Scenario 3: A 58-year-old Obese White Male with Chief Complaint of Fever
The case involves a male patient aged 58 years old complaining of chills, fever, pain, and swelling in the right great toe. The patient has a history of hypertension and type II diabetes mellitus. The patient is most likely to be having gout; though, the CRP level is also above the reference range. People with gout have increased uric acid levels due to the increased nucleoprotein turnover. The condition could also be linked with the diabetic state despite the metabolic panel is normal. The purpose of this work is to determine the neurological and musculoskeletal pathophysiology processes and the ethnic factors linked to the clinical manifestation.
The neurological processes are linked to the pain experienced by the patient. The pain is most likely to be linked with gout and attributed to the production of prostaglandins and bradykinin (Igel et al., 2017). The stimulation of the unmyelinated nerve fibers results in the production of the neuropeptides that eventually lead to vasodilation (Ragab et al., 2017). The musculoskeletal processes involved include the precipitation of the urate needle-shaped monosodium urate in the avascular tissues. Also, the crystals affect the skins around the distal joints. The pain experienced by the patient could be attributed to the crystal deposits in the joints.
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Gout is more common among the African American population. Therefore, there could be a genetic factor correlated with the high burden of gout among the population group. Studies have indicated that genetic variations in the renal urate could be the reason why different ethnic groups have varying risk levels for high uric acid levels in the blood (Ragab et al., 2017). The variations in the risk for diabetes and high blood pressure could also explain the differences. People with diabetes have a higher risk for gout. Similarly, the risk of diabetes and hypertension is higher among African Americans compared to whites and other ethnic groups.
Interaction of the Processes to Affect the Patient
The patient has a medical history of both diabetes and high blood pressure which increases the risk for gout. Gout is a condition characterized by the accumulation of the crystal in the joint leading to inflammation. The C-reactive protein levels are elevated in the patient and this is an indication of the high inflammatory reactions. The inflammation is characterized by reddening, pain, swelling, and heat (Towiwat et al., 2019). The patient’s history makes him more susceptible to disease development and progress. Furthermore, the patient is on hydrochlorothiazide 59 mg PO Q am and metformin 500 mg PO bid for managing diabetes. The hydrochlorothiazide increases the risk for accumulation of the uric acid in the blood and so could also be contributing to gout.
Understanding the patient’s medical history helps in guiding the clinician to make the right diagnosis. In this case, the patient was diabetic and this increased his risk of developing gout. Furthermore, the medications used also influenced his health outcomes. Both neurological and musculoskeletal systems are directly involved in the pathogenesis of the condition. The nerve system sense pain. On the other hand, the accumulation of uric acid crystals in the joints affects the cartilages, tendons, and other components of the musculoskeletal system. Finally, African Americans have a higher risk of developing gout. The patient, in this case, is white, though, the medical history makes him vulnerable to the disease.
Ragab, G., Elshahaly, M., & Bardin, T. (2017). Gout: An old disease in new perspective – A review. Journal of Advanced Research, 8(5), 495-511. https://doi.org/10.1016/j.jare.2017.04.008
Towiwat, P., Chhana, A., & Dalbeth, N. (2019). The anatomical pathology of gout: A systematic literature review. BMC Musculoskeletal Disorders, 20(1). https://doi.org/10.1186/s12891-019-2519-y
Igel, T. F., Krasnokutsky, S., & Pillinger, M. H. (2017). Recent advances in understanding and managing gout. F1000Research, 6, 247. https://doi.org/10.12688/f1000research.9402.1
Scenario 3: 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.
Scenario 4: A 67-year-old man presents to the HCP with chief complaint of tremors in his arms. He also has noticed some tremors in his leg as well. The patient is accompanied by his son, who says that his father has become “stiff” and it takes him much longer to perform simple tasks. The son also relates that his father needs help rising from his chair. Physical exam demonstrates tremors in the hands at rest and fingers exhibit “pill rolling” movement. The patient’s face is not mobile and exhibits a mask-like appearance. His gait is uneven, and he shuffles when he walks and his head/neck, hips, and knees are flexed forward. He exhibits jerky or cogwheeling movement. The patient states that he has episodes of extreme sweating and flushing not associated with activity. Laboratory data unremarkable and the HCP has diagnosed the patient with Parkinson’s Disease.
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