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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Identify major risk factors for developing gout in a given patient, including drugs that may contribute to or cause this disorder.

  • Develop a pharmacotherapeutic plan for a patient with acute gouty arthritis that includes individualized drug selection and assessment of the treatment for efficacy or toxicity.

  • Identify patients in whom maintenance therapy for gout and hyperuricemia is warranted.

  • Identify medications not used primarily for gout that may have a beneficial effect on serum uric acid (SUA) levels.

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PATIENT PRESENTATION

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Chief Complaint

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“My toe is on fire.”

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HPI

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Roy Huff is a 78-year-old man who presents to the ED complaining of significant toe pain. Mr Huff states, “I think I’m paying the price for my fun at Oktoberfest.” He reports having spent the weekend indulging on beer and sausage at the local Oktoberfest festival. In the early hours of Monday morning (approximately 3 hours ago), he awoke to sudden excruciating pain in his right big toe. Over the past hour, this toe has become red, swollen, and so painful that he cannot walk. He has not experienced any trauma or injuries. He also denies having experienced these symptoms previously.

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PMH

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  • HTN

  • PUD

  • Obesity

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SH

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The patient typically drinks “a can of beer or two” daily but drank significantly on Friday, Saturday, and Sunday. He does not smoke or use illicit drugs.

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Meds

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  • Chlorthalidone 25 mg PO daily, started 1 month ago

  • Omeprazole 20 mg PO daily

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All

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NKDA

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ROS

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Other than feeling somewhat dehydrated from all of his drinking, the patient has no major complaints prior to this ED visit. No chest pain, nausea/vomiting, or respiratory symptoms. Bowel habits are normal. He has no prior history of arthritic symptoms or joint problems.

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Physical Examination

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Gen
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A healthy-appearing, obese, white man in acute distress

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VS
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BP 120/60 mm Hg, P 110 bpm, RR 19, T 37.5°C; Wt 88 kg, Ht 5′6″

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Skin
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Poor skin turgor. No rashes or other dermatologic abnormalities.

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HEENT
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PERRLA, dry mucous membranes, throat/ears clear of redness or inflammation

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Neck/Lymph Nodes
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Negative for lymph node swelling or masses

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Lungs/Thorax
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Clear to auscultation bilaterally, symmetric movement with inspiration

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CV
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Tachycardic, normal rhythm, normal S1 and S2

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Abd
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Obese, but soft, nontender; positive ...

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