Musculoskeletal and Rheumatologic — Joint pain

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Case 1 of 8Musculoskeletal and RheumatologicJoint pain (e.g., inflammatory arthritis, osteoarthritis, gout)

A 50-year-old accountant presents to the clinic with sudden-onset swelling and pain in the right big toe for the past 10 hours, rating the pain 7/10. This is the second time he has experienced these symptoms. On examination, the right first metatarsophalangeal joint is erythematous, warm to the touch, and swollen. The patient's symptoms improve with your initial management. He returns to the clinic 3 months later with the same symptoms, is very upset, and asks whether there is any medication he can take to prevent future attacks.

Question 1 of 29

How would you manage this patient's condition at the initial visit?

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AAdvise to avoid starting or stopping urate-lowering therapy (e.g., allopurinol) during the acute attack

BProvide analgesia as needed

CIf NSAIDs are contraindicated: colchicine 1.2 mg orally once, then 0.6 mg 1 hour later, followed by 0.6 mg once or twice daily until resolution

DFor an acute gout flare (within 10–14 days of onset): NSAIDs – indomethacin 50 mg orally three times daily until symptoms improve (usually 3–5 days)

EStart allopurinol immediately during the acute attack to rapidly lower uric acid

FConfirm the clinical diagnosis (classic presentation – no need for joint aspiration unless atypical)

GOrder an emergent MRI of the affected joint

HIf both NSAIDs and colchicine are contraindicated: prednisone 30–40 mg orally daily for 5 days

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