Rheumatology Guideline For The Management of Gout Discussion Paper

Rheumatology Guideline For The Management of Gout Discussion Paper

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Management plan

Primary Diagnosis: Acute Gout with tophus

1. ICD-10 Code: M10.9
2. Rationale: The patient’s presentation with acute, worsening non-traumatic left knee pain, effusion, and a history of gout-related symptoms aligns with the diagnosis of acute gout.
3. Resources: American College of Rheumatoid Guidelines
4. CPT Codes:

1. 99213: Office visit for an established patient with an expanded problem-focused evaluation. (FitzGerald et al., 2020).
2. 36415: Routine venipuncture for blood collection.
3. CPT Code for Joint Aspiration: 20610 Rheumatology Guideline For The Management of Gout Discussion Paper

1. Procedural Codes: 49083: Aspiration of synovial fluid.
2. Vaccinations: T.G may benefit from the influenza and pneumococcal vaccines based on his age and medical history.
   

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Guidelines Used for Primary Diagnosis:

The American College of Rheumatoid Guidelines served as the foundation for diagnosing Acute Gout. These guidelines include recommendations for diagnosing and managing gout.  These guidelines consider clinical symptoms, medical history, and diagnostic tests like synovial fluid analysis and uric acid blood levels (FitzGerald et al., 2020).

Differential Diagnoses:

1. Arthritis, Septic

1. 1. Rationale: Septic arthritis can mimic gout. Synovial fluid analysis is imperative to differentiate between the two conditions (Handa & Handa, 2021).
   2. Resources: Joint aspiration and synovial fluid culture.

1. Calcium Pyrophosphate Dihydrate Deposition Disease (CPPD) Pseudogout

1. 1. Rationale: CPPD can present with similar symptoms to gout. Synovial fluid analysis can help differentiate between these crystal-induced arthropathies.
   2. Resources: Joint aspiration and synovial fluid analysis (Handa & Handa, 2021). Rheumatology Guideline For The Management of Gout Discussion Paper

1. Cellulitis

1. 1. Rationale: Cellulitis can cause erythema and swelling. It however lacks joint involvement.
   2. Resources: Clinical evaluation and, if needed, blood cultures.

1. Osteoarthritis

1. 1. Rationale: Osteoarthritis can cause joint pain and limited range of motion. It however lacks the characteristic tophus seen in gout (Handa & Handa, 2021).
   2. Resources: Radiological imaging (X-rays) for joint evaluation.

Medications:

1. Hydrochlorothiazide 25mg, 1 PO daily: G should be educated on its potential impact on gout.

Black Box Warning: None.

2. Aspirin 81mg, 1 PO daily: G should be educated on this and consider alternative pain relief options.

Black Box Warning: Aspirin may increase the risk of bleeding.

3. Ibuprofen 200mg, PRN pain: G should be advised to take ibuprofen with food to minimize gastrointestinal irritation and should be vigilant for gastrointestinal side effects.

Black Box Warning: Ibuprofen increases the risk of heart attack, stroke, and stomach bleeding.

Ancillary Tests:

1. CBC: To evaluate overall health and detect signs of infection.
2. ESR (Erythrocyte Sedimentation Rate): This test can help in assessing the severity of inflammation.
3. Synovial Fluid Analysis: To confirm the presence of monosodium urate crystals in the synovial fluid.
4. Uric Acid, blood: To determine T. G’s uric acid levels and guide treatment.
5. BMP (Basic Metabolic Panel): To assess electrolyte levels.
6. Liver Function Panel: To monitor liver function, especially with the use of medications.

Referrals: T.G should be referred to Rheumatologist for long-term management of his gout.

Follow-Up: Arrange a follow-up session in two weeks to assess the patient’s reaction to treatment and, if required, adjust prescriptions. Rheumatology Guideline For The Management of Gout Discussion Paper

Problem Statement:

T.G., a 57-year-old man with a history of hypertension, presents with acute, non-traumatic, deteriorating left knee pain with effusion for two days, matching a previous episode that occurred a year ago. The patient’s medical history includes a high purine diet, extensive alcohol use, the use of hydrochlorothiazide, recurrent left first metatarsophalangeal inflammation, and lately unprotected sexual activity. A physical examination discloses a left metatarsophalangeal tophus, an erythematous, swollen knee with restricted range of motion, and unremarkable vital signs.

Social Determinants of Health (SDOH):

1. Patient’s Access to Care: Ascertain that the patient can receive specialized care from a rheumatologist (Day et al., 2020).
2. Education Level: Give information on how to control gout.
3. Safety of His Environment: Assess the patient’s living conditions for factors that may contribute to gout.
4. Ability to Pay for Care: Evaluate the patient’s financial status and insurance coverage. This is to guarantee that they can afford the required medical care. Rheumatology Guideline For The Management of Gout Discussion Paper
5. Social Support: Discuss the patient’s support system for assistance with medication adherence and lifestyle changes (Day et al., 2020).

