A 58-year-old man is evaluated for a 3-year history of recurrent episodes of pain and swelling of the joints of the lower extremities. These episodes have an acute onset, are monoarticular, reach maximum intensity within 1 day, and last between 2 and 7 days. The right great toe is most often affected, but the knee also is involved. During the past 6 months, he has had three episodes.
On physical examination, vital signs are normal. Musculoskeletal examination is normal except for bony enlargement of the right first metatarsophalangeal joint with valgus deformity. There are no tophi.
Which of the following diagnostic studies will be most helpful in establishing this patient™s diagnosis?
A-24-Hour urine uric acid
B-Radiography of the right foot
C-Serum uric acid
D-Synovial fluid leukocyte count
pursuit! Do u want to try one more NBME 3,3,19.. acid base.. i am ???
It's acute gout attack, Is it underlying is gout or OA? may be chronic gout.
synovial fluis crystal is good.. not there
serum UA.. not reliable
radiology... not for acute
90% of gout is underexcreter
ans. C or A?
hmmm, same reason I lost
pick 1
Correct Answer: B
Gout typically manifests as acute intermittent attacks of joint and tenosynovial inflammation associated with redness, swelling, and intense pain. Early attacks of gout are typically monoarticular and involve joints in the lower extremities, particularly the first metatarsophalangeal joint. These episodes usually last between several days and 2 weeks. As the disease progresses, these attacks become more frequent and increasingly polyarticular and involve the upper extremities. Because this patient™s presentation is classic for gout, a presumptive diagnosis can be established based solely on his history and a supportive radiograph.
In patients with gout, radiographs often reveal bony asymmetric erosions with overhanging edges that usually involve the feet. These changes are supportive of the diagnosis but are not diagnostic.
Gout is often associated with hyperuricemia, but an elevated serum uric acid level is not diagnostic of this condition. More than 20% of patients with gout have normal or low uric acid levels during an acute attack; similarly, approximately 5% of the adult general population has elevated uric acid levels, but most of these patients remain asymptomatic. A 24-hour urine measurement of uric acid excretion would help to determine whether this patient is an underexcretor or overproducer of uric acid. Results of this study would therefore help to guide treatment but would not confirm the diagnosis.
Synovial fluid analysis during an acute attack of gout may not reveal monosodium urate crystals in up to 25% of affected patients. Therefore, aspiration of an affected joint during a subsequent attack may be appropriate if crystals are not initially seen on synovial fluid analysis in suspected gout. However, a synovial fluid analysis documenting a synovial fluid leukocyte count higher than 15,000/µL is compatible with gout but does not help to establish the diagnosis.
*synovial fluid leukocyte count ...more than 50,000, but crystals present...that is GOUT
*synovial fluid leukocyte count ..less than 50,000, but crystals absent....that is SEPTIC
X-rays while useful for identifying chronic gout have little utility in acute attacks.[6]...wikipedia
Thankx, i learn from you.
forever07...I think U wanted to say less than 50,000 for gout and more than 50,000 for septic ..right?
Nop, this is exception ,refer to Kaplan 44, Read details here.
@cheetos.. your figure is general cut off bt gout n septic.
My one is exception.
I want to point out wbc count is not reliable, crystals are more specific .