Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are currently a doctor working in family medicine. Your next patient is a 34-year-old gentleman (Michael A Jordan) presenting with foot pain. Please take a history and perform an appropriate examination.
Patient History:
Michael A Jordan, 34-year-old chef.
You have been having sudden increasing left foot pain over the last two days. The pain is located in your big toe, and it is hot and swollen. The pain is sharp, and you rate it 10/10. The pain does not radiate. The pain is always there and is worsened by touching it. You have not tried paracetamol, and it doesn't seem to help. Currently, you are unable to move your toes because of the pain. The joint is also stiff, especially in the morning. No other joint problems.
You feel a little warmer than usual. Unsure if you have any fever. However, last week, you had some nausea and vomiting due to food poisoning, and since then, you have had a poor appetite. You have lost a bit of weight because of this.
Ideas, Concerns, Expectations:
You have no idea what this might be. You think this might be arthritis, as your mother has rheumatoid arthritis. You are concerned as the pain is currently unbearable, and you would like to have some strong pain relief.
Past Medical History:
Obesity, hypercholesteremia, Heart failure, hypertension, previous TIA
Drug History:
Furosemide, ramipril, aspirin, lansoprazole
NKDA
Family History:
Your dad has type 2 diabetes.
Your uncle suffers from a heart condition.
Mother has rheumatoid arthritis.
Social History:
You drink three cans of beer daily
Ex-smoker
You work as a chef in a fine dining restaurant
You live with your wife in a house
Independent at home
Examination Findings:
Erythematous, hot swelling of the left big toe (metatarsophalangeal joint).
Tender to touch – patient moves leg away on palpation of swelling.
Desquamation of overlying skin.
Differentials:
Gout
To rule out Septic Arthritis
Pseudogout
Cellulitis / tenosynovitis
RA/ OA
Investigations:
Bedside:
Observations
Bloods:
FBC/CRP (infection)
U&E (renal function + dehydration)
Serum urate Levels (can be raised, but can be normal in acute gout)
Imaging:
Consider XR foot (lytic lesion in bone / punched-out erosion / sclerotic borders with overhanging edges in gout)
Consider US foot (double-contour sign in gout)
Consider Dual-energy CT (erosions, tophi, double contour line for gout)
Special Test:
Consider Joint aspiration (culture to rule out septic arthritis/gout will show negative birefringent of polarised light + monosodium urate crystals)
Management: