A 62-year-old man presents with acute swelling of his left knee. He describes excruciating pain and swelling for the past 2 days. The patient presented with a similar episode 2 years ago, but is unable to recall what condition he was diagnosed with and what medication he was administered. He has a past medical history of diabetes, hyperlipidemia, hypertension, and chronic alcoholism. He drinks 5 to 6 beers per day. He has a temperature of 38.4°C, blood pressure of 120/80 mmHg, and heart rate of 75 beats per minute. Physical examination reveals a tender and erythematous left knee with significantly limited range of motion and marked swelling.
Which of the following is the best next step in management for this patient?
A. IndomethacinJoint aspiration with synovial fluid analysis. This patient is presenting with signs and symptoms consistent with an acute gout attack. Although unable to recall the exact name of his previous diagnosis, the previous acute episode and patient’s alcohol use lend credence to the history of gouty arthritis. Furthermore, the patient is presenting with acute left knee pain, swelling, and low-grade fever, all confirming the likely diagnosis of gout. Given that septic arthritis and pseudogout can show clinical similarities to gout, it is imperative to first perform joint aspiration and synovial fluid analysis. Synovial fluid analysis of gout will demonstrate a leukocyte count of 2,000 to 50,000/mm3 and negatively birefringent needle-shaped crystals with a negative gram stain and negative culture. (A) Indomethacin (an NSAID) is very helpful in treating acute gout. Nonetheless, the diagnosis of gout must first be confirmed prior to administering indomethacin especially with its side effect profile. (C) Uric acid levels will certainly be elevated in gout (elevated uric acid is the underlying cause of the clinical manifestations); however, uric acid levels do not have a high degree of sensitivity or specificity for diagnosing gout. (D) An x-ray of the knee is not as specific as synovial fluid analysis for diagnosing gout.