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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Recognize the major risk factors for developing gout

  • Identify the goals of therapy for gout

  • Select an appropriate drug to provide acute pain relief and reduce serum uric acid concentrations in patients with gout, and outline a plan for monitoring efficacy and toxicity

  • Properly educate a patient on appropriate lifestyle modifications to help prevent gouty arthritis attacks

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PATIENT PRESENTATION

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Chief Complaint

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"My feet throb when I walk or stand and my big toe is swollen."

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History of Present Illness

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John Smith is a 62-year-old Caucasian male who presents to his primary care physician complaining of bilateral foot pain (L > R) and swelling of the first phalanx (hallux) of the left foot (Figure 66-1). The patient describes the pain as a constant throbbing sensation when standing or walking. Initially the patient thought the pain could have been from an ingrown toenail. He became more concerned when his other foot started to hurt and his left big toe started swelling with redness and warmth present. The pain has been present for approximately 2 weeks but has worsened over the past few days. He has tried to alleviate the pain through soaking his feet in a warm bath with Epsom salts, which provided minimal relief. He has no prior history of diabetes, and his fasting blood glucose level 3 months ago was 105 mg/dL (5.8 mmol/L).

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FIGURE 66-1.

Typical inflammatory changes of gout at first metatarsal phalangeal joint. (Adapted, with permission, from Usatine RP, Smith MA, Mayeaux Jr EJ, Chumley H, Tysinger J. The Color Atlas of Family Medicine. New York, McGraw-Hill, 2009, Fig 94-3.)

Graphic Jump Location
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Past Medical History

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Atrial fibrillation

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HTN

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Hyperlipidemia

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Depression

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Dyspepsia

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Family History

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Father had type 2 diabetes mellitus and died from a stroke at age 72; mother is alive at age 82 with hypertension and osteoarthritis

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Social History

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Married and lives with his wife of 40 years; has no children; works as a service mechanic at a local automobile dealership

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Tobacco/Alcohol/Substance Use

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Drinks 3–4 beers weekly and may consume more in social situations; nonsmoker ×10 years; denies any illicit drug use

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Allergies/Intolerances/Adverse Drug Events

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No known drug allergies

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Medications (Current)

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Atenolol 50 mg PO daily for hypertension

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Hydrochlorothiazide/lisinopril 12.5/20 mg PO daily for hypertension

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Omeprazole 20 mg PO q am

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Sertraline 100 mg PO daily

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Simvastatin 40 mg PO daily

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Extended-release niacin 1,000 ...

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