Question

A 58-year-old obese white male came to ED with the chief complaint of fever, chills, pain, and swelling in the right great toe. He states that symptoms came on very suddenly, and he cannot put any weight on his foot. Physical test reveals exquisite pain on any attempt to assess the right first metatarsophalangeal (MTP) joint. Past medical history is positive for hypertension and Type II diabetes mellitus. Current medications include hydrochlorothiazide 50 mg by mouth every morning, and Metformin 500 mg by mouth twice a day. The complete blood count is normal except for elevated sedimentation rate (ESR) of 33 mm/hr, and C-reactive protein (CRP) is 24 mg/L. Metabolic panel normal. Uric acid level 6.7 mg/dl.

In your Case Study Analysis related to the scenario provided, explain the following:

What are the neurological and musculoskeletal pathophysiological symptoms that the patient displays?

Are there any racial/ethnic variables that may impact physiological functioning?

How do these processes interact to affect the patient?

Answer 1

Case scenario:

Patient: White old male , 58 year old

Chief complaints: Fever, chills, Pain and swelling in the right  great toe.

Analysis of the scenario: Gout

Gout or Gouty Arthritis:

Gout is an extremely painful joint inflammation, especially of the big toe , that may occur due to a metabolic defect resulting in the accumulation of uric acid in the blood and the deposition of urates around the joints. Inflammation of a joint occurs due to Gout, is called Gouty Arthritis.  

Osteoarthritis: A form of arthritis affecting many older people , caused by chronic degeneration of the cartilage and synovial membrane of the joints leading to pain and stiffness. In the above case scenario the patient is suffering with Gout nor Osteoarthritis as He doesn't have complaints of pain in any othef joint. His Uric acid level also meeting the criteria of Gout,  above 5.8 mg / dl, Patient's uric acid level is 6.7 mg / dl. Pain and swelling in the Great toe is a characteristic feature of Gout.

Pathophysiologic Process:

The main etiology is the defect in purine metabolism, that results in increased Uric acid level . It may be associated with Genetic predisposition, life style, especially Dietary factors, purine rich food items like organ meat, fish , alcoholic beverages, mussels , turkey etc.  

Due to etiological and risk factors

? ( leads to)

Increased Purine intake and during metabolism Purine get converts into Uric acid.

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Under excretion of uric acid and urates by kidney.

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Increased uric acid level in the blood and rapid changes in the uric acid level may occur due to certain drugs like Diuretics, climate changes, alcohol consumption and stress

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Crystallization of Uric acid into Mono Sodium urates.

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Deposition of this urate crystals into joints, tendons and surrounding tissue, especially this crystal deposition happens around the big toe joint.  

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Crystal deposition initiate an inflammation in the right first metatarsophalangeal joint by the action of inflammatory mediator interleukin.  

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Inflammation of toe joint   results in pain , and swelling of the bog toe.

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Presence of inflammatory mediator in the blood sensitise the hypothalamus in brain, and fever starts as a protective mechanism of the body, associated with Chills.  

Racial, ethnic variables and its influence on patient:

Gout was known as the ' rich man's disease ' in the past, as it was common in upper class community, may be due to their dietary factors and life style. Gout is common in western countries. But the prevalence rate of hyperuricemia is more in Blacks. It mainly occur in males especially after 55 years.

Interaction of factors in the patient:

In the above case scenario, the patient is suffering with Hypertension and Diabetes Mellitus. Also he is taking Diuretics for reducing his Blod pressure. Diuretics may cause sudden changes in the Uric acid level, thay may stimulate the crystallization as urates. His age and associated diseases and drugs contributing his risk for Gout. Elevated C- reactive protein, indicates the presence of severe inflammation, that contributes to the increased intensity of his right great toe pain.