A 64 year old man has a painful, swollen right knee. The symptoms began two days earlier. There is no history of trauma. His joint aspirate shows pus cells, negatively birefringent crystals and no organisms. What is the diagnosis?
a. Septic arthritis
b. Pseudogout
c. Gout
d. Reactive arthritis
e. Not enough information to make a diagnosis
Q. A 63-year-old male presents with severe pain in his left wrist. The wrist is swollen, tender to touch and red. Aspiration reveals fine needle shaped yellow birenfringent crystals. Which treatment is unlikely to help this patient?
A. Colchicine
B. Indomethacin
C. Allopurinol
D. Corticosteroids
In gout:
a) Only about 5% of hyperuricemic patients develop gout
b) Monosodium urate crystals are demonstrable in synovial fluid leukocytes
c) May occur as a result of PRPP synthetase deficiency
d) The great toe is the site of first attack in 90% of the cases (wrong! 90% 1st attacks are monoarticular, while 50% are podagra, and 90% pf gout patients eventually get podagra in the 1st MTP joint.
e) Nephropathy may occur due to obstruction of the collecting system by urate crystal
Treatment of an acute gout attack is achieved by:
a) Colchicine
b) Allopurinol
c) Uricosuric agents
d) Indomethacin
e) Methorexate
Pseudogout. Mark T or F.
a) It occurs as a result of calcium pyrophosphate deposition
b) It usually affects younger individuals (older)
c) It can be associated with hyperthyroidism, ochronosis and Wilson’s disease
d) Chondrocalcinosis is a known x-ray finding
e) Intraarticular injection of steroids is useful
The side effects of colchicine are all of the following except:
a. Diarrhea
b. Liver toxicity
c. myelosuppresion
d. Peripheral neuropathy
What is the key enzyme needed to salvage the pathway off purine synthesis?
a. Hyperxanthine guanine phosphoribyosltransferase (HGPRT)
b. Hypoguanine xanthine phosphoribyosltransferase (HXPRT)
c. Hyperibysl guanine phosphoribyosltransferase (HGPRT)
d. Hypoxanthine guanine phosphoribyosltransferase (HGPRT)
T or F:
In Lesch-Nyhan Syndrome, in addition to lack of HGPRT-no salvage pathway, characterized by hypouricemia, self-mutilation and mental retardation
The goal of chronic gout meds is to:
a. control pain (limit inflammation)
b. modify purine metabolism
c. control HGPRT
Purines are converted to hypoxanthine and xanthine via what enzyme?
a. Xanthine peroxidase
b. Xanthine oxidase
c. Oxypurinol
Lesch-Myman syndrome is due to deficiency of ______ caused by _______ mutation.
Mutations in the HGPRT gene lead to (leading to high levels of uric acid in he blood, gouty arthritis, uric acid stones)
a. Hyperuricemia
b. Hypouricemia
Phosphoribosylpyrophosphate synthetase (PRPS) deficiency is:
a. A rare disorder where an enzyme (Phosphoribosylpyrophosphate synthetase) deficiency causes mental retardation and hypouricemia.
b. A fairly common disorder where an enzyme (Phosphoribosylpyrophosphate synthetase) deficiency causes mental retardation and hypouricemia.
Probenecid is used for treating gout and hyperuricemia and the main action if the drug is to:
a. decrease uric acid in the urine
b. increase uric acid in the urine
A 50-year-old man has severe pain at the base of his left great toe, around the forward portion of the arch. The first metatarsophalangeal joint of his left foot is tender, markedly inflamed, and erythematous. Laboratory studies show a serum uric acid level of 10.4 mg/dL. A 24-hour urine specimen contains 550 mg of uric acid. Light microscopy of a synovial aspirate shows the presence of monosodium urate crystals. The most appropriate treatment for this patient’s arthritic pain is:
A. allopurinol
B. aspirin
C. colchicine
D. probenecid
E. sildenafil
What are MSU crystals?
a. intra-articular mono sodium urate crystals (or in tissues)
b. intra-articular mono sodium uranium crystals (or in tissues)
Febuxostat may cause problems with liver transaminases, and therefore
periodic liver function tests are required.
a. T
b. F
For patients with a history of allopurinol hypersensitivity, what drug may be considered an alternative?
a. Metformin
b. Febuxostat (structurally different than allopurinol, but similar function)
Febuxostat is good drug to use for patients with what type of issues:
a. Liver
b. Kidney
c. Heart
Allopurinol and Probenecid are known as “suicide substrates”. By inhibiting XO they decrease purine metabolism which decreases uric acid. They are used in ____ gout because these are prodrugs that are converted by xanthine oxidase to alloxanthine which then inhibits the enzyme xanthine oxidase itself.
a. Acute
b. Chronic
Probenecid inhibits the _______ tubular reabsorption of urate. Probenecid (Lannett’s Probalan) is a uricosuric drug, that is, it increases uric acid excretion in the urine.
a. proximal
b. distal
Should allopurinol be used in renal failure?
a. yes
b. No
Once a diagnosis of gout is confirmed, goals of therapy should include which of the following?
a. Decrease the serum uric acid level to less that 4.0mg/dl
b. Decrease the serum uric acid level to less that 6.0mg/dl
T or F?
If a patient gets a rash after taking allopurinol, they should be re-started on the same drug with a lower dose.
Which of the following drugs does not impair uric acid excretion?
a. Low dose aspirin
b. Thiazides
c. Losartan
d. Cyclosporin
e. Alcohol
(Losartan is a good drug to switch to)
T or F?
An inflammatory reaction that is in full swing can be worsened by a change in serum urate concentration. Urate lowering drugs should not, therefore, be initiated during an acute attack of gout.
(First, take care of the inflammatory reaction)
Which of the following is not associated with hyperuricemia?
a. HPRT deficiency (leads to hyperuricemia)
b. Psoriasis (rapid turnover of cells, DNA)
c. hemolytic anemia (destruction of RBCs)
d. PRPP deficiency (because hyperuricemia is associated with PRPP hyperactivity, not deficiency)
c. Ketogenic diet (high protein)
Pseudogout invloves what type of crystals?
a. CPP
b. PPC
c. PCP
With gout and pseudogout, joint inflammation is caused by crystals that form in the synovial fluids. In pseudogout, these crystals are:
a. Nitrate
b. uric acid
c. purine
d. calcium pyrophosphate 
With acute gout, we can use an NSAID, but if the NSAIDs are contraindicated pt with renal issues, or peptic ulcer disease, then we may consider Colcichine (but this also may have side effects- GI etc ). Another alternative to an NSAID is a glucocorticoid (such as hydrocortisone) So, think of NSAID, Colcichine, or glucocorticoids for acute gout.
For prophylaxis, such as allopurinol (but must wait until pt is asymptomatic). Also, you could use a uricosuric drug if they are allergic to allopurinol (probenecid).

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