Return to Diagnosis ListShow Learning Points most relevant to Phase 1:

Gout / acute pain and swelling of knee

Clinical Discipline(s)/Organ System(s)
Musculoskeletal System, Rheumatology, Hauora Māori
Progress Test Topic(s)
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.
Progress Test-Type Questions:   Question 1 | Question 2
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
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
psoriatic arthritis, Behçet’s disease, rheumatic heart disease, sarcoid arthropathy