White Female With GOUT

/ Blogs / By

Discuss about a 65-year-old white female with GOUT

Describe your clinical experience for this week:

  • Did you face any challenges, any success? If so, what were they?
  • Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.
  • Mention the health promotion intervention for this patient.
  • What did you learn from this week’s clinical experience that can beneficial for you as an advanced practice nurse?
  • Support your plan of care with the current peer-reviewed research guideline.

white female with GOUT

Clinical Experience Reflection – 65-Year-Old White Female with Gout

Clinical Experience Summary:

This week in clinical, I encountered a 65-year-old white female presenting with complaints of acute joint pain, redness, and swelling in her right first metatarsophalangeal joint (big toe). The patient reported that the pain began two days ago, was sudden in onset, and has progressively worsened. She rated her pain as 8/10. She has a known history of hypertension and osteoarthritis and has had one previous episode of gout two years ago.

Challenges and Successes:

One challenge I faced was distinguishing the symptoms of gout from septic arthritis, as both can present with similar acute joint inflammation. However, by conducting a thorough history and physical exam, and ordering appropriate labs (e.g., serum uric acid, joint aspiration), I was able to rule out other differentials. A key success was recognizing the patient’s dietary habits (high in purines such as red meat and alcohol) and medication nonadherence, which contributed to the flare.

Patient Assessment:

  • Subjective Data:

    • Chief complaint: Severe pain in the right big toe.

    • History: Onset 2 days ago, acute and worsening.

    • Associated symptoms: Swelling, warmth, redness, decreased range of motion, inability to bear weight.

    • No history of fever or systemic symptoms.

  • Objective Data:

    • Vitals: BP 138/85, HR 82, Temp 98.6°F

    • Physical exam: Erythematous, edematous right first MTP joint, very tender to touch, decreased ROM. No other joints involved.

Plan of Care:

  1. Diagnostics:

    • Serum uric acid (elevated at 9.8 mg/dL)

    • ESR/CRP (elevated)

    • CBC (normal WBC count, helping to rule out septic arthritis)

    • Joint aspiration (if signs of infection were present, but deferred in this non-febrile case)

  2. Pharmacological Management:

    • Initiate NSAIDs (e.g., Naproxen 500 mg BID for 5-7 days)

    • Consider colchicine 1.2 mg followed by 0.6 mg an hour later if within 36 hours of flare onset

    • Allopurinol 100 mg/day after flare subsides (long-term urate-lowering therapy)

  3. Non-Pharmacological Interventions:

    • Elevation of the foot, ice application

    • Avoid weight-bearing activities on affected foot

    • Diet counseling (low-purine diet, reduce red meat, shellfish, alcohol intake)

  4. Follow-Up:

    • Re-evaluate in 1 week to assess response to treatment and consider starting urate-lowering therapy if not already on one

    • Monitor renal function before increasing allopurinol dose

Three Differential Diagnoses with Rationales:

  1. Septic Arthritis

    • Rationale: Presents with acute monoarthritis; however, patient is afebrile, has normal WBC, and no systemic signs of infection.

  2. Pseudogout (Calcium Pyrophosphate Deposition Disease)

    • Rationale: Similar presentation, but more common in knees and wrists; confirmed with joint aspiration showing calcium pyrophosphate crystals.

  3. Cellulitis

    • Rationale: Redness and swelling can resemble cellulitis, but cellulitis is often more diffuse, with systemic signs like fever and chills, which are absent in this case.

Health Promotion Interventions:

  • Educated patient on lifestyle modifications, including dietary changes, increased hydration, and weight loss if overweight.

  • Discussed importance of medication adherence and routine follow-up for serum uric acid monitoring.

  • Provided educational materials on recognizing early signs of gout flare and avoiding known triggers.

Lessons Learned:

This clinical experience reinforced the importance of a comprehensive history and targeted diagnostic evaluation. As an advanced practice nurse, it is crucial to differentiate between inflammatory and infectious causes of monoarthritis. Understanding evidence-based treatment guidelines and engaging the patient in their care plan through education and support can improve outcomes and prevent future flares.

Evidence-Based Support:

According to the 2020 American College of Rheumatology (ACR) Guideline for the Management of Gout:

  • NSAIDs, colchicine, and corticosteroids are first-line therapies for acute flares (FitzGerald et al., 2020).

  • Allopurinol is recommended as the preferred initial urate-lowering therapy for most patients.

  • Emphasis is placed on lifestyle changes, particularly dietary modifications and weight control, to reduce serum urate levels and prevent recurrent attacks.

References (APA 7th Edition):

FitzGerald, J. D., Dalbeth, N., Mikuls, T., Brignardello-Petersen, R., Guyatt, G., Abeles, A. M., … & Khanna, D. (2020). 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care & Research, 72(6), 744–760. https://doi.org/10.1002/acr.24180

Richette, P., & Bardin, T. (2017). Gout. The Lancet, 389(10085), 349–360. https://doi.org/10.1016/S0140-6736(16)00346-9

error: Content is protected !!
Scroll to Top