The most common presentation of gout is a flare, characterised by acute onset of one, or occasionally more, hot, red, swollen joints which are very painful and tender. Less common is insidious onset of chronic usage related joint pain, especially in joints already affected by osteoarthritis. Subcutaneous tophi can also be the presentation, particulary in older people. In typical cases, clinical assessment alone is sufficient for diagnosis. Gout is also associated with comorbidities such as nephrolithiasis, chronic kidney disease, metabolic syndrome and heart disease, and increased mortality.