Topic: Gout
Subject: Surgery
What The Candidate Reads
Candidate's Instructions
This is exactly what is posted by the patient's room door.
You will have 1.5 - 2 minutes to read these instructions, before entering the room.

OPENING STEM: A 58-year-old male patient presents with right toe pain.

CANDIDATE'S TASK: In the next 6 minutes, obtain a focused and relevant history.

At the next station, you will be asked to answer questions about this patient.


PATIENT INFORMATION
This information is what the standardized patient (SP) has memorized.
You will not receive this information on the actual MCCQE Part 2 Exam.
This information is presented in this QBank to assist you in your preparation for the exam.

PATIENT STARTING POSITION: Sitting comfortably in a chair

CLOTHING: Wearing jeans, a polo shirt, sandals without socks

MAKE-UP: Redness to right D1 MTPJ (optional)

PATIENT'S OPENING STATEMENT: "My right big toe is really sore"

PATIENT BEHAVIOR, AFFECT AND MANNERISMS: Patient is relaxed

QUESTIONS PATIENT MUST ASK: What can I do to prevent this from happening in the future?
Answer: There are several things we can try. One is a modification in diet that avoids or limits certain foods, such as alcohol and certain meats, cheeses, and fish. As well, there are medications that can be taken long-term to prevent episodes such as your current one.

QUESTIONS PATIENT MAY ASK: Can this occur in other joints?
Answer: Yes, it can occur in other joints, typically the ankle or knee. It is most common in the big toe joint, however.

HISTORY OF PRESENT PROBLEM: Onset: 1 day ago
Duration: constant pain
Progression: pain is getting worse
Frequency: had a similar pain a 3 years ago
Location: right big toe (D1 MTPJ)
Radiation: none
Quality: throbbing
Intensity: At its worst, the pain is 8 out of 10.
Alleviating factors: none. Acetaminophen provides minimal relief.
Aggravating factors: moving right big toe, walking, tight/closed-toe shoes

PATIENT ISSUES: Patient is concerned about the pain, but not worried about the seriousness

RELEVANT MEDICAL HISTORY | ALLERGIES | MEDICATIONS: Past illnesses: hyperlipidemia
Accidents/ injuries: none
Allergies: NKDA
Medications: currently takes atorvastatin
Hospitalizations: none

RELEVANT SOCIAL / FAMILY HISTORY: Alcohol- 2-3 beers/ day
Smoker: 1/2 pack per day for 45 years.
Lives at home in the city with his wife. 2 grown kids living away in different cities
Sexual history: monogamous with wife (no concerns for STI)
No known FHx

REVIEW OF SYSTEMS: n/a

PATIENT SIMULATION: Patient must not move R D1 toe

PHYSICAL FINDINGS: n/a

INFORMATION GIVING: Patient is calm but uncomfortable

PERTINENT NEGATIVES: No fever, no history of trauma, no relevant sexual history


What the examiner completes

EXAMINER'S CHECKLIST
These are the exact items you need to complete satisfactorily for this case to score the points you need to pass.

During this period you will be observed by a physician examiner who will assess your performance using standardized scoring instruments.

The physician examiner will fill in the bubble for each item completed satisfactorily

1) Elicits onset of pain (when did it start)  [Answer: My pain started 1 day ago.]

2) Elicits duration (how long does it last)  [Answer: This pain is constant. ]

3) Elicits progression (has it become worse, better or the remained the same)  [Answer: The pain is getting worse.]

4) Elicits frequency (how often does it happen)  [Answer: This is the second time this has happened. ]

5) Elicits location (where exactly do you feel the pain)  [Answer: My right big toe.]

6) Elicits radiation (does the pain move anywhere else)  [Answer: The pain is only in the toe. ]

7) Elicits quality (aching, throbbing, tearing, sharp, dull etc)  [Answer: The pain is throbbing.]

8) Elicits intensity (on a scale from 1 to 10)  [Answer: At its worst, the pain is 8 out of 10.]

9) Elicits alleviating factors (what makes it better)  [Answer: I tried Acetaminophen. It provides minimal relief.]

10) Elicits aggravating factors (what causes it or makes it worse)  [Answer: Moving my toe, walking, and wearing closed-toe shoes makes the pain worse.]

11) Have you had this pain in the past?   [Answer: I had an episode of similar toe pain 3 years back that lasted about a week.]

12) Have you undergone any surgeries in the past?  [Answer: I have not had any surgeries.]

13) Do you presently take any medications?  [Answer: I take atorvastatin every day. ]

14) Do you have any known allergies?  [Answer: No]

15) Do you smoke?  [Answer: I smoke cigarettes.]

16) How many cigarettes do you smoke a day?  [Answer: I smoke a half a pack of cigarettes a day.]

17) For how long have you been smoking?  [Answer: I have been smoking for 45 years.]

18) Do you drink alcohol?  [Answer: Yes.]

19) What do you drink?  [Answer: I drink beer.]

20) How much do you drink on a typical day?  [Answer: I drink 2-3 beers a day in the evening. ]

21) Are there any illnesses in your family?   [Answer: Nothing that I know of. ]

22) Where do you live?  [Answer: In the city.]

