CPC: The case of the swollen great toe

• Based on the history of present illness, medical history, social history, family history, and clinical exam findings, a differential diagnosis is developed. Which of the following is this patient’s most likely primary diagnosis?

A 49-year-old male is evaluated in the Medtigo Medical Clinic for a 1-day history of worsening right foot pain, swelling, erythema, and difficulty bearing weight on his right foot. Although he has been a regular patient of the clinic for years and has never been one to complain about much of anything, he has not had an appointment with the clinic for a nearly two years. The patient reports waking up yesterday morning with moderate pain, swelling, redness in his right foot as well as difficulty walking due to the sudden onset of right foot pain despite going to bed the preceding night without any of the aforementioned issues. He also reports worsening of his right foot pain when attempting to walk or even when applying mild pressure to the area of the right metatarsophalangeal joint of the great toe. The patient denies any recent trauma and does not recall any prior history of experiencing similar symptoms. After further questioning, it is clear that the patient has no other complaints associated with his current right foot pain. His medical history is notable for hypertension, hyperlipidemia, type 2 diabetes mellitus, benign prostatic hyperplasia, obesity, and generalized anxiety disorder. His current medications are lisinopril, chlorthalidone, amlodipine, rosuvastatin, metformin, doxazosin, buspirone, and low-dose aspirin. He has no history of tobacco or recreational drug use. He admits to regularly consuming at least two to three beers daily and has been doing so for approximately 20 years. He is the owner and chief foreman of a small business which builds wooden decks and wooden privacy fences for residential and commercial properties. He has a family history of heart disease, rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis, type 1 diabetes, type 2 diabetes, difficult-to-control hypertension, and major depressive disorder. The rest of his medical history, social history, and family history is non-contributory.

On physical examination, temperature is 99.2°F (37.3°C), blood pressure is 152/91 mm Hg, pulse rate is 91 beats/min, respiration rate is 18/min, and oxygen saturation is 98% breathing ambient air. Height is 5’10 (177.8 cm), weight is 240 lbs (108.9 kg), and body mass index is 34.4 kg/m². Cardiac exam reveals a normal S1 and S2. Pulmonary exam reveals clear bilateral breath sounds with no wheezing or crackles. Examination of the right foot reveals a swollen, erythematous, warm and tender to palpation right metatarsophalangeal joint of the great toe which extends beyond the confines of the affected joint and has a similar appearance to cellulitis. Active and passive range of motion testing of the right great toe at the metatarsophalangeal joint is limited and causes the patient to exhibit significant pain. He is barely able to apply pressure on his right foot during gait assessment without grimacing in severe pain. The remainder of the physical examination is unremarkable.

• Which of the following is the most appropriate next step in confirming this patient’s most likely primary diagnosis?

• With a confirmed primary diagnosis of gout with acute flare, which of the following is the least appropriate next step in management of this patient’s diagnosed medical condition?

After reviewing the patient’s blood work which includes an elevated serum uric acid level of 9.1 mg/dL, which of the following is conditionally recommended as a first-line medical treatment in conjunction with other first-line medical treatment for this patient’s first episode of acute gouty flare?

• The clinician decides to order some laboratory tests to be performed during the patient’s current clinic visit. The results of the lab tests are as follows: