Acute Monoarticular Gouty Arthritis: Diagnosis and Inpatient Management Guide

🩺 Provisional Diagnosis:

Acute Monoarticular Gouty Arthritis

📋 Diagnosis Criteria (based on 2015 ACR/EULAR Gout Classification Criteria):

A. Entry criterion (must be met):

• At least one episode of swelling, pain, or tenderness in a peripheral joint or bursa

B. Clinical and Diagnostic Features (scored):

• Pattern of joint involvement: Monoarthritis, especially 1st MTP joint (“podagra”) [4 pts]

• Time to maximal pain < 24 hr [0.5 pts]

• Redness over joint [1 pt]

• Tophus present clinically or by imaging [4 pts]

• Serum uric acid > 6.0 mg/dL [2 pts]

• Polarized microscopy showing monosodium urate (MSU) crystals [definitive]

• Imaging evidence of MSU deposits (e.g., double contour sign on US) [4 pts]

Score ≥ 8: Classified as gout

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🏥 Criteria for Admission:

Admit the patient for inpatient (IPD) management if one or more of the following are present:

Reason	Explanation
Severe uncontrolled pain	Pain not relieved with outpatient oral meds
Polyarticular involvement or systemic symptoms	Fever, chills, leukocytosis mimicking septic arthritis
Suspected septic arthritis	Must exclude joint infection with arthrocentesis
Recurrent gout with renal insufficiency	Need for IV meds, fluid adjustment, or renal dose adjustment
Poor response or contraindication to PO meds	GI bleed history, NSAID allergy, unable to take PO meds
Gout flare with cardiac decompensation	E.g., CHF exacerbation due to volume overload with steroids
Unusual presentation or diagnostic uncertainty	Rule out crystal arthropathy, pseudogout, or infection

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🧠 Management Plan for Acute Gout Attack (IPD case)

Management Setting: Inpatient Department (IPD) – due to [choose one: uncontrolled pain, renal impairment, diagnostic uncertainty, etc.]

⚕️ 1. Definitive Treatment:

Use one anti-inflammatory regimen (monotherapy) or combination in severe or polyarticular attack.

• Colchicine: Colchicine 0.6 mg → 2 tabs stat (1.2 mg), then 1 tab (0.6 mg) in 1 hour ➤ Max: 1.8 mg/24 hrs; Avoid in severe renal impairment (CrCl < 30 mL/min)
  

• NSAIDs: Naproxen (250 mg) 1 tab po bid pc x 5 days ➤ Avoid in patients with CKD, GI ulcer, CHF
  

• Systemic Corticosteroids (if above contraindicated or combination needed): Dexamethasone 4 mg IV stat, then 4 mg IV q12h for 2–3 days ➤ Use tapering dose if course > 3–5 days
  

🤲 2. Supportive Treatment:

• Paracetamol (500 mg) 1 tab po q6h prn pain

• Omeprazole (20 mg) 1 tab po od ac (for GI protection)

• 0.9% NaCl 1000 mL IV drip at 80 mL/hr (if euvolemic and no CHF)

🧪 3. Investigations:

• Joint aspiration (arthrocentesis): Look for MSU crystals (diagnostic gold standard), exclude infection

• CBC, ESR, CRP: Rule out sepsis

• Renal function test: For drug dosing (esp. colchicine, NSAIDs)

• Serum uric acid: May be normal/low during acute flare, but still done

• X-ray: Joint erosion, tophi if chronic

• ECG, electrolytes: If fluid or steroid use planned

📉 4. Urate-Lowering Therapy (NOT during acute attack):

• Delay allopurinol or febuxostat initiation until after resolution of the acute flare

• Long-term management begins ≥2 weeks after complete symptom resolution

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📚 Patient Education and Long-Term Plan

• Avoid high-purine foods (red meat, seafood, alcohol)

• Encourage hydration

• Check comorbid conditions: HTN, CKD, DM, metabolic syndrome

• Monitor uric acid target: <6 mg/dL (or <5 mg/dL in tophaceous gout)

Would you like to generate the case write-up using clinical format (CC, PI, PE, DDx), or convert this to OSCE table format for practice?