Question

Mr. Evans is an 82 year old resident of a long-term care facility who tells the nurse, “I have an ache in my left foot.” He offers an explanation, suggesting, “I must have stepped and twisted my ankle. Maybe I was bit by a bug outside this morning.” The nurse notes the medial aspect of Mr. Evans left ankle is reddened, warm, and swollen. His temperature is 98.6°F. He has a strong pedal pulse bilaterally.

Mr. Evans ankle is x-rayed and there is no fracture noted. He has full range-of-motion of his left ankle and lower extremity, although the pain in his ankle increases with movement. A Doppler ultrasound rules out deep vein thrombosis.

Prior to the Doppler ultrasound, how could the nurse explain this diagnostic procedure to prepare Mr. Evans?

Briefly explain what gout is and describe the causes of primary and secondary gout.

What are the common characteristics of each of the four stages of gout?

Answer 1

1. Doppler ultrasound patient preparation:

Doppler ultrasound is an imaging test that can be used to estimate blood flow through the blood vessels. This non invasive technique make use of bouncing of ultrasound waves off tissue/ fluid or RBCs ( Red blood cells) in circulating blood. This test can be used to check the problems with the blood flow such as poor circulation, Deep vein thrombosis etc.

* During the procedure, patient can lie on a table and needed area can be exposed .

* A special gel will be applied on the skin of required area by health care provider.

* The healthcare professional will move a transducer, that sends sound waves, over the body parts.

* The waves produced from the body are recorded and turned into images or graphs in the monitor. The image will display the movement of blood flow on the particular part.

* Health care provider will wipe off the gel from the area of exposure. The procedure will take an approximately haf an hour.

Preliminary steps:

* Doctor may ask the patient to be Nil per oral for 6 to 10 hrs , before Doppler test.

* Remove the jewellery or clothing from the area of exposure.

* Patient should not smoke for 2 hrs before the test. Nicotine can narrow blood vessels, which causes abnormality in the test results.

2. Gout:

Gout refers to a condition of an extremely painful joints , especially of the big toe, caused by a metabolic defect resulting in the accumulation of uric acid in the blood and the deposition of urates around the joints.

* Primary Gout: It occurs due to the deposition of urate crystals in the joint, as a result of hyperuricemia in the body. This condition may occur in the under excretion of uric acid in the kidney and over production from dietary excess ( purine rich diet: organ meat, turkey, bacon,  fish: Sardines,  anchovies, mussels, codfish, shellfish, Alcoholic beverages )

* Secondary Gout : is a disorder, that have the symptoms of Gout and hyperurecrnia, but occured as a result of medicine use , secondary disease of bone marrow or blood or due to kidney failure etc .

As no past medical history or current medications are not given, Mr. Evan may be suffering with Primary Gout.  

3. 4 stages of Gout:

Gout may occur in 4 stages, if it not treating at the early stage:

stage 1: Asymptomatic hyperuricemia

Uric acid level may increase in the blood due to increased intake purine rich diet ( purine breaks down into uric acid), sudden changes in uric acid level due to certain drugs like Diuretics, under excretion of uric acid by kidneys. This stage more likely be asymptomatic stage.

Stage 2: Acute Gout:

* Attack of Gout symptoms, probably night time

* pain , redness, swelling of joints , as urate crystals are deposited near to the joints and it may release into joint fluid, it may result in inflammatory reactions.  

Stage 3:

Stage 3 is called Inter critical gout. In this stage the gout symptoms may queit down after the first attack of Gout symptoms. This may extend to months or some years. Treatment or measures for lowering the uric acid level has to be started in this stage, or again gout attack may occur.  

Stage 4: Tophaceous Gout

Stage 4 is called chronic gout or tophaseous gout. Nodules will be formed at or near to the joints due to urate crystals deposition. This nodules are called tophi.

This satge is characterised with joint pain, nodules and progressive joint damage.

Gout , as it is an inflammatory process can lead to clot formation. It can lead to complications such as Deep vein Thrombosis ( DVT). A potentially fatal condition in which one or more clot or thrombi form in the leg or in the arm . The clot may break free from the venous wall and travel via circulatory system to the lungs or heart.