Mr. Sampson is a 62-year-old male who presents to the Emergency Department (ED) complaining of severe right knee pain x 3 days. His gait is unsteady and he is limping and guarding that right leg. When the nurse walks in the room, he tells the nurse he has a history of Hepatitis C and HIV.

Upon further assessment, Mr. Sampson’s right knee is very swollen, reddened, and warm and tender to the touch. Mr. Sampson reports that his joints swell up like this all the time, and proceeds to show the nurse his hands, where she notes a swollen nodule on the left wrist, and two swollen nodules on the proximal knuckles of the right hand.

The provider orders X-rays of the right knee and bilateral hands, as well as some basic laboratory tests, including an ESR and CRP. When the nurse goes to draw blood, she notes another swollen nodule over the patients left elbow that is shiny and has two white spots on it. She now knows that she needs to recommend one more test for the provider to order.

The joint x-rays show crystal deposits around the swollen joints, and Mr. Sampson’s uric acid level is elevated significantly. When asked if he has a history of gout, Mr. Sampson replies “oh yeah, that, too.”  He reports that he drinks wine daily.

After 2 days of anti-inflammatory treatments and physical therapy assistance, Mr. Sampson’s joint swelling has decreased and he is able to walk easily without pain and will be discharged home today. The nurse is concerned that he may not understand what triggers his gout flare ups, considering how frequently he reports that they happen.