USMLE Forum - Largest USMLE Community

A 42-year-old man presents to your clinic with a
1-week history of pain and inflammation involving
his right first metatarsophalangeal (MTP) joint. He
describes the pain as sudden in onset and worse at
night. He denies experiencing any fever or traumatic
injury to the joint and states that he has never had
this type of pain before. He denies any chronic medical
conditions, any prior surgery, and any current
medication use. Besides an erythematous and
exquisitely tender right first MTP joint, the remainder
of his physical examination is unremarkable.

1. Aspiration of the patient™s right first MTP joint
space is likely to reveal which of the following?

(A) negatively birefringent crystals
(B) positively birefringent crystals
© nonbirefringent crystals
(D) acellular synovial fluid
(E) gram-positive cocci in clusters

2. Which of the following is true of the patient™s
condition?

(A) It commonly presents in premenopausal
women.
(B) It commonly presents as a monoarticular
arthritis.
© Episodes of pain and inflammation
become more frequent but resolve more
quickly as the disease progresses.
(D) The presence of tophi is a common early
finding.
(E) A blood test is the diagnostic gold
standard.

3. Which of the following interventions is most
appropriate at this time for your patient™s
condition?

(A) probenecid
(B) allopurinol
© indomethacin
(D) sulfinpyrazone
(E) aspirin

4. What is a potential long-term complication of
this patient™s condition?

(A) CHF
(B) nephrolithiasis
© anemia of chronic disease
(D) recurrent urinary tract infection (UTI)
(E) rheumatoid arthritis (RA)

5. After 1 week of treatment, your patient states
that his pain and inflammation have resolved.
You measure a serum urate level and find it
elevated. Urinary urate excretion is high.
Which of the following interventions is now
most appropriate?

(A) no further treatment is necessary
(B) daily oral allopurinol
© daily oral probenecid
(D) daily oral colchicine with allopurinol
(E) daily oral colchicine with probenecid

A
B
C
B??
E

it's vague

C/B/C/B/B

A, B, C, B, B

oops A/B/C/B/B...typo

it's not vague!
coming back

it's not vague, it's simple/easy.

A..
B..
C..
B...
D...

giving last one explan.

Allopurinol is the first-line drug for longterm
use in patients with excessive urate
excretion. It functions by irreversibly inhibiting
xanthine oxidase, which is necessary for
urate formation.

However, allopurinol can precipitate acute gout attacks during the period
immediately after initiation of therapy. So, colchicine is typically used in addition to
allopurinol for its anti-inflammatory effects

Probenecid is a first-line drug in patients who
have normal-to-low urate excretion

your questions are good.the last answer for the question is wrong.
you will never start allopurinol just for single attack.
why
bcoz gout attacks to recur take a long time and some wont have recurrences so why expose him to drug toxicity
next thing
no probencid what ever always allopurinol form current recommendations
please correct me if iam wrong.
thanks

I Appreciate your input that forced me to read more.

Agree with you because always there™s controversy.

However, in many cases, patients who have a first attack of gout should undergo therapy with agents that lower uric acid
But, some rheumatologists advocate waiting for the second attack to initiate therapy to lower uric acid levels.

And Prophylaxis with colchicine can be started during an acute attack. Lowering uric acid with either allopurinol or probenecid can precipitate attacks of gout. When used prophylactically, colchicine can reduce such flares by 85%.

Monotherapy with colchicine may help prevent flares of inflammatory arthritis but does not prevent the accumulation of uric acid in the joints, which can lead to further joint destruction --------------------
And finally,

In all cases, the risks and benefits need to be judged based on the individual patient. For instance, in an elderly patient with multiple underlying medical problems and renal insufficiency, the risks of therapy to lower uric acid levels may outweigh the benefits.
And my patient is young.

If you are interested Ref: http://emedicine.medscape.com/article/329958-treatment.

Thanks.