This week, my clinical experience was caring for a 67-year-old patient with acute gout in the great toe’s metatarsophalangeal joint. The patient had been suffering from acute intermittent synovitis, which manifested as joint inflammation and pain. Following my diagnosis, I began urate-lowering treatment (ULT) to lower my increased uric acid level, which is typically linked to congestive heart failure. The goal was to reduce the serum urate level from 8 mg/dL to 6 mg/dL, which is optimal. I also requested the administration of Febuxostat to reduce uric acid production, Indomethacin to treat pain, and colchicine to reduce inflammation, in addition to therapeutic dietary changes.
Although the patient responded effectively to the ULT, and I could prevent the development of chronic arthropathy, I faced some difficulties. For example, I found it challenging to discuss gout medications and dietary changes with the patient.
Due to the insufficient degree of patient knowledge, I tried to find an acceptable method of providing the facts about the problem. Communication was hampered further because I needed to attend to other patients and couldn’t spend more time discussing the condition. Furthermore, the patient was perplexed by the prescription to use NSAIDs (colchicine) to minimize inflammation since she was concerned about activating a comorbid disease (asthma) that he already had. As a result, I had to discuss the medication’s effectiveness and suitability to the patient.
Gout physical examination requires paying particular attention to the joints to look for signs of inflammation. A single or multiple joint acute attacks cause swelling (synovitis), warmth, erythema, and discomfort in the affected location. Another test is to look for fever, a sign of systematic inflammation, especially in a polyarticular flare. Checking for subcutaneous deposition of monosodium urate (MSU) crystals called tophi on the fingers, helix of ears, and toes is also part of the examinations. If gout is detected during the physical examination, laboratory tests and light microscopy are used to provide a conclusive diagnosis. MSU crystals and polymorphonuclear leukocytes in the aspirated joint fluid will indicate a positive diagnosis for gout.
Furthermore, high serum uric acid concentrations (>6 mg/dL) will be found in the laboratory results. It’s worth mentioning that gout is frequently confused with pseudogout. MSU crystals in gout are needle-shaped and have negative birefringence, whereas MSU crystals in other diseases are rhomboid-shaped and have weak positive birefringence (Newberry et al., 2017).
The importance of patient awareness about gout and suitable drugs, as well as the characteristics of practitioner communication, were key takeaways from this week’s clinical experience. I now understand how the two themes might negatively or positively affect the management of any clinical illness, such as gout, due to this week’s clinical experience. According to Firdous and Hiba (2019), effective communication is a critical factor in achieving positive health outcomes. As a result, as an APRN, I will work to improve the ways and channels through which I exchange information with patients to improve patient knowledge and understanding and increase clinician-patient agreement.
The American College of Rheumatology recommends that APRNs inform patients about the importance of using a treat-to-target strategy with urate-lowering medications to achieve the ideal level of less than 6 mg/dL (Eliseev, 2020). The ACR also suggests anti-inflammatory drugs like colchicine for three to six months, with regular monitoring and changes based on clinical outcomes. Patients should also be told about the detrimental effects of excessive alcohol consumption and heavy meat and seafood consumption on the severity of the disease. Finally, for this discussion, the ICD-10 code for gout is M10.9.
Eliseev, M. S. (2020). Commentaries on the updated American College of rheumatology guidelines for the management of gout. Urate-lowering drugs (Part 1). Modern Rheumatology Journal, 14(3), 117-124. https://doi.org/10.14412/1996-7012-2020-3-117-124
Firdous, J., & Hiba, S. (2019). Good Communication between Doctor-Patient Improves Health Outcome. EJMED, European Journal of Medical and Health Sciences, 1(4).
Newberry, S. J., FitzGerald, J. D., Motala, A., Booth, M., Maglione, M. A., Han, D., … & Shekelle, P. G. (2017). Diagnosis of gout: a systematic review in support of an American College of Physicians clinical practice guideline. Annals of internal medicine, 166(1), 27-36.