Robert presented with this swollen big toe 2 days ago. It came on suddenly, without incident, and initially was only in the big toe joint. The foot was red around the ball of the foot with the redness over the last 3 weeks spreading to his ankle. His pain is now throughout the big toe, but does not involve the toe nail itself. These presentations are either infection or gout, and there was no reason he should have an infection (no cuts in the skin, etc). His primary care doctor has placed him on 2 courses (10 days each) of antibiotics without relief. Unfortunately, if you have a gout attack, the uric acid crystals leave your blood stream and attack the involved joint, so the blood levels are temporarily within normal limits (but they still are high normal). I decided to place Robert in a post op shoe since he was walking around in his sock (can not take any pressure), and gave him 2 low dose cortisone shots into the 2 involved joints. He called me the next day saying that he was so much better, and actually slept for the first time all night in 2 weeks. Of course, you do not want to give cortisone into a joint that may be infected, but his history and exam did not point to anything but gout. I will check him next week. I also recommended icing 10 minutes 3 to 5 times a day to cool down the joint. I will get blood work in 3 weeks to see what his blood levels of uric acid are then.