Station 90

Richard Palmer

Age: 61 year old male

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis

  • Ask about current symptoms such as level of pain, any ongoing swelling or redness, and whether mobility is improving
  • Confirm if this is the patient’s first episode of gout. 
  • Ask about systemic symptoms such as fever, chills, or feeling unwell to exclude septic arthritis.
  • Ask about the impact on daily functioning including whether the patient can bear weight or walk. 
  • Ask about side effects from colchicine including diarrhoea, abdominal pain, nausea, or vomiting. 
  • Ask about lifestyle factors including diet (how often the patient consumes red meat), alcohol intake, and whether he smokes. 
  • Ask about any family history of gout or similar conditions  
  • Ask about the patient’s occupation and how symptoms have affected his ability to work
  • Ask about any previous joint problems or similar episodes in the past
  • Ask about the patient’s ideas, concerns, and expectations
  • Provide a working diagnosis of a resolving acute gout flare 



Example of explanation to patient​

Thank you for calling today, Mr Palmer. From what you have described, it sounds like your gout flare is beginning to improve, which is encouraging, although I appreciate you are still experiencing some discomfort.

Before we go ahead, can I just check what you already know about gout? 

Gout is a condition that tends to flare up from time to time. It happens when a chemical in the blood called uric acid builds up and forms tiny crystals in the joints. These crystals cause inflammation, leading to the swelling and pain you have been experiencing.

According to current medical guidance, we would not normally prescribe a further course of colchicine after a patient has completed a full course at the maximum recommended dose, as you have. This is because colchicine has a narrow safety margin and can lead to side effects, including the diarrhoea you mentioned.

Since you are still in pain, I can prescribe a medication called naproxen, which is an anti-inflammatory that can help reduce the discomfort. Before I go ahead, can I just check – do you have any history of stomach problems such as indigestion or reflux? 

I would prescribe a medication alongside it to protect your stomach, just to be cautious. Is that okay? 

Other things you can do to help include resting your foot, keeping it elevated, applying an ice pack, and avoiding tight footwear, all of these can support your recovery and help reduce discomfort

Going forward, it is worth thinking about preventing future attacks. Once this flare has fully resolved, we can discuss a medication called allopurinol. This helps reduce the build-up of uric acid in the body and lowers your risk of gout returning.

As you have been off work for three days, you can continue to self-certify for up to seven days in total. If your symptoms persist beyond that and you are still unable to work, please let us know and we can arrange a fit note for you.

Management

Management

  • Do not offer a repeat course of colchicine. It should not be taken for more than 3 days due to the risk of toxicity. According to the BNF, the recommended dose is 500 micrograms two to four times daily until symptoms improve, with a maximum total dose of 6 mg per course. The course should not be repeated within three days. This is because colchicine has a narrow therapeutic window, meaning the difference between an effective dose and a toxic dose is small. So, small differences in the therapeutic dose can lead to toxicity/ adverse drug reaction
  • If there are no contraindications, offer an NSAID such as naproxen or ibuprofen for ongoing pain. Alternatively, consider short-course oral prednisolone (30 mg once daily for 3 to 5 days), which is an off-label option.
  • Prescribe a proton pump inhibitor (PPI) for gastric protection if an NSAID is used, especially in patients over the age of 55.
  • Reassure the patient that a face-to-face review is not required at this time, as symptoms are already improving and he was assessed recently.
  • Provide simple self-care advice including resting and elevating the affected foot, keeping the joint uncovered in a cool environment, and applying an ice pack to reduce pain and swelling.
  • Advise that the patient can self-certify for up to 7 days. If symptoms persist beyond this period, offer a fit note to support further time off work.   
  • Discuss lifestyle modifications including reducing alcohol intake, limiting consumption of red meat and seafood, and maintaining good hydration to reduce uric acid levels.
  • Explain that once this flare settles, there is an option to start a preventative medication called allopurinol to reduce the risk of future gout attacks. This can be discussed at a follow-up if the patient is interested.
  • Safety-net by advising the patient to seek urgent medical attention if the joint becomes hot, red, and swollen again, or if systemic symptoms such as fever or feeling unwell develop.
  • Arrange a follow-up in 2 to 3 weeks to review blood tests and discuss long-term management options, including preventative treatment.

Learning point from this station: ​

It is important for GPs to be aware of medication safety, especially when prescribing drugs with a narrow therapeutic index like colchicine. The recommended dose for colchicine in acute gout is 500 micrograms 2–4 times a day until symptoms are relieved, with a maximum total dose of 6 mg per course, and it should not be repeated within 3 days.

This strict dosing is due to colchicine’s narrow therapeutic index, meaning that small differences between the therapeutic and toxic doses can lead to serious adverse effects

Further reading