A 52-year-old man comes to the office for follow-up after recent emergency department evaluation for knee pain. The patient had sudden-onset, severe pain in the right knee associated with swelling and difficulty walking. Arthrocentesis was performed; microscopic findings from the synovial fluid are shown in the exhibit. The patient's symptoms have improved with medical treatment. Medical history is notable for hypertension treated with amlodipine. The patient drinks 2 or 3 beers daily but does not use tobacco or illicit drugs. He works in a warehouse and his job involves lifting heavy boxes. He is divorced, has had 2 sexual partners in the past 6 months, and rarely uses condoms.
Blood pressure is 130/82 mm Hg and pulse is 80/min. BMI is 32 kg/m². Physical examination is normal.
Which of the following is the most appropriate intervention for this patient to decrease the future risk of similar episodes?

Question

A 52-year-old man comes to the office for follow-up after recent emergency department evaluation for knee pain. The patient had sudden-onset, severe pain in the right knee associated with swelling and difficulty walking. Arthrocentesis was performed; microscopic findings from the synovial fluid are shown in the exhibit.

The patient's symptoms have improved with medical treatment. Medical history is notable for hypertension treated with amlodipine. The patient drinks 2 or 3 beers daily but does not use tobacco or illicit drugs. He works in a warehouse and his job involves lifting heavy boxes. He is divorced, has had 2 sexual partners in the past 6 months, and rarely uses condoms.
Blood pressure is 130/82 mm Hg and pulse is 80/min. BMI is 32 kg/m². Physical examination is normal.
Which of the following is the most appropriate intervention for this patient to decrease the future risk of similar episodes?

Quizplus · Accepted Answer

11ec193a_9931_5f77_853d_499fc37e6b2b_MD0002_00 This patient had an acute gout attack, with synovial fluid showing needle-shaped, negatively birefringent monosodium urate crystals. Patients with recurrent attacks, evidence of joint damage, tophi, or uric acid nephrolithiasis warrant treatment with urate-lowering medication (eg, allopurinol) after acute symptoms have resolved to prevent further attacks. This patient does not yet require prophylactic medication (Choice E). However, he has risk factors for recurrence, including obesity, hypertension, and alcohol intake, which should be addressed. urate crystals Ethanol increases uric acid production by inducing net conversion of ATP to AMP. Beer in particular raises serum uric acid levels and increases the risk for initial and recurrent gout attacks. Patients with gout should be counseled to limit alcohol intake to one or fewer beverages per day. Additional lifestyle modifications are shown in the table. (Choice A) High-impact joint trauma increases the risk of hemarthrosis in patients with an underlying bleeding diathesis. This patient's synovial fluid microscopy shows crystals rather than blood. (Choice B) Thiazide diuretics decrease the fractional excretion of urate and increase the risk of gout. Other antihypertensives associated with increased gout risk include ACE inhibitors, most angiotensin II receptor blockers, and beta blockers. Losartan and calcium channel blockers (eg, amlodipine) are associated with decreased risk of gout flare. (Choice D) Disseminated gonococcal infection can present as acute purulent monoarthritis or a triad of migratory polyarthralgias, tenosynovitis, and dermatitis. Gram stain of synovial fluid in purulent arthritis shows gram-negative diplococci. Educational objective: Ethanol increases serum uric acid levels. Patients with gout should limit alcohol intake to one or fewer beverages per day to reduce the risk of gout attacks. __________ References: A prescription for lifestyle change in patients with hyperuricemia and gout. (http://www.ncbi.nlm.nih.gov/pubmed/20035225)

A 52-Year-Old Man Comes to the Office for Follow-Up After