Cases/Musculoskeletal Health

Second Attack of Gout This Year — Free SCA Practice Case

Man with a second attack of gout this year

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Paul Griffiths

Age

52 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation.

Reason for Encounter

"My gout's flared up again — my ankle's red and agony. This is the second time this year. I need something for it."

Medical Records

●PMH: Gout (confirmed; ED attendance ~4 months ago). Overweight (BMI 33). Hypertension.
●Medications: Ramipril 5 mg OD. (Colchicine used previously for the acute attack.)
●Allergies: NKDA.
●Recent notes (ED, ~4 months ago): Right ankle pain/swelling; serum urate raised; discharged with colchicine, responded well.

Patient Script

For the friend playing the patient role

Character Overview: You are Paul, a 52-year-old plasterer. You have had gout before — you went to A&E about four months ago with a hot, swollen ankle, were told your uric acid was high, given colchicine, and it settled. Now the same ankle is red, hot, and extremely painful again — the second attack this year. You want something to ease it. You know you are overweight and have a sweet tooth (you love cake) and enjoy a few beers. You are pragmatic and will engage with advice, though you are a little resistant to the idea of a daily tablet forever.

Opening Sentence: "Hello Doctor. My gout's come back — my right ankle's red, hot, and absolute agony, same as before. This is the second time this year. I just need something to settle it down, please."

History if Asked (Data Gathering Phase)

●The attack: "Right ankle again — red, hot, swollen, and so painful I can't put weight on it or bear the bedsheet on it. Came on over a day."
●Previous attack: "About four months ago I went to A&E with the same thing. They said my uric acid was high, gave me colchicine, and it settled in a few days."
●This year: "So this is the second flare this year, same ankle."
●Triggers/diet: "I do love my cake and sweet stuff, and I'll have a few beers at the weekend. I know I'm overweight."
●How unwell (if asked): "I feel alright in myself — no fever or feeling really ill, just the ankle."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Paul understands this is his gout recurring and expects the same treatment (colchicine) that worked before. "I know it's the gout back again — I just need the same tablets that fixed it last time."
●Concerns: He is worried about the recurring, disabling pain and it affecting his physical job; he is a bit resistant to the idea of a daily preventive tablet for life. "It's the pain and not being able to work I worry about. And I'm not keen on the idea of a tablet every day forever."
●Expectations: He expects acute treatment to settle this flare. "I want something to sort this attack out."

If Asked — Septic-Arthritis and Cause Screen

The patient answers these only when directly asked.

●If asked about fever, feeling systemically unwell, or rigors: "No fever, I don't feel unwell in myself — it's just the ankle." (Reassuring against septic arthritis, but the candidate must ask.)
●If asked about whether the joint is a single hot swollen joint vs multiple: "Just the one ankle, like before."
●If asked about previous joints affected / tophi: "It's been the ankle and once my big toe. No lumps that I've noticed."
●If asked about diet detail (alcohol, sugary drinks, red meat, seafood): "Beer at weekends, lots of cake and sweet things, a fair bit of red meat. Not many fizzy drinks."
●If asked about fluid intake: "Probably don't drink enough water."
●If asked about diuretics or other medications: "Just the ramipril — no water tablets."
●If asked about kidney problems or stones: "No kidney problems that I know of."
●If asked about family history: "My dad had gout too."

Responses to Management (The Negotiation Phase)

●If the Doctor prescribes acute treatment: "So the same colchicine as before? How quickly should it work?" (The tested point is appropriate acute treatment, tailored to his comorbidities.)
●If the Doctor recommends starting urate-lowering therapy (allopurinol): "A daily tablet for life? Do I really need that — can't I just treat the attacks when they come?" (The tested point is explaining the indication for ULT after recurrent attacks and negotiating long-term prevention.)
●If the Doctor explains ULT initiation and cover: "So I start it after this settles, and I take something alongside it at first? Why?" (The tested point is explaining timing, the target urate, and cover against initiation flares.)
●If the Doctor negotiates lifestyle: "So the cake and beer are making it worse? What would I actually need to change?" (The tested point is realistic lifestyle negotiation — weight, alcohol, sugary/fructose intake, hydration.)
●If the Doctor safety-nets for septic arthritis: "What would mean this is something more serious than gout?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Acute Gout

●Acute gout causes a rapidly developing, red, hot, swollen, exquisitely painful joint (often the first MTP joint or, as here, the ankle). Acute treatment options are an NSAID (with gastroprotection), colchicine, or a corticosteroid, chosen according to comorbidities and renal function, plus rest and elevation.

Always Consider Septic Arthritis

●A single hot swollen joint should always prompt consideration of septic arthritis (a joint emergency). Features such as fever/systemic illness raise concern; a typical recurrent gout picture in a well patient can be managed as gout with safety-netting and a low threshold for urgent assessment/joint aspiration.

Indication for Urate-Lowering Therapy (NICE NG219)

●Offer urate-lowering therapy (ULT) after recurrent attacks (≥2 in a year), or with tophi, joint damage, renal stones, or CKD. Recurrent gout, as here, is a clear indication.

Initiating ULT

●Allopurinol is first-line (febuxostat an alternative). Start after the acute attack settles, at a low dose, titrated to a target serum urate <360 micromol/L (<300 if tophi/severe/frequent), with serial urate monitoring and attention to renal function.

Cover During Initiation

●Provide prophylactic cover (colchicine or NSAID) for up to ~6 months when starting ULT, to prevent mobilisation flares. Do not stop ULT during an acute flare once established.

Lifestyle

●Advise weight loss, reduced alcohol (especially beer), reduced sugary/high-fructose intake and red meat/seafood, and good hydration, and review precipitating drugs (e.g. diuretics) and associated cardiovascular/metabolic risk.

Communicating Long-Term Prevention

●Explain why lifelong ULT is worthwhile — preventing recurrent attacks, joint damage, and tophi — to secure adherence, and negotiate rather than dictate.

Common Candidate Mistakes in This Case

●Treating only the attack: missing the indication to start urate-lowering therapy after recurrent gout.
●Not considering septic arthritis: failing to screen/safety-net for a hot joint.
●Incorrect ULT initiation: wrong timing/dosing, no target, or no initiation cover.
●Choosing an unsafe acute agent: ignoring comorbidities/renal function.
●Lecturing on lifestyle: shaming rather than negotiating realistic change, and failing to explain the rationale for prevention.

Free MRCGP SCA practice case for GP registrars covering Second Attack of Gout This Year — Musculoskeletal Health. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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