What questions should I ask to obtain a thorough history for a patient with tophaceous gout?

History-Taking for Tophaceous Gout

When evaluating a patient with tophaceous gout, systematically inquire about the pattern of acute attacks, presence and location of tophi, risk factors for hyperuricemia, and associated comorbidities that impact both disease severity and treatment decisions.

Acute Attack Characteristics

• Ask about the speed of symptom onset: Gout characteristically reaches maximum pain intensity within 6-12 hours, which is highly suggestive of crystal inflammation 1
• Determine if pain reached its peak within 24 hours: Rapid development of severe pain, swelling, and tenderness is a key diagnostic feature 1
• Inquire about overlying erythema: Erythema over the affected joint has 92% sensitivity and 62% specificity for gout 1
• Ask about the duration of attacks and whether they resolve within 2 weeks: This pattern has 98% sensitivity for gout 1
• Document the frequency of attacks: Recurrent episodes are highly suggestive, and patients with ≥2 flares per year require urate-lowering therapy 1, 2

Joint Involvement Pattern

• Specifically ask about first metatarsophalangeal joint involvement (podagra): This has 96% sensitivity, 97% specificity, and a likelihood ratio of 30.64 for gout 1
• Document whether attacks are monoarticular or polyarticular: While monoarticular involvement is classic, polyarticular disease can occur, especially in patients with multiple comorbidities 2
• Ask about involvement of other typical sites: Including ankles, knees, elbows, wrists, and small joints of hands 1, 2

Tophus History

• Ask about visible or palpable nodules: Definite tophi have 30% sensitivity but 99% specificity with a likelihood ratio of 39.95 1
• Inquire about tophus locations: Common sites include metacarpophalangeal joints, elbows, proximal interphalangeal joints, ears, and extensor surfaces 3
• Ask about symptoms from tophi: Including pain (83% of surgical cases), limited range of motion (56%), deformity (50%), and functional limitation (28%) 3
• Specifically ask about ulceration or drainage from tophi: Ulcerated tophi are uncommon but represent severe disease requiring specialized management 4
• Document any history of tophus-related complications: Such as nerve compression (e.g., sciatica from spinal tophi) or tendon involvement 5

Disease Duration and Progression

• Establish when symptoms first began: Disease duration affects imaging sensitivity and treatment approach 1, 2
• Ask about the intercritical periods: Document the length of symptom-free intervals between attacks 1
• Determine if there has been progression from intermittent to chronic symptoms: This suggests either joint damage or chronic synovitis 1
• Ask about any history of crystal-proven gout: Previous synovial fluid analysis showing MSU crystals is definitive 1, 2

Risk Factors and Triggers

Dietary Factors

• Quantify alcohol consumption: Particularly beer and spirits, which increase gout risk 2
• Ask about dietary intake of high-purine foods: Including red meat, shellfish, and organ meats 1, 2
• Document consumption of high-fructose corn syrup: Found in non-diet sodas and processed foods 1, 2

Medications

• Ask about diuretic use: Associated with relative risk of 1.72 for gout 2
• Document use of low-dose aspirin: This increases gout risk 1, 2
• Inquire about immunosuppressants: Cyclosporine and tacrolimus are risk factors 1, 2

Family History

• Ask about family history of gout: Particularly early-onset gout (age <25 years) 2
• Document any family history of renal calculi: This may indicate urate overproduction 2

Associated Comorbidities

Systematically screen for the following conditions, as they frequently coexist with gout and influence management:

• Chronic kidney disease: Relative risk 4.95; ask about known renal impairment and obtain history of creatinine levels 2
• Obesity: Relative risk 3.81; document BMI history 2
• Hypertension: Relative risk 3.93; ask about blood pressure control and medications 1, 2
• Cardiovascular disease: Including ischemic heart disease and heart failure 1, 2
• Diabetes mellitus: Document glycemic control 1, 2
• Dyslipidemia: Ask about cholesterol levels and treatment 1, 2

Previous Diagnostic Testing

• Ask about prior joint aspirations: Document if MSU crystals were ever identified 1, 2
• Inquire about previous serum uric acid levels: Note that 10% of patients with acute gout have normal uric acid during attacks 2
• Document any prior imaging: Including ultrasound, dual-energy CT, or plain radiographs 1, 2

Current and Previous Treatment

• Ask about current urate-lowering therapy: Including allopurinol, febuxostat, or other agents 1, 2
• Document adherence to urate-lowering therapy: Poor adherence leads to breakthrough flares 2
• Inquire about prophylactic anti-inflammatory therapy: Colchicine or NSAIDs used to prevent flares 1, 2
• Ask about treatments for acute attacks: Including colchicine, NSAIDs, and corticosteroids 1
• Document any adverse effects from previous treatments: Such as gastrointestinal toxicity from NSAIDs or colchicine intolerance 5

Functional Impact

• Ask about impact on daily activities: Including work, self-care, and mobility 3
• Document any occupational limitations: Tophaceous gout can cause significant disability 3
• Inquire about quality of life: Severe tophaceous gout markedly impairs quality of life 6

Red Flags Requiring Urgent Evaluation

• Ask about fever or systemic symptoms: These suggest possible septic arthritis, which can coexist with gout 1, 2
• Inquire about signs of infection in tophi: Including increased warmth, purulent drainage, or rapidly expanding lesions 6, 4
• Document any neurological symptoms: Such as radicular pain from spinal tophi 5