A 45-year-old 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 three hours. He denies any trauma, fever, systemic symptoms, or prior similar episodes. It is a history of hypertension when she takes hydrochlorothiazide. He admits to consuming a great amount of wine last night with dinner.

On examination, his temperature is 98.0 Fahrenheit, his pulse is 90 bpm, his respirations are 22 bpm, and his blood pressure is 129/88. Heart and lung examinations are unremarkable. The patient is reluctant to flex the left knee wincing in pain at touch and has passive range of motion. The knee is edematous, hot to touch and has erythema of the overlying skin. No capitation or deformity is apparent. No other joints are involved. Inguinal lymph nodes are not enlarged. Complete what cannot reveals a white blood cell count of 10,900 this otherwise normal.

1. What is the next diagnostic step?

2. What is the most likely diagnosis? 

3. What is the next step in therapy?

 

Answer:

1. The next diagnostic tests include arthrocentesis, ESR/CRP, and pain Xray.

2. The most likely diagnosis is acute monarticular arthritis with possible causes as gout or infection.

3. Supportive therapy involves pain management using NSAIDS. Specific therapy depends on cause.

Step-by-step explanation

1. The next diagnostic tests include:

Arthrocentesis: The joint fluid aspiration for culture, cell count as well as analysis of crystals such as monosodium urate crystals.

ESR/CRP - These are markers of inflammation and may be elevated.

Plain X ray of the kee to rule out any bone deformities.

2. The most likely diagnosis is acute monarticular arthritis with possible causes as gout or infection. The history of heavy wine intake may indicate a precipitant of gout but the signs and symptoms overlap with those of infectious arthritis.

3. Supportive therapy involves pain management using NSAIDS. Specific therapy depends on cause. If culture results reveal infectious arthritis, antibiotics should be given. However, if monosodium urate crystals are seen, treatment with colchicine is recommended. Further prevention of attacks should be done by giving medication that lower uric acid levels eg probenecid or allopurinal. The patient should also avoid alcohol intake.

Reference

Neogi, T., Chen, C., Niu, J., Chaisson, C., Hunter, D. J., & Zhang, Y. (2014). Alcohol quantity and type on risk of recurrent gout attacks: an internet-based case-crossover study. The American journal of medicine, 127(4), 311-318.