Gout is an inflammatory arthritis caused by uric acid crystals that form in and around joints when blood uric acid stays high. Flares come on fast, often at night, and the big toe is the classic first joint.
Key symptoms
- Sudden severe pain, often in the big toe, ankle or knee
- Joint turns red, hot and swollen within hours
- Even the touch of a bed sheet hurts
- Triggers: alcohol, red meat, seafood, sugary drinks, diuretics, dehydration
What you find on exam
- Hot, red, swollen, very tender joint with limited motion
- Usually one joint; several joints in later disease
- Tophi: firm lumps on the ear, elbow or fingers in long-standing gout
- Fever can occur; always consider septic arthritis
Tests
- Joint aspiration: needle-shaped, negatively birefringent crystals confirm gout
- Gram stain and culture of joint fluid to exclude infection
- Serum uric acid (can be normal during a flare), kidney function
- X-ray or ultrasound in chronic disease
Treatment basics
- Flare: NSAIDs, colchicine or steroids, started early
- Rest, ice and raise the joint
- Long-term allopurinol for frequent flares, tophi or kidney stones; target uric acid below 6 mg/dL
- Give flare prevention, such as low-dose colchicine, when starting allopurinol
- Limit alcohol and sugary drinks; review diuretics
Red flags
- Fever, chills or a very sick patient: rule out septic arthritis
- Prosthetic joint or weak immune system
- Rash or fever after starting allopurinol
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.