History Taking · Foundation · Rheumatology

Acute Foot Pain with Swelling in a 52-Year-Old Man

Practise this PLAB 2 history taking station on Acute Gout. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mr Jin Sung, a 52-year-old man, has come to see you with severe pain and swelling in his left big toe that started suddenly three days ago. He appears uncomfortable and can barely walk. Please take a focused history and discuss your initial management plan.

Background notes: PMH: Hypertension, Hypercholesterolaemia, Appendectomy

What this station tests

  • Distinguishing gout from septic arthritis: sudden onset with identifiable trigger (alcohol) versus fever with potential inoculation source
  • Not starting allopurinol during an acute attack: this is a commonly tested pharmacological point
  • Serum urate limitation: levels may be normal during an acute attack and do not exclude the diagnosis
  • First-line acute treatment: NSAID with gastroprotection, colchicine as alternative, prednisolone as third-line
  • Long-term prevention counselling: alcohol reduction (especially beer), dietary modification, allopurinol for recurrent attacks

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Acute monoarthritis requires the candidate to distinguish gout from septic arthritis, which is the most important differential. Both can present with a hot, swollen, painful joint. The distinguishing features are the history and risk factors. Mr Sung is 52, presenting with 3 days of severe left big toe pain and swelling after a night of heavy drinking. Open with: 'Mr Sung, I can see you are in a lot of pain. Tell me what happened.' Acknowledge the pain before taking the history.

Core approach

Classic podagra (first MTP joint gout). Sudden onset at 2am, maximal pain within hours, exquisitely tender (cannot bear bedsheet touching it), erythematous and swollen. Preceded by heavy alcohol intake (lager and curry). This is textbook acute gout: sudden onset, first MTP, alcohol trigger.

Exclude septic arthritis. No fever (gout can cause low-grade fever but not high spiking fever). No recent joint injection or surgery. No skin break near the joint. No immunosuppression. No prosthetic joint. However, the only definitive way to exclude septic arthritis is joint aspiration. If there is any doubt, aspirate. Gout crystals: negatively birefringent needle-shaped monosodium urate.

Risk factors: hypertension (thiazide diuretics can precipitate gout, check if he is on one), hypercholesterolaemia, overweight, high purine diet (red meat, shellfish, offal), alcohol (especially beer and spirits), renal function (check, as renal impairment reduces urate excretion). Check serum urate (may be normal or low during acute attack due to acute phase response, so a normal level does not exclude gout).

Functional impact: he is a warehouse supervisor who cannot walk, and his employer is annoyed about time off. He needs to get back to work.

Closing and safety netting

Acute treatment: NSAID first-line (naproxen 500mg BD or indomethacin 50mg TDS) with gastroprotection. If NSAID contraindicated: colchicine 500mcg BD to TDS. If both contraindicated: short course prednisolone. Do NOT start allopurinol during an acute attack (it can prolong or worsen the flare).

Explain the diagnosis: 'This is gout, caused by uric acid crystals forming in your joint. The alcohol and rich food triggered the attack.' Long-term prevention: lifestyle (reduce alcohol, especially beer; reduce red meat and shellfish; weight loss; adequate hydration). If recurrent attacks (>2/year), allopurinol for long-term urate lowering, started only after the acute attack has fully resolved.

Address his work concern: with treatment, acute gout typically resolves within 7 to 10 days. He should be able to return to work once pain allows. Safety net: 'If the pain is not improving after 48 hours of treatment, you develop a high fever, or other joints become swollen, come back as we may need to investigate further.' Follow-up to check renal function and consider long-term prevention.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for acute gout. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Classic podagra pattern identified. Septic arthritis actively excluded (no fever, no skin break, no immunosuppression). Trigger identified (alcohol). Risk factors assessed (hypertension medication, diet, renal function). Functional impact documented.

Costs marks: Not excluding septic arthritis. Not identifying triggers. Not checking renal function.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Correct acute treatment (NSAID with gastroprotection). Not starting allopurinol acutely. Understanding serum urate limitation. Long-term prevention discussed. Lifestyle advice specific (beer, red meat, hydration). Work return timeline.

Costs marks: Starting allopurinol acutely. Using normal urate to exclude gout. No lifestyle advice.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Acknowledging his pain immediately. Addressing work concern practically. Explaining gout without judgment about alcohol intake. Providing a clear recovery timeline.

Costs marks: Being judgmental about drinking. Not addressing work impact. Not providing recovery timeline.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Starting allopurinol during the acute attack. Allopurinol should only be started after the acute flare has completely resolved (typically 2 to 4 weeks later). Starting it during an attack can prolong or worsen the flare.
  2. Not excluding septic arthritis. A hot, swollen, painful joint could be infected. Candidates who diagnose gout without considering septic arthritis miss the most dangerous differential. If doubt exists, joint aspiration is needed.
  3. Using a normal serum urate to exclude gout. Urate levels drop during the acute phase response and may be normal during a flare. Candidates who say 'urate is normal so it is not gout' demonstrate a knowledge gap.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take an acute gout history in PLAB 2?

Acute monoarthritis requires the candidate to distinguish gout from septic arthritis, which is the most important differential. Both can present with a hot, swollen, painful joint. The distinguishing features are the history and risk factors.

Where are marks won and lost in this acute gout station?

Examiners reward: Classic podagra pattern identified. Septic arthritis actively excluded (no fever, no skin break, no immunosuppression). Trigger identified (alcohol). Candidates are penalised for: Not excluding septic arthritis. Not identifying triggers. Not checking renal function.

Where do candidates most often go wrong in this station?

Starting allopurinol during the acute attack. Allopurinol should only be started after the acute flare has completely resolved (typically 2 to 4 weeks later). Starting it during an attack can prolong or worsen the flare.

Can I do well in this station without real-world experience of acute gout?

Structure beats experience here. Focus on not starting allopurinol during an acute attack: this is a commonly tested pharmacological point. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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