Gout (also known as podagra when it involves the big toe[1]) is a medical condition usually characterized by recurrent attacks

of acute inflammatory arthritisa red, tender, hot, swollen joint. The metatarsal-phalangeal joint at the base of the big toe is the most common affected, in around half of all cases. However, it may also present as tophi, kidney stones, or urate nephropathy. It is caused by elevated levels of uric acid in the blood which crystallize and are deposited in joints, tendons, and surrounding tissues. Case history:

Patient profile: Name: Saerah Mahmud Age: 55 year House wife Jammha Chief complaint: Joint pain for 4 years diagnosed as a gout case History of present illness: She was doing well until 4 years ago when the pain started in the left big toe as a severe pain that interrupted her daily activities. Then the pain appeared in the other big toe and in fingers with some nodules. After being diagnosed, she is on medication and meat diet. The case is under control now; the nodules disappeared and the pain rarely attacks. She has hypertension for 10 years and is well controlled. She has also diabetes mellitus for 6 years and is well controlled. Systemic review: Respiratory system: - No cough, no sputum - No nasal discharge - No chest pain - No wheezes Cardiovascular system: - Shortness of breath on exertion - No Orthopnea - No PND - No cyanosis Gastrointestinal system: - No abdominal pain - No diarrhea - No constipation

- Normal color & odor of stool, no blood - No nausea, no vomiting - No abdominal bloating - No jaundice Urogenital system: - No flank pain - No burning micturition - No blood in urine - No bad smell - No frequency - No urgency - No incontinence - No intermittency - Amenorrhea Central nervous system: - No blurred vision - No hearing problems - No dizziness - No numbness Musculoskeletal system: - No back pain - No joints pain or swelling (at time of visit) - No bone fractures or abnormalities Past medical history: Hypertension for 10 years DM for 6 years. Past surgical history: 1 Caesarean section surgeries 22 years ago Family history: Her mother was diagnosed with gout at age of 65. She complaint of DM for 15 years and died 6 years ago. Her father died due to MI at age 60. Drug history: Zyloric 300mg Renitec20 mg Metformin Allergy history: No allergy for any type of food or medication.

Social history: She lives in her own house with her husband and her younger son. She has 3 daughters and other 4 sons who are married. The average income : 400 JD They are insured (army insurance) and the insurance cover the cost of the treatment. Her medical status is under control. she is active and happy, there is no any effect of the problem on her social and job function except during the acute attack there is limitation on movement couples of days. She does check up on HT & DM every other day at home, and once a month in the hospital. Her utilization of health services is easy and comfortable. Physical examination: HR: 80 BP: 130/90 Temp: 37 C Respiratory rate: 19/min By inspection: No pallor . no cyanosis. No scars. No abnormalities. Normal toes and fingers with no swelling or redness or nodules. By palpation : No joint tenderness. No limitation on movement . No hotness