Rheumatology · Model history
A sudden, agonizing big toe: a model rheumatology history
- Setting
- Urgent care clinic
- Patient
- Mr. Baker, 59, woke at night with sudden severe pain, redness, and swelling in his right big toe.
- Listen
- 3 min
After listening
Say the next question
Read the patient’s answer, say your next question aloud, then reveal the model.
“Actually, yes. I had a big steak dinner with several beers last night at a work event.”
Ask whether the patient has had a fever or feels generally unwell, to help exclude joint infection.
Have you had a fever or felt generally unwell?
Model interview
Full transcript
- Doctor
Mr. Baker, I'm Dr. Ellis. What's brought you in?
- Patient
My big toe woke me up in the middle of the night. It's red, swollen, and incredibly painful.
- Doctor
Tell me exactly how it started.
- Patient
I went to bed feeling fine, then around three in the morning I woke up because my toe was throbbing. Even the bedsheet touching it was unbearable.
- Doctor
Which joint exactly, and how does it look right now?
- Patient
It's the big toe on my right foot. It's swollen, shiny, and bright red.
- Doctor
On a scale of zero to ten, how bad is the pain?
- Patient
It's a nine or ten. I can barely put weight on it.
- Doctor
Have you eaten a lot of red meat or had much alcohol recently?
- Patient
Actually, yes. I had a big steak dinner with several beers last night at a work event.
- Doctor
Have you had a fever or felt generally unwell?
- Patient
No, I don't think I have a fever, and other than the toe I feel okay.
- Doctor
Has this happened before, in this or any other joint?
- Patient
No, this is the first time I've ever had anything like this.
- Doctor
Have you injured the toe recently, or had any cuts or wounds near it?
- Patient
No, no injury and no cuts.
- Doctor
Do you have any other medical conditions, like kidney problems or high blood pressure?
- Patient
No, I'm generally healthy. No kidney problems that I know of.
- Doctor
Do you take any regular medicines, including water pills or aspirin?
- Patient
No, I don't take anything regularly.
- Doctor
Any medicine allergies?
- Patient
No, none that I know of.
- Doctor
What do you think is causing this?
- Patient
I think it might be gout, from the steak and beer. My uncle used to get something like this.
- Doctor
What's worrying you most?
- Patient
I'm worried this could be something serious, or that it might keep coming back or get worse.
- Doctor
What were you hoping we could do today?
- Patient
I want to know for certain what this is, and I want the right treatment started right away.
- Doctor
Let me summarize. Your right big toe became suddenly red, swollen, and extremely painful overnight, following a meal of steak and alcohol, with no fever, injury, or previous episodes. Is that accurate, and is there anything else I should know?
- Patient
That's exactly right. Nothing else.
- Doctor
Thank you. This sudden pattern in the big toe after a rich meal and alcohol is very characteristic of gout, but because fever or infection can sometimes look similar, we'll examine the joint carefully and may take a small sample of fluid from it to confirm the crystals under the microscope and rule out infection at the same time. Once we've confirmed it, we'll start treatment to calm the inflammation quickly.
- Patient
That sounds reasonable. I just want the pain to stop.
Flow at a glance
The route through the history
- Invite the patient's story
- Establish sudden nighttime onset
- Localize and characterize the joint
- Ask about dietary and alcohol triggers
- Screen for fever and prior episodes
- Rule out local injury or infection sources
- Review background, medicines, and allergies
- Summarize and explain the plan to confirm and treat
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Editorial record
Tied to one reviewed case
This model uses a fictional Bedside English case as its source. The page and pre-generated WAV audio are checked against the same transcript and source-case fingerprints.
Editorial update: