Rosh Emergency Medicine Practice Test

In a patient with knee pain and negatively birefringent crystals present in synovial fluid, what is the most appropriate management for current symptoms?

1. Allopurinol PO and discharge

2. Hydrocodone-acetaminophen PO and discharge

3. Indomethacin PO and discharge

4. Systemic antibiotics and admission

The correct answer is: Indomethacin PO and discharge

The presence of negatively birefringent crystals in synovial fluid is a strong indicator of gout, which is characterized by the deposition of monosodium urate crystals due to elevated serum uric acid levels. For managing the acute symptoms of a gout flare, nonsteroidal anti-inflammatory drugs (NSAIDs) are the first line of treatment. Indomethacin is a specific NSAID that has been traditionally used to rapidly reduce inflammation and pain associated with acute gout attacks. Administering indomethacin orally addresses the acute inflammation caused by the gout attack, helping to alleviate the significant pain and swelling that the patient is experiencing. This management option focuses directly on symptom relief, which is essential in helping patients feel better quickly. The other options are less suitable for immediate symptomatic relief. Allopurinol is a urate-lowering therapy that is not used during acute attacks since it can worsen symptoms if started while inflammation is acute. While hydrocodone-acetaminophen can provide pain relief, it does not address the underlying inflammatory process and is not a specific treatment for gout. Systemic antibiotics might be appropriate if there is a concern for infection, but in the presence of crystals indicating gout, it would not be the first choice for