1. Mr. Smith, 51, came to the family doctor because of severe pain in his left knee. The patient gave the pain began suddenly at 2 am, woke him from his sleep, he was so strong that even a touch of linen was unbearable.
Morning insulated knee was swollen and tender.
The patient was holding his leg bent at the knee joint, because straightening her intensified.

2. Interview
A year ago, the patient experienced pain and swelling of the base of the big toe of the left foot, the pain disappeared spontaneously after 2-3 days after use of ibuprofen. In the interview, the patient is given only hypertension, whose normalization was achieved using hydrochlorothiazide and lisinopril
The patient is a financial advisor, has a wife, do not smoke cigarettes, drink 1-2 beers after work once or twice a week.

3. PHYSICAL EXAMINATION
temp. 37,1C body, heart rate 90 / min, blood pressure 136/ weight 85 kg, height 175cm BMI 27.8 kg / m2 waist circumference 96 cm There was no swelling, soreness or distortion of other joints or skin changes

4. PHYSICAL EXAMINATION
Swollen left knee, with an average amount of liquid, with erythema, insulated and very tender to the touch.

5. What do you suspect. How should look next
What do you suspect? How should look next? What treatment should be used?

6. Differentiation: Possible diagnosis?
Infections ? Reactive arthritis?
Rheumatoid arthritis-involvement of a single joint ?
Foreign body (eg. a spike) ?
Osteoarthritis?
Gout? Crystal-Induced Arthritis

7. Diagnosis: Laboratory tests: uric acid 9 mg% glucose 116 mg%
total cholesterol 190 mg%
HDL 39 mg%
LDL 149 mg%
triglycerides mg%
examination of synovial fluid ?
radiography ?

8. Diagnosis: acute attack of gout
metabolic syndrome overweight hypertension dyslipidemia

9. ROUTINE PROCEDURE Treating the acute attack
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as diclofenac
Corticosteroids
Colchicine (now less commonly used for acute gout than it once was)
Combinations of drugs (colchicine plus NSAIDs, oral corticosteroids plus colchicine, intra- articular steroids plus colchicine or NSAIDs)

10. treatment of gout between attacks
Dietary restriction (what?)
Exclusion of drugs that increase the concentration of urate (which?)
Reduction of uric acid (when?)

11. Nonpharmacologic measures
Avoidance or restricted consumption of high- purine foods (sardines, salmon, herring, liver, mackerel, meat extracts, veal)
Avoidance of excess ingestion of alcoholic drinks, particularly beer
Avoidance of sodas and other beverages or foods sweetened with high-fructose corn syrup
Limited use of naturally sweet fruit juices, table sugar, and sweetened beverages and desserts, as well as table salt
Maintenance of a high level of hydration with water (≥8 glasses of liquids daily)

12. Indications for the use of drugs that reduce uric acid levels in a patient with gout when the concentration of less than 12mg / dl is: 1) tophi identified on the basis of clinical 2) frequent attacks of gout (≥2 per year) 3) chronic inflammation of the joints with the formation of erosions 4) chronic kidney disease stage ≥2,. GFR <50 ml / min / 1.73 m2) 5) nephrolithiasis (well traveled).

13. Other treatment Weight loss, reduced abdominal circumference
Increasing physical activity
The diet of carbohydrate restriction
Treatment of dyslipidemia: fibrates
Limiting alcohol