Date:
Patient:
MRN:
Clincian: (Rheumatologist, Primary Care Physician)
Reason for Visit:
Follow-up for gout
Evaluation of gout flare (acute attack) or intercritical period (between flares)
Review of laboratory and imaging results
Discussion of treatment plan and gout management
History of Present Illness:
Briefly describe the patient’s current status:
Acute gout flare:
Location and duration of the joint pain (typically sudden onset, often involving the first metatarsophalangeal joint – the big toe)
Severity of pain and associated symptoms (swelling, redness, warmth, tenderness)
Triggers for the flare (diet, alcohol intake, recent illness)
Intercritical period:
Presence of any residual joint pain or stiffness
Frequency and severity of previous gout flares
Past Medical History:
Underlying medical conditions that may contribute to gout (hypertension, hyperlipidemia, obesity, diabetes)
Use of medications that can increase uric acid levels (diuretics, low-dose aspirin)
Previous diagnoses of gout or related conditions (urate kidney stones)
Social History:
Diet (high purine intake can worsen gout)
Alcohol consumption (can trigger gout flares)
Physical Exam:
Musculoskeletal exam:
Focus on the affected joint(s) during a flare, looking for swelling, redness, warmth, and tenderness.
Assess for joint deformity or tophi (urate crystal deposits under the skin) in the intercritical period.
Vital signs: May be elevated during a flare due to inflammation.
Labs:
Serum uric acid level: Elevated levels are suggestive of gout, but urate crystals in the joint fluid are necessary for definitive diagnosis.
Consider mentioning other labs ordered as needed (CBC to rule out infection, electrolytes, renal function tests).
Imaging:
X-ray: May be normal during an acute flare but can show joint damage with recurrent gout.
Consider mentioning other imaging studies performed (ultrasound for joint fluid aspiration and analysis to confirm urate crystals) depending on clinical suspicion.
Assessment:
Summarize the diagnosis and disease activity:
Confirmation of gout diagnosis based on clinical presentation, laboratory findings, and imaging results (if available).
Acute gout flare or intercritical period.
Plan:
Outline the treatment plan based on the assessment:
Acute gout flare:
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of treatment to reduce inflammation and pain.
Colchicine or corticosteroids may be used in some cases.
Intercritical period:
Urate-lowering therapy (ULT) with medications like allopurinol or febuxostat to prevent future flares and reduce urate crystal burden.
Lifestyle modifications (diet, weight management, alcohol restriction) are crucial for long-term management.
Consider mentioning the importance of good hydration to promote uric acid excretion.
Prognosis:
Briefly discuss the prognosis. Gout is a chronic condition, but effective treatment can significantly reduce the frequency and severity of flares and improve overall well-being.
Emphasize the importance of ongoing treatment, adherence to lifestyle modifications, and regular follow-up to monitor uric acid levels and adjust medications as needed.
Education:
Document any education provided to the patient regarding:
The nature of gout, its causes, and risk factors
The importance of identifying and avoiding gout triggers
The benefits and potential side effects of gout medications
Healthy lifestyle practices for gout management (diet, exercise, weight management)
Warning signs and symptoms of gout flares
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about medication side effects, long-term management, or the impact of gout on daily activities.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a rheumatologist or primary care physician for diagnosis, treatment recommendations, and prognosis.