc.)
      • Limit alcohol consumption
      • Instruct patient to follow up with PCP for future gout flares for evaluation and to determine the necessity for a gout maintenance medication (ex: allopurinol)

https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-gout?search=gout&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H87543959

https://www.uptodate.com/contents/treatment-of-gout-flares?search=gout&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

https://www.uptodate.com/contents/lifestyle-modification-and-other-strategies-to-reduce-the-risk-of-gout-flares-and-progression-of-gout?search=gout&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H392008962

PANCE Prep Pearls V3 – Dwayne Williams