One afternoon, we received a call that an ambulance was on its way to the ER with a landscaper who was suffering excruciating right foot pain and very high blood pressure. As I was envisioning some sort of serious accident with a runaway mower, a slightly overweight but generally healthy-looking man was wheeled into the ER. It was clear, however, from the grimace on his face and the groans he was making that this man was in severe pain. Alex, who I soon learned was 45 years old, said there had been no accident or injury. In fact, he had initially blamed his foot pain on the stiff new work boots he had been wearing at his job site. But when he bumped his foot against a pile of debris and was brought to his knees in pain, he knew something was really wrong. That’s when he called 911.
Alex’s right foot was so tender and painful that he needed a generous dose of morphine before he could even tolerate having the boot removed. When I finally got to examine Alex’s foot, I found a very warm and swollen big toe with extremely red skin at the base. The toe and much of the surrounding area of his right foot were exquisitely tender despite the pain relief provided by the morphine. I immediately suspected gout, a form of arthritis that’s relatively common in men and closely tied to one’s diet. When asked about his previous medical history, Alex recalled having a similar episode about 20 years earlier. At the time, the doctor had put a needle in the inflamed joint and collected telltale uric acid crystals—the most definitive way to diagnose gout. Alex said that the procedure was intensely painful, and he absolutely forbade me from going anywhere near his sore toe with a needle.
Not wanting to put himself through such an excruciating procedure, Alex agreed to a simple blood test to check his uric acid level, which was well above normal, as often occurs with gout. With a high level of uric acid in the blood, crystals can appear in virtually any joint (most commonly the big toe) and cause sudden and severe pain. Fortunately, recently published research in the journal Rheumatology proposed a rule for making the diagnosis of gout without collecting joint fluid. According to the researchers, the diagnosis of gout is reasonably certain if the patient is male…has had a previous such attack…has sudden, severe pain often affecting much of the big toe…has high blood pressure…and has an elevated blood level of uric acid.
Alex’s profile checked all the boxes, and he was happy that we could make the diagnosis with no further infliction of pain. He went home on an oral steroid medication to combat the joint inflammation and a potent painkiller. He was much better the following day and planned to follow up with his family doctor to get his uric acid level (and blood pressure) under control. This would include losing some weight and not consuming beer or excessive amounts of meat, poultry or seafood—all of which can raise uric acid levels.
Lesson learned: Before agreeing to a painful medical procedure, ask your doctor if it could be bypassed and a presumptive diagnosis made so that treatment can begin. This is often possible with small boils (they may not need to be aspirated with a needle to determine the exact microbe…just treated with topical or oral antibiotics)…and allergies (over-the-counter drugs often work with no need for extensive blood or skin tests with needles).