A 45-year-old white male presents to your office complaining of left knee pain that started last night. He says that the pain started suddenly after dinner and was severe within a span of 3 hours. He denies any trauma, fever, systemic symptoms, or prior similar episodes. He has a history of hypertension for which he takes hydrochlorothiazide (HCTZ). He admits to consuming a great amount of wine last night with dinner.
On exam, his temperature is 98°F, his pulse is 90 beats/min, his respirations are 22 breaths/min, and his blood pressure is 129/88 mm Hg. Heart and lung examinations are unremarkable. The patient is reluctant to flex the left knee, wincing in pain at touch, and passive range of motion. The knee is edematous, hot to touch, and has erythema of the overlying skin. No crepitation or deformity is apparent. No other joints are involved. Inguinal lymph nodes are not enlarged. Complete blood count reveals a white blood cell count of 10.900 cells/mm3 and is otherwise normal.
^ What is the next diagnostic step?
♦ What is the most likely diagnosis?
♦ What is the next step in therapy?
ANSWERS TO CASE 3: Joint Pain
Summary: This is a 45-year-old male who presents with the sudden onset of monoarticular, nontraumatic joint pain. Evolution from onset to severe pain was rapid. The patient denies any trauma, systemic signs of illness, or any prior episodes. That he takes hydrochlorothiazide and drank a lot of alcohol the night that his symptoms started are important. His vital signs are stable, and he does not appear to be systemically ill. There is pain to movement and touch of the left knee, with evident edema, erythema, and warmth of the joint. No other joints are involved. His white blood cell count is not indicative of an acute infectious process.
♦ Next diagnostic step: Joint aspiration for examination of joint fluid to identify crystals and exclude infection.
^ Most likely diagnosis: Crystal-induced gout of the left knee.
^ Next step in therapy: Nonsteroidal antiinflammatory drug and provide analgesia: may consider using colchicine.
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