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Elbow joint
An easy one here.
A 73 year old man who is known to have chronic renal disease presented to PPUKM with multiple painful nodules on the upper and lower limbs for 1 year duration.
1) Describe the nodules(sorry for the bad image quality, my Hp camera only 2 megapixel)
2) What are your differentials? What do you think is the most likely diagnosis? What makes you say so?
3) What investigation do you want to do? What to expect?
4) The best way to diagnose this condition is clinically. How do you do that?
4) How do you manage this patient?
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6 comments:
Long time no 'hear' d... how is ur assignment going on... hope it is progressing smoothly....
i guess and see... lol
1. Firm nodules appear on the 1st metatarsophalangeal joint with overlying tophi which is inflamed with redness and swelling and another one just under the knee.
2. Crystal arthritis… septic arthritis…. Rheumatoid nodule….
In view of chronic renal disease an d DM, gout is the most likely diagnosis in my opinion due to underexcretion of uric acid…
3. Joint aspiration with the findings of negatively birefringent crystals.
4. May consider using the ACR preliminary criteria for diagnosis of gout or EULAR.. not sure….
5. As I think it is due to flare-up of gout, Rx NSAIDs for 2 weeks and if the signs subside, may consider to prescribe allopurinol with the dosage adjusted to the renal function test in view of his frequent attacks and also the presence of tophi
Yes...its chronic tophaceous gout. The differentials are correct but Pseudogout is also one possible differential as this patient has CRF
The next question will be what do you expect the uric acid level to be during the acute attack?
At what value is one considered to have hyperuricaemia?
As for the clinical diagnosis, in Malaysian CPG 2 of these 4 criteria must be fulfilled.
1) Hx of 2 attacks of gout, which resolve in 2 weeks
2) Observation of podagra
3) observation of a tophi
4) rapid resolution of symptoms with colchicine in 48 hours
Gout is classified into acute, intercritical and chronic. How long must a patient have gout before being classified as chronic? What other criteria can be present?
Surprisingly this patient have been having this nodule for 1 year without treatment. Therefore he is started on Voltaren with Ranitidine as symptomatic treatment. Why can't we use aspirin?
Yes......allopurinol should be deferred till acute attack resolve to avoid rebound flaring of symptoms.
Interesting eh? haha my proposal had already been submitted :P
i thought pseudogout is part of crystal arthritis, isn't it...
for the uric acid lecel, i think the level does not provides us significant value as gout is mainly due to the rapid flux in the level of uric acid....
redarding the hyperuricemia, i would say more than 6 mg/dL but it depends on the renal function as well
Aspirin is not used as the low dose aspirin theoretically reduce the excretion of uric acid in the proximal tubule....
for chronicity, not sure how many months but in this case the presence of tophi is highly suggestive of chronic tophaceous gout...
Thx for the case...
uric acid level can be normal or raised in gouty arthritis, and thus, like you said, does not indicate anything
for hyperuricaemia, one is considered to have hyperuricaemia if his uric acid level is more than 2 standard deviation over the mean uric acid for that population, because different population have different tolerance for uric acid level
Chronicity, basically one is considered to have chronic gout if they have more than 3 attacks in a year, if there is renal involvement and if there is tophi, like you said.
Cheers:)
Cheers.....
i would like to ask is it possible to differentiate btw common cold and flu...lol
as far as i know, common cold is not usually associated with myalgia and fever is usually low grade. of course, if a patient present with myalgia and fever we might think of other disease such as dengue fever.
Influenza disease is usually more fulminant, that is it occur with sudden severity. Common cold is more gradual.
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