Question

Using the case study below - What are the neurological and musculoskeletal pathophysiologic processes that would account for the patient presenting these symptoms, Are there any racial/ethnic variables that would impact the physiological functioning, How do these processes interact to affect the patient?

Case Study: A 58-year-old obese white male presents to ED with chief complaint of fever, chills, pain, and swelling in the right great toe. He states the symptoms came on very suddenly and he cannot put any weight on his foot. Physical examination reveals exquisite pain on any attempt to assess the right first metatarsophalangeal (MTP) joint. Past medical history positive for hypertension and Type II diabetes mellitus. Current medications include hydrochlorothiazide 50 mg po q am, and metformin 500 mg po bid. CBC normal except for elevated sedimentation rate (ESR) of 33 mm/hr and C-reactive protein (CRP) 24 mg/L. Metabolic panel normal. Uric acid level 6.7 mg/dl.

Answer 1

The above case scenario indicates that patient is having Gout. He is having pain in the right Great toe. The assessment revealed the involvement first metatarsal phalangeal joint and elevated C reactive protein ( indication of serious inflammation) and Uric acid level 6.7 mg / dL . Uric acid above 5.8 mg is one of the Diagnosti criteria of Gout. It may be associated with fever and chills.

Gout :

An extremely painful inflammation of joints, especially of the big toe , caused by a metabolic defect resulting in the accumulation of Uric acid in the blood and the deposition of urates around the joint .

Pathophysiologic process:

The crystallization of uric acid is the main etiology for Gout. Elevated uric acid level in the blood may occur due to the elevated purine metabolism, under excretion of uric acid and urates by kidney, genetic predisposition . Dietary style is influencing uric acid level , especially diet that contain purine, such as organic meat, bear consumption , chicken, potatoes etc. The end product of purine metabolism is Uric acid.

Due to etiological and factors

?( leads to)

Elevated level of Uric acid in the blood ( under excretion of uric acid and urates by kidney )

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Crystallization of uric acid into Mono sodium urates . ( cool temperatures, rapid changes in uric acid due to drugs, acidosis can trigger crystallization. Patient uses Diuretic: Hydrochlorothiazide, may cause rapid changes in uric acid level )

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Deposition of this urate crystal into joints, tendons and surrounding tissue. In gout usually the deposition occurs in Big toe joint.

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Triggering of local immune mediated response and inflammation

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Activation of Prointerleukin into interleukin ( inflammatory mediator)

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Inflammation can result in pain , swelling and redness. Also it causes generalized symptoms like fever , chills, (as the presence inflammatory mediators in the blood, signals the hypothalamus about an infection, results in fever.) Elevated C - reactive protein also shows the presence of severe inflammation.

Racial , ethnic variables in Gout:

Studies show that western population are more affected with Gout. Gout is usually associated with Obesity, High blood pressure and Metabolic syndromes . seasonal changes, dietary styles also affecting the occurance.

The above case scenario, the patient is a White, male, 58 year old and suffering with obesity, Hypertension and Diabetes, and increased uric acid level.   He is in high risk category of developing Gout