“My toe is on fire.” HPI RH is a 78-year-old man who presents to the ED complaining of significant toe pain. Mr RH states, “I think I’m paying the price for my fun at the festival.” He reports having spent the weekend indulging on beer and sausage at the local festival. In the early hours of Monday morning (approximately 3 hours ago), he awoke to sudden excruciating pain in his right big toe. Over the past hour, this toe has become red, swollen, and so painful that he cannot walk. He has not experienced any trauma or injuries. He also denies having experienced these symptoms previously. PMH HTN × 28 years PUD × 15 years Obesity × 40 years SH The patient typically drinks “a can of beer or two” daily but drank significantly on Friday, Saturday, and Sunday. He does not smoke or use illicit drugs. Meds Chlorthalidone 25 mg PO daily, started 1 month ago Pantoprazole 20 mg PO daily All NKDA ROS Other than feeling somewhat dehydrated from all of his drinking, the patient has no major complaints prior to this ED visit. No chest pain, nausea/vomiting, or respiratory symptoms. Bowel habits are normal. He has no prior history of arthritic symptoms or joint problems. PE Gen A healthy-appearing, obese man in acute distress VS BP 135/70 mm Hg, P 105 bpm, RR 17, T 37.5°C; Wt 88 kg, Ht 158 cm Skin Poor skin turgor. No rashes or other dermatologic abnormalities. HEENT PERRLA, dry mucous membranes, throat/ears clear of redness or inflammation Neck/Lymph Nodes Negative for lymph node swelling or masses Lungs/Thorax Clear to auscultation bilaterally, symmetric movement with inspiration CV Tachycardic, normal rhythm, normal S1 and S2 Abd Obese, but soft, nontender; positive bowel sounds in all quadrants. Genit/Rect Deferred MS/Ext Erythematous, edematous right first metatarsophalangeal joint, which is very warm to touch; joint is exquisitely painful with patient relating the pain as currently a 10/10 (on a 1–10 scale with 0 being no pain and 10 being the worse pain the patient has ever suffered); no s