Makindo Medical Notes

History Taking

• Onset and Duration:
  • When did the pain and swelling start? Was the onset acute or gradual?
  • Is it the first episode, or has the patient experienced recurrent attacks?
• Location of Affected Joints:
  • Which joints are involved (e.g., first metatarsophalangeal joint in gout, knee in pseudogout)?
  • Is the involvement monoarticular (one joint) or polyarticular (multiple joints)?
• Associated Symptoms:
  • Ask about fever, chills, or systemic symptoms suggesting an inflammatory process.
  • Any history of kidney stones (gout) or chronic joint issues?
• Risk Factors:
  • Dietary habits: High intake of purine-rich foods (e.g., red meat, seafood) in gout.
  • Alcohol consumption, obesity, diuretics, or other medications (e.g., loop diuretics) that may increase the risk of gout.
  • In pseudogout, consider a history of metabolic diseases (e.g., hyperparathyroidism, hemochromatosis).

Physical Examination

• Joint Inspection:
  • Look for signs of inflammation: Redness, swelling, warmth, and tenderness over the affected joint.
  • In chronic cases, palpate for tophi (in gout) or joint deformities.
• Range of Motion:
  • Assess active and passive range of motion. Pain and limited mobility are common in acute attacks.
• Systemic Examination:
  • Check for systemic signs of inflammation (e.g., fever, malaise).
  • In chronic cases of gout, assess for signs of kidney involvement (e.g., flank pain, haematuria).

Differentials

Investigations

• Joint Aspiration and Synovial Fluid Analysis:
  • Aspirate the affected joint for synovial fluid analysis to identify the type of crystals.
  • Gout: Monosodium urate crystals (negatively birefringent, needle-shaped).
  • Pseudogout: Calcium pyrophosphate dihydrate crystals (positively birefringent, rhomboid-shaped).
• Blood Tests:
  • Serum uric acid levels to assess for hyperuricemia in gout (note: uric acid may be normal during acute attacks).
  • Inflammatory markers (e.g., ESR, CRP) to assess for systemic inflammation.
  • Calcium, phosphate, and parathyroid hormone levels in suspected cases of pseudogout related to metabolic disease.
• Imaging:
  • Plain radiographs may show joint damage, erosions, or soft tissue calcifications (e.g., in chronic gout or pseudogout).
  • In chronic gout, radiographs may reveal punched-out erosions with overhanging edges.

Management

• Acute Attack Management:
  • NSAIDs: First-line treatment for pain and inflammation.
  • Colchicine: Effective in both acute gout and pseudogout. Use early in the attack for maximum benefit.
  • Corticosteroids: Oral or intra-articular injections if NSAIDs and colchicine are contraindicated or ineffective.
• Chronic Management (for recurrent attacks):
  • Gout: Uric acid-lowering therapies like allopurinol or febuxostat to maintain serum uric acid below target levels (typically <6 mg/dL).
  • Dietary Modifications: Reduce purine intake (red meat, seafood), limit alcohol, and maintain a healthy weight.
  • Pseudogout: Treat underlying metabolic conditions (e.g., hyperparathyroidism, hypomagnesemia) and maintain joint function with physical therapy.
• Non-Pharmacological Interventions:
  • Ice packs and rest during acute flares to reduce pain and swelling.
  • Physical therapy for chronic joint issues to maintain mobility and function.