23) Who do you live with?  [Answer: My wife.]

24) Do you have any children?  [Answer: Yes, two but they are grown up and live in different cities. ]

25) Are you sexually active?  [Answer: Yes.]

26) Do you have multiple partners?  [Answer: No. Just my wife. ]

27) Do you have a fever or chills?  [Answer: No.]

28) Do you have pain in any other joints?  [Answer: No.]

29) Did you recently injure your right toe or foot?  [Answer: No.]

30) Elicit past medical history  [Answer: I have high cholesterol.]

31) Have you ever been hospitalized?  [Answer: No.]

SCORING TABLE

The physician examiner will complete this scoring table after your encounter with the patient

If UNSATISFACTORY, please specify why:
Inadequate medical knowledge and / or provided misinformation
Could not focus in on this patient's problem
Demonstrated poor communication and / or interpersonal skills
Actions taken may harm this patient
Actions taken may be imminently dangerous to this patient
Other:
Did this candidate demonstrate a lapse in professional behaviour? Yes No
Disrespectful to others (e.g., to patient, nurse)
Over-investigated / over-managed the patient
Actions raised ethical and / or legal concern
Briefly describe the behaviour for any of the above reasons or any other observed lapse:




PATIENT INTERACTION RATING SCALES

Up to a total of seven interaction items may be added to a 10 minute case, depending on the task that candidates are asked to complete. One or two interaction items may be added to a 6 minute case.

Individual interaction items are weighted on their relative importance to each other for a specific station. The weight for the combined items ranges from 10% to 50% of the total score for any one station. The MCC OSCE interaction rating scales are here:

PATIENT INTERACTION RATING SCALE ITEMS

Look through the Rating Scale file above and select the Patient Interaction items that are relevant to this case.

FOR THIS 6 MINUTE CASE, YOU MAY BE EVALUATED ON ONE OR TWO OF THE FOLLOWING PATIENT INTERACTION ITEMS:

14


What the candidate receives

POST-ENCOUNTER PROBE (PEP)
These are the sample questions that you will need to answer for this case. The correct answers are included here.

Q1. What is the most likely diagnosis?

Q2. What is the most appropriate next step in the patient care in terms of diagnostic testing?

Q3. Assuming the most likely diagnosis is gout, what is the most appropriate treatment for this patient?

What the post-encounter probe marker receives

ANSWER KEY
Q1.What is the most likely diagnosis?Score
A1Gout3
 Pseudogout2
 Osteoarthritis1
 Maximum3
 
Q2.What is the most appropriate next step in the patient care in terms of diagnostic testing?Score
A2Joint aspiration and synovial fluid analysis2
 X-ray of the affected joint1
 Serum uric acid levels1
 Maximum2
 
Q3.Assuming the most likely diagnosis is gout, what is the most appropriate treatment for this patient? Score
A3NSAIDs1
 Colchicine1
 Allopurinol0
 Corticosteroids1
 Maximum1
 


Explanation

This is a case of a 58-year-old man presenting with presumably his second case of gout. He presently does not take any prophylactic medications.

A1.
Gout is the most likely diagnosis based on the patient's presentation and history of recurrent episodes of monoarticular D1 MTPJ pain. Gout commonly affects males in the 4th-6th decades and often presents in the great toe.

Pseudogout is more common in patients > 60 years of age, affecting more proximal joints and presenting classically with monoarticular knee pain. Given the patient's history of D1 MTPJ pain and age, gout is a more likely diagnosis.
Although osteoarthritis is a common cause of joint pain in older patients, given this patient's history of recurrent but infrequent episodes of monoarticular joint pain, age, and presentation of severe, sudden onset pain, gout is a more likely diagnosis.

A2.
Patients with a suspected gout flare should have synovial fluid analysis, blood test, and/or imaging. Joint aspiration and synovial fluid analysis is a diagnostic test, which assesses for the presence of crystals/analyzes crystals for negative birefringence, which is indicative of the monosodium urate crystals of acute gout.
X-ray of the affected joint can be helpful to assess for chondrocalcinosis, which are common in pseudogout. The presence of chondrocalcinosis, however, is not diagnostic of acute gout.
Elevated serum uric acid levels indicate a state of hyperuricemia (saturation of serum for urate), which can contribute to the development of gout. Hyperuricemia, however, is not diagnostic of acute gout.

A3.
NSAIDs, such as naproxen and indomethacin, are considered the first-line treatment option of acute gout.

Colchicine interferes with the inflammatory processes of gout and is an effective medication in the treatment of acute gout when initiated within the first 24-36hours.
Allopurinol is a urate-lowering therapy and is of no direct benefit in the treatment of acute gout flare. Additionally, urate-lowering medications should not be initiated during an acute gout flare, as in this patient, as it may worsen symptoms. However, it may be considered as prophylactic management in patients with recurrent gout.
Corticosteroids are considered useful in the treatment of acute gout. Due to the side-effects of steroids, however, they are typically considered when the use of NSAIDs is contraindicated.