Station 90

Richard Palmer

Age: 61 year old male

Full Case

Station List
Doctor
Patient
Examiner

Patient’s Data​

Patient’s Name: Richard Palmer

Age: 61-year-old male

Past Medical History:

  • Hypertension

Drug and Allergy History:

  • Amlodipine 10mg OD
  • No Known Drug Allergy 

Recent Notes/Consultation:

Letter from St Mary’s Urgent Care Service (3 days ago) 

 To: General Practitioner
 Re: Mr. Richard Palmer | 61 years old | Male

Dear Colleague,

Mr. Richard Palmer presented to the Urgent Care Centre with a rapid-onset swelling and severe pain affecting the right first metatarsophalangeal (MTP) joint, which developed overnight. Clinical examination revealed redness, swelling, and tenderness consistent with an acute gout flare.

He was systemically well with no fever or constitutional symptoms, and there were no features to suggest septic arthritis at the time of review.

A blood test showed an elevated serum uric acid level of 350 µmol/L. A diagnosis of acute gout was made.

He was commenced on colchicine 500 micrograms four times daily for 3 days. He was safety-netted appropriately, including advice regarding signs of septic arthritis and when to seek urgent medical attention.

Mr. Palmer was advised to follow up with his GP once the acute flare has resolved to discuss the possibility of initiating urate-lowering therapy to reduce the risk of future attacks.

Kind regards,
Dr Kelechi Onwudiwe, MBBS, MRCGP, MRCEM
Urgent Care Physician

Patient booked an urgent telephone appointment to discuss concerns 

Patient's Story (Role player’s brief)

Patient’s Story 

You are Richard Palmer, a 61-year-old male. 

Opening Statement: “Hi doctor, I would like to request a prescription for a medication I was given at the out-of-hours service called colchicine. Could you please provide me with this?”

If asked to explain further: You are calling because your right big toe is still painful, even after finishing a 3-day course of colchicine that urgent care gave you. The swelling has gone down a bit, and you can now bear weight, but it still hurts, especially when you walk. You have no fever, and you feel well in yourself. 

You experienced diarrhoea for the last 2 days, which you later discovered is a known side effect of the medication. The diarrhoea has now settled.

You have not had any previous episodes of gout prior to this one. You are now wondering whether you need more colchicine for pain relief. You are also keen to know what can be done to prevent future attacks.

Social History: You do not smoke or use recreational drugs. You occasionally drink alcohol, mainly beer at weekends, although not every weekend. You eat red meat regularly. You live with your wife and work as a postman. You have been off sick for the past 3 days due to the pain but are eager to return to work soon as you enjoy your job.

Ideas: You suspect that the gout flare has not fully resolved and may need further treatment.

Concerns: You have been off work for 3 days and are keen to return as quickly as possible.

Expectations: You hope for additional colchicine or a stronger painkiller to completely resolve the current symptoms. You are also interested in finding out if there is a treatment that could help prevent future flares.

Say NO to any other questions outside of the details already provided.

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