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Gout summary
1.
Gout
History Mono/ oligoarticular crystal arthropathy characterised by presence of negatively Joints monoarticular + - progressing to oligoarticular involvement • st birefringent uric acid crystals in joints; associated with hyperuricemia 1 metatarsal • knees, ankles • inflammation believed to be due to WBCs phagocytosing urate crystals; WBCs acute onset release inflammatory mediators • pain, swelling, warmth, decreased movement, loss of function • 90% men, women mostly postmenopausal asymptomatic between attacks • >30y To exclude Autoimmune/ CTD other causes of • alopecia, malar rash, photosensitivity, oral ulcers Clinical Manifestations (5) arthritis • nodules, conjunctivitis, keratitis • asymptomatic hyperuricemia (technically not gout) • stretching of skin, dysphagia • acute arthritis • systemic involvement – lungs, cardiac, renal • chronic tophaceous gout IBD • urate urolithiasis • chronic bloody mucoid diarrhea • urate nephropathy • eye involvement Gonococcal DDx: • sexual history • Septic Arthritis (can coexist with gout) • urethral discharge • Pseudogout Reiters • If oligoarticular, rheumatoid arthritis • genital ulcers, diarrhea, conjunctivitis • other autoimmune conditions Reactive • st history of diarrhea/ URTI 2 weeks before 1 episode Skin Tophi (big toe, ears, hands, feet) Causes of gout pruritis, desquamation of surrounding skin after attack Renal Renal colic, loin to groin pain suggesting stones Primary Hyperuricemia S/S CRF Increased production of purine Idiopathic • decreased urine output 0 Genetic Enzyme Defects e.g. Lesch 2 causes Malignancies Nyhan Syndrome • LOW/ LOA Decreased renal clearance of uric acid Idiopathic • LNs Anemia history Secondary Hyperuricemia Long-standing renal disease Increased turnover of purine Malignancies Drug history • myeloproliferative disorder MTX/ aspirin/ diuretics • lymphoproliferative disorder e.g. Gout • as follows leukemia Medications Chronic hemolytic anemias Associated • HTN Cytotoxic drugs e.g. MTX Metabolic • DM Decreased renal clearance of uric acid Renal disease conditions • Hyperlipidemia Drug-induced • IHD • low dose aspirin • loops and thiazides
2.
Physical Exam (Short
Case Style) Between Attacks Lifestyle changes lose weight st Feet palpate tophi - podagra seen on 1 metatarsal joint avoid alcohol palpate metatarsal – warm/ tender? suggests acute attack avoid hyperuricemia medx Other joints Ankles, knees avoid purine-rich foods – all Tophi Olecranon bursa meats, yeasts, beans, seafood Helix of ear Allopurinol avoid during acute attacks, rash -> SJS Achilles tendons (xanthine oxidase exacerbates it hepatitis Causes of • LNs and abdomen to suggest hemato malignancy inhibitor) good for secondary gout • Signs of CRF – sallow skin, pruritus • chronic tophaceous gout Complications • Signs of CRF – sallow skin, pruritus • urate renal stones Associated mtb • BP – HTN • urate nephropathy conditions • dipstick - glycosuria Uricosurics probenicid • ineffective in patients with sulfinpyrazole renal insufficiency • MUST encourage drinking lots of water, Investigations ensure urine output • confirm diagnosis of gout >2L/day, else crystals • etiology of gout may form in GU tract • complications of gout • associated metabolic conditions Bloods FBC+PBF • raised WBC suggest septic arthritis • grossly raised WBC + blasts suggest blood CA Serum uric acid level U/E/Cr for RF Radio Xray affected joint • soft tissue swelling • punched-out erosions adjacent to tophi strongly suggests gout Joint aspiration send for culture if acute attack send tor histopatholody • neddle-shaped crystals, negatively birefringent Associated • fasting plasma glucose conditions • serum lipids Management Acute Episode Bed Rest For 24h after pain subsides Digitally signed by DR WANA HLA SHWE NSAIDS Indomethacin DN: cn=DR WANA HLA SHWE, c=MY, o=UCSI University, School of Medicine, KT-Campus, Colchicine Abdominal cramps Terengganu, ou=Internal Medicine Group, D+V email=wunna.hlashwe@gmail.com Reason: This document is for UCSI University, School marrow suppression of Medicine students. renal Date: 2009.02.26 15:04:08 +08'00' Steroids if above don’t work
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