Last updated on 21 Jan 2016 at 5:19 PM (Rh05)

Gout / acute pain and swelling of knee
A 56 year old Samoan man is admitted to hospital with an acute myocardial infarction. He has a history of hypertension treated with a thiazide diuretic, type 2 diabetes that is diet controlled, hyperlipidaemia and high alcohol consumption. Three days following his admission to hospital he develops acute pain and swelling of his knee.

 

Applied Science for Medicine
Structure, function and common pathologies of the knee, including crystal arthropathy, haemarthrosis and septic arthritis
Biochemistry of urate production and excretion
Pathology of acute inflammation
Current hypotheses underlying aetiology of the metabolic syndrome
Pharmacology of xanthine oxidase inhibitors (e.g. allopurinol)
Principles of pharmacokinetic variability, monitoring drug therapy and drug interactions

Clinical and Communication Skills
History of acute onset joint pain and potential contributory factors including gout, dehydration, weight loss and diuretic use; take a medication history
Examination of an acutely tender joint
Differential diagnosis of acute joint pain
Use of radiographs in investigation of oligo-articular pain
Perform injection and aspiration of a joint
Interpret synovial fluid analysis
Two phases of gout management: acute gout attack and chronic (or tophaceous) gout; recognise and manage the metabolic syndrome
Ascertain dietary triggers and be aware of dietary interventions in management of chronic gout
Prescribe drugs safely, effectively and economically; write legal prescription that takes into account the needs of individual patient; discuss prescribing options with patient
Define adherence, compliance and concordance with regard to prescribed medicines
Empirical antibiotic (best-guess therapy) for septic arthritis based on Gram stain result

Personal and Professional Skills
Deal with potential negative feelings such as anger and/or guilt associated with a diagnosis of gout
Interventions to assist reduction in alcohol consumption and dietary measures
Counselling a patient on the importance of prophylactic medications despite being free of symptoms
Explanation of medications and their side effects (including gout as a potential side effect of diuretics)

Hauora Māori
Appropriate engagement and consultation with whānau
Ability to cater for differential health literacy needs of Māori patients and whānau
Awareness of differing risk profiles for Māori (and other disadvantaged populations)
Understanding of inequities in the incidence, management and outcomes of myocardial infarction and gout for Māori compared with non-Māori, and application of this to clinical decision making and management
Acknowledgement of the disproportionate impact of illness on whānau employment/income, and therefore availability to attend outpatient clinics/appointments
Understanding of the role of kaupapa Māori health policies, services and research in reducing cardiovascular disease and gout inequalities
Consideration of access to cultural /spiritual support for patient and whānau

Population Health
Prevalence and impact of gout including sequelae such as renal calculi, renal failure and gout arthritis
Prevention: cardiovascular risk and metabolic syndrome

 

Conditions to be considered relating to this scenario

Common

gout, septic arthritis, haemarthrosis, spondyloarthritis, calcium pyrophosphate dihydrate disease (CPPD) arthritis, osteoarthritis, rheumatoid arthritis, gonococcal arthritis (disseminated gonococcal infection)

Less common but 'important not to miss'

bleeding diathesis

Uncommon

psoriatic arthritis, Behçet’s disease, rheumatic heart disease, sarcoid arthropathy