Soundings by by Brady Pregerson, MD & Teresa Wu, MD 

 

It’s the middle of a slow weekend shift in the rural ED where you work when a 72-year-old female patient with a history of hypertension comes in complaining of pain and redness on the dorsum her left foot.  The pain started “without warning” about 36 hours ago and isn’t getting any better. It seemed like it got really bad within 6-12 hours of onset then sort of hit a plateau. There was no injury, so she thought it was going to get better, but unfortunately it hasn’t. She says the pain makes it  hard to walk and she can’t wear her regular shoes. There has been no fever, trauma or other complaints. She has no prior history of a similar condition, and other than hypertension, her past medical history is unremarkable. Her medications include atenolol, hydrochlorothiazide and baby aspirin.

On exam, your patient appears to be in mild distress. Her vital signs are normal except for a blood pressure of 172/86. An examination of the head and neck is normal except for a few whitish lumps on both ears, which she says have been there “for years”.  The lungs are clear and the heart is regular with a soft systolic ejection murmur. Her extremities are normal except for the feet. The skin is intact and the pulses are strong, but the dorsum of the left foot is definitely red, slightly swollen and tender. Although the area is red, it is not really that much warmer than the other side and motion of the foot and toes seems to aggravate the pain a lot more than palpation.

While you are examining the left foot, your patient says, “while you’re checking my feet, can you take a look at my right foot too. I have two lumps, one on the top and one on the bottom that I’ve been meaning to have checked out.”  On the dorsum of the painless foot toward the toes there is a non-tender mobile cluster of nodules, each about 1 cm in size, and on the plantar surface there is a fullness and possible deep seated mass that has too much overlying structure to really palpate well.

Given her age, the atraumatic onset of redness and pain without much in the way of localized warmth or fever, the rapid peak of symptoms in a way that would be atypical for an infection, and the lesions in her ears that look like gouty tophi, you suspect your patient may be suffering her first clinical attack of gout. Your suspicion is heightened when you learn that she recently started taking hydrocholorothiazide; a medication known to precipitate an attack of gout. You would like to confirm the diagnosis by aspirating some uric acid crystals, but the area of her foot that is symptomatic is not at a joint. Knowing that gout can affect tendons as well, you wonder if she’s developed a fluid collection around her tendon that is amenable to aspiration.

A few minutes later you find the time to scan the dorsum of her left foot, and while you’re at it, you take a look at the other foot where she has the chronic asymptomatic “lumps”.

You obtain images 1, 2 and 3. What do you see? Should you stick a needle in any of these?

 

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