What is the appropriate admitting plan for a 71-year-old female with acute gouty arthritis in flare, anemia of unknown etiology, and possible acute leukemia, who has a history of anemia and elevated white blood cell (WBC) count, and presents with joint swelling, pain, tenderness, and dyspnea?

Admitting Plan for 71-Year-Old Female with Acute Gouty Arthritis, Anemia, and Possible Acute Leukemia

Immediate Priorities

This patient requires urgent hematologic evaluation alongside gout management, as the combination of anemia, elevated WBC, and acute gout raises serious concern for acute leukemia, which can present with gouty arthritis. 1

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1. Acute Gouty Arthritis Management

Initial Anti-inflammatory Therapy

Given the polyarticular involvement (both upper and lower extremities) and associated dyspnea, initiate oral corticosteroids as first-line therapy rather than NSAIDs or colchicine. 2

• Prednisone 0.5 mg/kg/day (approximately 25 mg daily for this 50 kg patient) for 5-10 days at full dose, then stop or taper over 7-10 days 2
• NSAIDs are contraindicated given her age, possible renal impairment from anemia, and dyspnea suggesting potential cardiopulmonary compromise 2, 3
• Colchicine should be avoided until renal function is assessed, as dose adjustment is critical in renal impairment 2

Treatment Timing

• Initiate pharmacologic therapy immediately upon admission, as treatment within 24 hours of symptom onset provides optimal outcomes 2, 3

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2. Urgent Hematologic Workup

The constellation of anemia, elevated WBC, and acute gout mandates immediate evaluation for acute leukemia, as leukemia can present with gouty arthritis due to rapid cell turnover and hyperuricemia. 1, 4

Required Laboratory Studies

• Complete blood count with differential to assess blast cells 4
• Peripheral blood smear for morphology 4
• Comprehensive metabolic panel including creatinine, uric acid level 5
• Lactate dehydrogenase (LDH) - elevated in cell turnover states 1
• Bone marrow aspiration and biopsy if peripheral smear or clinical picture suggests leukemia 4
• Flow cytometry and cytogenetics if leukemia suspected 4

Anemia Evaluation

• Reticulocyte count, iron studies, B12, folate
• Direct antiglobulin test (Coombs) if hemolysis suspected
• Type and screen for potential transfusion needs

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3. Cardiovascular and Respiratory Assessment

The dyspnea requires immediate evaluation given her tachycardia (HR 140) and borderline hypotension (BP 100/70).

• Chest X-ray to exclude pulmonary edema, infection, or leukostasis
• Electrocardiogram to assess for cardiac ischemia or arrhythmia
• Arterial blood gas if respiratory distress worsens
• Continuous pulse oximetry and cardiac monitoring
• Echocardiogram if cardiac dysfunction suspected

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4. Supportive Care Measures

Fluid Management

• Intravenous hydration with normal saline at 75-100 mL/hour to maintain urine output >100 mL/hour, which helps prevent tumor lysis syndrome if leukemia confirmed and aids uric acid excretion 6
• Monitor strict intake/output given borderline blood pressure

Joint Care

• Rest and elevation of affected joints 6
• Topical ice application to inflamed joints 6

Monitoring Parameters

• Vital signs every 4 hours, including oxygen saturation
• Daily complete blood count
• Daily basic metabolic panel to monitor for tumor lysis syndrome (potassium, phosphate, calcium, uric acid, creatinine)

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5. Urate-Lowering Therapy Considerations

Do NOT initiate urate-lowering therapy (allopurinol or febuxostat) during the acute attack. 2, 3

• If patient was already on urate-lowering therapy, continue it without interruption 2, 3
• Defer initiation of new urate-lowering therapy until after acute attack resolves and hematologic diagnosis is established 2, 3

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6. Consultations

Hematology/Oncology - URGENT

• Immediate consultation for evaluation of possible acute leukemia 1, 4
• Bone marrow biopsy coordination if indicated

Rheumatology

• Consultation for gout management optimization once acute phase controlled 2
• Consider joint aspiration for synovial fluid analysis if diagnosis uncertain, though clinical picture is consistent with gout 7

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7. Critical Pitfalls to Avoid

• Do NOT use NSAIDs in this elderly patient with anemia, tachycardia, and unknown renal function 2, 5
• Do NOT delay hematologic workup - acute leukemia can present with gouty arthritis and requires urgent diagnosis 1, 4
• Do NOT start allopurinol during acute attack if patient not already on it - this will worsen and prolong the flare 3, 5
• Do NOT use full-dose colchicine without knowing renal function - requires dose adjustment in renal impairment 2
• Do NOT attribute all symptoms to gout alone - the dyspnea and hemodynamic instability require separate evaluation 4

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8. Patient Education

• Educate patient on dietary triggers: avoid alcohol (especially beer), sugar-sweetened beverages, red meat, and seafood 5
• Encourage low-fat dairy products and adequate hydration 5
• Explain that definitive gout treatment will be deferred until hematologic diagnosis established 3

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9. Disposition Planning

• Admit to monitored bed given tachycardia, borderline hypotension, and need for urgent hematologic evaluation
• Daily reassessment of gout symptoms, vital signs, and laboratory parameters
• Discharge criteria: resolution of acute gout symptoms, hemodynamic stability, established hematologic diagnosis with appropriate treatment plan