Health Promotion and Patient Risk Factors:

The recommended health screening exams are:

1. Regular Blood Pressure Monitoring: Given his history of hypertension.
2. Annual Uric Acid Level Testing: To monitor and manage his gout.

• Cardiovascular Risk Assessment: As he is on aspirin, it’s essential to assess his cardiovascular risk and consider appropriate preventive measures (Day et al., 2020).
  

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References

Day, R., Nguyen, A., Graham, G., Aung, E., Coleshill, M., & Stocker, S. (2020). Better outcomes for patients with gout. Inflammopharmacology, 28(5), 1395-1400. https://doi.org/10.1007/s10787-020-00694-7

FitzGerald, J. D., Dalbeth, N., Mikuls, T., Brignardello‐Petersen, R., Guyatt, G., Abeles, A. M., … & Neogi, T. (2020). 2020 American College of Rheumatology guideline for the management of gout. Arthritis care & research, 72(6), 744-760. https://doi.org/10.1002/acr.24180

Handa, R., & Handa, R. (2021). Gout and Other Crystal Arthritides. Clinical Rheumatology, 41-49. Rheumatology Guideline For The Management of Gout Discussion Paper

Problem Statement:

T.G is a 57-year-old male with a past medical history of hypertension presenting with acute, worsening, non-traumatic left knee pain with effusion for 2 days similar to a prior episode 1 year ago. History is positive for Hydrochlorothiazide use, a high purine diet, regular alcohol use, episodic left first metatarsophalangeal inflammation, and recent unprotected intercourse. Physical exam reveals unremarkable vital signs, an erythematous and swollen left knee with limited range of motion and left metatarsophalangeal tophus. Rheumatology Guideline For The Management of Gout Discussion Paper

The Primary Diagnosis is Acute Gout with tophus.

Differential DX are:

1. Arthritis, Septic
2. Calcium Pyrophosphate dihydrate deposition disease (CPPD) pseudogout
3. Cellulitis
4. Osteoarthritis

DIAGNOSTIC TESTS PERFORMED

1. CBC
2. ESR
3. Synovial fluid analysis
4. Uric Acid, blood
5. BMP
6. Liver Function Panel

MEDICATIONS:

1. Hydrochlorothiazide 25mg 1 PO daily
2. Aspirin 81mg 1 PO daily
3. Ibuprofen 200mg PRN pain

GUIDELINES used to develop diagnosis

1. American College of Rheumatoid Guidelines

Please use these to answer the following questions on the Management Plan Rheumatology Guideline For The Management of Gout Discussion Paper

The Management Plan has to be in this order EXACTLY

Instructor docked points on the last Management Plan because of the following: Please include CPT Codes and any procedural codes, including nurse lab draws i.e., Troponin, EKG. Also, on Health Promotion and patient risk factors (Health Promotion should include a list of recommended health screening exams based on patients age/sex/risk factors). This is what instructor said about last Management plan you and I did.  Give education on medication (side effects/risks). Red flags for immediate follow up or ER visit would include vomiting blood, black or tarry stools, worsening pain, syncope. -5 pts Problem Statement. This is different than your HPI. Include findings from your ROS/PE and testing that led to your diagnosis. In this case it is immediate relief with GI Cocktail and a normal 12 lead EKG- – 2 pts Social Determinants of Health to consider (there are 5 points to review: Patient’s access to care, ability to pay for care, education level, social support and safety of his environment). SDOH can be reviewed on the WHO website.2 pts Rheumatology Guideline For The Management of Gout Discussion Paper

When listing medications, instructor wants information about the medication and any Black Box Warnings.

References have to be at least 3 SCHOLARLY and APA Format

Management plan template
Primary Diagnosis with ICD-10 code, rationale and
resources. Include CPT codes, and any procedural codes,
including nurse lab draws, vaccinations given, biopsies,
etc…10 pts. Rheumatology Guideline For The Management of Gout Discussion Paper
Guidelines used to develop this primary diagnosis. 5 pts
Differential diagnoses with rationale and resources. 3-5
Ddx required, unless well visit. 5 pts
Medications including OTC, dosage and education,
additional ancillary tests needed, referrals and follow up –
10 pts
Problem Statement – 5 pts
Social Determinants of Health to consider, Health
Promotion and Pt risk factors – 5 pts
Must use 3 scholarly references
Worth 40 points
Management Plan Template– must include these
headings Rheumatology Guideline For The Management of Gout Discussion Paper