A 62-year-old man is evaluated on postoperative day 3 following an uncomplicated laparoscopic inguinal hernia repair. He reports the acute onset of severe pain, swelling, and redness in his right first metatarsophalangeal joint that began overnight. The patient has a history of hypertension and hyperlipidemia. His temperature is 37.8°C (100.0°F), blood pressure is 135/85 mmHg, and pulse is 88/min. Physical examination reveals an exquisitely tender, warm, and erythematous right big toe. Synovial fluid analysis of the affected joint reveals a leukocyte count of 22,000/mm³ and the presence of needle-shaped, negatively birefringent crystals. Gram stain shows no organisms. Which of the following is the most appropriate next step in management?
- Prescribe oral indomethacinCevap
- BAdminister intravenous vancomycin and ceftriaxone
- CInitiate therapy with oral allopurinol
- DPerform surgical irrigation and debridement of the joint
- EAdminister intravenous furosemide
Cevap
The most appropriate next step in management is to prescribe an oral nonsteroidal anti-inflammatory drug, such as indomethacin.
This patient is experiencing an acute gout flare, which is strongly suggested by his presentation of podagra (inflammation of the first metatarsophalangeal joint) and confirmed by the synovial fluid demonstrating needle-shaped, negatively birefringent monosodium urate crystals. Acute gout attacks frequently occur in hospitalized or postoperative patients due to physiological stress, dehydration, or changes in diet and medications. The most appropriate immediate management is to reduce joint inflammation. First-line therapies for an acute gout attack include oral nonsteroidal anti-inflammatory drugs (NSAIDs) such as indomethacin, colchicine, or systemic/intra-articular glucocorticoids. Since the patient has no apparent contraindications (such as active peptic ulcer disease or severe kidney injury), an NSAID is the correct next step.
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Anahtar Kavram
Diagnosis and acute management of gouty arthritis