What are the key components of a physical exam for gout?

Key Components of a Physical Examination for Gout

The most essential components of a physical examination for gout include careful joint examination focusing on the first metatarsophalangeal joint (podagra), assessment for tophi, and evaluation of erythema and swelling, as these findings have the highest diagnostic value for gout. 1, 2

Joint Examination

• First metatarsophalangeal joint (podagra): Examination of this joint is critical as it has a high likelihood ratio (LR 30.64) for gout diagnosis 1
• Other commonly affected joints: Ankles, knees, midtarsal joints, wrists, fingers, and elbows should be systematically examined 2, 3
• Pattern of involvement: Note if the presentation is monoarticular (most common in early gout) or polyarticular 2
• Joint swelling: Assess for asymmetrical joint swelling, which has a likelihood ratio of 4.13 1
• Tenderness: Document areas of maximal tenderness 2
• Range of motion: Evaluate limitations in joint mobility

Inflammatory Signs

• Erythema: Presence of erythema over affected joints has a likelihood ratio of 2.44 1
• Warmth: Assess for increased temperature around affected joints
• Rapid onset: Document if pain and swelling developed rapidly (within 6-12 hours), which is highly suggestive of crystal-induced inflammation 1

Tophi Assessment

• Definite tophi: Examine for hard, irregular nodules in periarticular regions, which have a very high likelihood ratio (39.95) for gout diagnosis 1
• Common locations for tophi: Helix of the ear, olecranon bursa, Achilles tendon, and over interphalangeal joints 3
• Consistency and size: Note the firmness, size, and any overlying skin changes of suspected tophi

Periarticular Structures

• Bursae: Examine for inflammation of bursae, particularly the olecranon bursa 3
• Tendons: Assess for tendon involvement and inflammation 3

Associated Comorbidities Assessment

• Cardiovascular examination: Assess for hypertension, heart failure, and other cardiovascular diseases 2
• Body habitus: Note obesity as it's a common comorbidity 2
• Metabolic syndrome features: Look for clinical signs of metabolic syndrome components (obesity, hypertension) 1, 2

Differential Diagnosis Considerations

• Septic arthritis: Assess for signs suggesting infection (severe systemic symptoms, marked inflammation) 2
• Other crystal arthropathies: Consider features that might suggest pseudogout (different joint distribution) 2
• Rheumatoid arthritis: Look for symmetrical joint involvement and morning stiffness 2

Documentation of Findings

• Document the pattern, distribution, and characteristics of joint involvement
• Record the presence or absence of tophi and their locations
• Note the timing and rapidity of symptom onset
• Document associated comorbidities

Pitfalls and Caveats

• Relying solely on serum uric acid levels for diagnosis is unreliable, as levels may be normal during acute attacks 1, 2
• Not examining the first metatarsophalangeal joint, which is affected in approximately 50% of initial gout attacks 3
• Failing to distinguish between gout and septic arthritis, which may require joint aspiration for definitive diagnosis 2
• Overlooking the presence of small tophi, which can be subtle but diagnostically valuable 1

When the clinical presentation is typical (such as podagra with hyperuricemia and characteristic rapid onset), a clinical diagnosis based on physical examination findings may be appropriate. However, when the presentation is atypical or when infection is a concern, joint aspiration for synovial fluid analysis remains the gold standard for diagnosis 1, 2.