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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 weigh
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 exam 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.
In your Case Study Analysis related to the scenario provided, explain the following:
- Both the neurological and musculoskeletal pathophysiologic processes that would account for the patient presenting these symptoms.
- Any racial/ethnic variables that may impact physiological functioning.
- How these processes interact to affect the patient.
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- ANSWER
Case Study: Gout
The 54-year old male patient is suffering from Gout. Gout normally affects the right great toe, however it can also occur in any other joint. Gout is usually characterized by sudden fever, chills, joint swelling, and pain, as exhibited by the patient (Narang & Dalbeth, 2020, pg.551). Further, the medical history of the patient points supports the diagnosis. Patients with a medical history of certain diseases such as hypertension, obesity, high blood pressure and diabetes are at a higher risk of developing gout (Narang & Dalbeth, 2020, pg.551). The patient has a history of Type II diabetes, hypertension and is also obese. The levels of uric acid increase when one’s body max index is high or one has obesity, high uric acid levels is a risk for formation of gout.
The patient is taking aspirin and hydrochlorothiazide, which may affect uric acid secretion; thus, the cause is most like gout. In at least 80% of the patients, an attack on a single joint is the first attack by gout. The risk of developing gout is higher when a patient has obesity.
Musculoskeletal and Neurological pathophysiologic processes of Gout
The pathophysiology of gout involves multiple interacting processes. Gout initially presents itself as an acute type of inflammation on the foot. In the patient's case, it has attached to the right big toe (Desai et al., 2017, pg.761). If untreated, it advances to several other joints and may even spread to the upper limb joints.
Decreased or under-secretion of uric acid in the renal system leads to the accumulation of uric acid in the tissues and blood (Narang & Dalbeth, 2020, pg.552). With time, the tissues become oversaturated leading to precipitation of urate salts and formation of monosodium urate which is crystal-like, these further lead to accumulation of the crystals and deposition (Narang & Dalbeth, 2020, pg.552). Upon deposition into the joint, the crystals spread into the joint space and cause an inflammation which develops into gout.
High levels of Uric acid above 7 mg/dL are usually signs of gout due to decreased excretion of uric acid (Desai et al., 2017, pg.768). The patient's level of uric acid is within the normal range for males. However, this does not rule out gout as the patient still has an elevated ESR of 33mm/hr, which is a sign of a gout attack (Desai et al., 2017, pg.768). Besides, the patient's CRP level is 24mg/L which is way above the limit of 10 mg/L. During gout attacks, ESR rates rise, and CRP levels confirming that the patient's condition is caused by gout.
Racial and Ethnic variables in gout
Ethnic and racial disparities in health care are widespread. They are caused mainly by barriers to healthcare, social-economic status, communication, health numeracy and literacy, and societal beliefs. According to recent studies in the United States, the prevalence of gout was found to be higher among African Americans compared to whites. Racial and health disparities influence treatment options and treatment adherence (Singh et al., 2016). According to a National Ambulatory Medical Care Survey, African Americans were less likely to visit health facilities for treatment due to gout-related symptoms compared to white people. Outpatient visits for patients with gout were reportedly high for whites compared to African Americans despite the high prevalence among African Americans. Also, the research showed that African Americans with gout disease have a double probability of being non-adherent for medications for gout (Singh et al., 2016). The patient, in this case, is white and will most likely adhere to the medications prescribed to him; whites are more likely to seek treatment and adhere to the medicines.
References
Desai, J., Steiger, S., & Anders, H. J. (2017). Molecular pathophysiology of gout. Trends in molecular medicine, 23(8), 756-768.
Narang, R. K., & Dalbeth, N. (2020). Pathophysiology of gout. In Seminars in Nephrology (Vol. 40, No. 6, pp. 550-563). WB Saunders.
Seifert, R. (2019). Drugs for Treatment of Gout. In Basic Knowledge of Pharmacology (pp. 279-286). Springer, Cham.
Singh, J. A., Bharat, A., Khanna, D., Aquino-Beaton, C., Persselin, J. E., Duffy, E., ... & Khanna, P. P. (2016). Racial differences in health-related quality of life and functional ability in patients with gout. Rheumatology, kew356.