MEDICAL FACULTY MUSLIM UNIVERSITY OF INDONESIA

2016

Muh. Asy Shidiq 110 2015 0003

A. Muh. Yasser Mukti 110 2015 0022

Andira Ratu Nurrasyid 110 2015 0030

Andi Aisya Zealand 110 2015 0051

Nur Zamzam Azizah 110 2015 0059

Amaliah Hakim 110 2015 0070

Rifqy Aditya 110 2015 0078

Rindang Cahyani Abas 110 2015 0101

Elsa Shafira Prasetyati 110 2015 0117

Cindy Purnamasari 110 2015 0136

Atika Rahmah Mustapa 110 2015 0147

A man of 45 years, came by way of a limp, because severe painin the joints of the right big toe. Experienced by patients whileawake this morning, according to the patient, last night he stillhad time shopping at the mall with friends. Medical history ofreoccurens that happens often.

Limp : to walk in a slow and awkward way

because of an injury to a leg or foot; to go or

continue slowly or with difficulty

Joint : a point where two bones meet in the body

http://www.merriam-webster.com/dictionary/limp http://www.merriam-webster.com/dictionary/joint

A man 45 years

Limps

Severe pain in the joint of big

toe

Occurs often

What are the anatomy structure involved?

(Ir. Suryo.2011)

MUSCLE

ARTICULATIO

INNERVATION

Explain the mechanism of pain !

Perception

• Is the last proccess that had reached the cortex

Modulation

• Is the proccess of modication to stimuli

Transmission

• The proccess to ditributing the electrical impulse generated

Transduction

• Is an evolutionary proccess pain stimuli into electrical activity

Explain the patology anatomy of the scenario !

(A)Multiple, white–yellow nodules (tophi) of gout.

(B)Monosodium urate crystals deposited within the

dermis.

(C)In routine, formalin-fixed specimens, remnants of

crystals appear as fan-shaped sheaths, surrounded by

foreign body-type multinucleated giant cells.

GOUT

The inflammation associated with rheumatoid

arthritis can lead to fibrosis (arrowhead) and

fusion of the joint (ankylosis).

(Hematoxylin and eosin, 40x.)

RHEUMATOID

ARTHRITIS

Although osteoarthritis is not associated with ankylosis of the

joint as is rheumatoid arthritis, it is possible for osteophytes to

cross a joint and fuse (arrow), producing immobility of the joint.

The histologic features of osteoarthritis include fibrillation and

loss of basophilia of the cartilage (arrowhead) and subchondral

cysts (arrow). (Hematoxylin and eosin, 40x.)

OSTEOARTHRITIS

What are the differential diagnose for this scenario?

GOUTY ARTHRITIS

DEFINITION

Gouty arthritis or arthritis piral is aninflammation of the joints as a manifestation of theaccumulation of monosodium urate crystalsprecipitate, which is collected in the joint as a resultof the high levels of uric acid in the blood(hyperuricemia).

Noor, Zairin. 2012. Gangguan muskuloskeletal 2th edition. Jakarta : salemba medika.

http://goodearth-usa.com/image/Picture2.png

ETIOLOGY

Factors that influence as a cause of gout are:

a. Hereditary factors

b. Increased levels of uric acid

c. Excessive alcohol consumption

d. The resistance of the removal of uric acid due to certain diseases, especially renal impairment.

e. Use of certain medications that increase uric acid levels, especially diuretics (furosemide and hydrochlorothiazide)

f. Other factors such as stress, diet, injury to the joints, high blood pressure and excessive exercise. (VitaHealth, 2007)

Noor, Zairin. 2012. Gangguan muskuloskeletal 2th edition. Jakarta : salemba medika.

OSTEOARTHRITIS

Definition

Osteoarthritis is a degenerative disease of the joints which is caused by a number of factors. This disease has characterized by damage to joint cartilage (cartilage).

Reference : Noor, Zairin. 2012. Gangguan muskuloskeletal 2th edition. Jakarta : salemba medika.

https://i.ytimg.com/vi/41IMR_Dp5bs/hqdefault.jpg

ETIOLOGY

Some etiologic factors that have known to be associated with the occurrence of knee osteoarthritis include:

a. Age

b. Obesity

c. Hereditary or congenital factor

d. Trauma to the joint and damage to the joints previous

e. Collinear leg

f. The work and activities of daily living

Reference : Soeroso, Joewono. 2015. Ilmu Penyakit Dalam 6th edition Jilid III. Jakarta : interna publishing.

RHEUMATOID ARTHRITIS

Definition

Rheumatoid arthritis (RA) is a chronic inflammatory disease of unknown etiologymarked by a symmetric, peripheralpolyarthritis. It is the most common form ofchronic infl ammatory arthritis and oftenresults in joint damage and physical disability

http://www.thefitindian.com/wp-content/uploads/2013/11/Rheumatoid-Arthritis-Causes-and-Symptoms.jpg

DEFORMITIES SEEN RHEUMATOID HAND

Rheumatoid Arthritis

-

+

>30 thn

+

+

+

+

-

Fingers

-

+

-

-

-

+

Complaints Osteoarthritis Gouty arthtritis

Men - +

Woman + -

Age 40-60 thn >40 thn

pain + +

Stiff morning + +

Disturbance moves + +

Symmetrical + -

Unsymmetrical - +

The affected joint Knee MTP I

Monoarthritis - +

Poliarthritis + -

Obesity + -

DM + -

Redness - +

Fever - -

What are the general examination for this scenario?

Anamnesis and physical examination :

• Pain of joint• Barrier to the movement of joints• Morning stiffness• Crepitation• Deformity of joints• Change of gait• Markers of inflammation

• How long• How many and which part• Big or small toe

What are the additional examination for the scenario?

ANSWER

Laboratory

examination :1. Serum calium and phosphate2. The alkaline phosphate3. Eritrocyte sedimentation rate4. Serum muscle enzyme5. Rheumatoid factor6. FNA ( Fine Needle Aspiration)

Radiological

examination :1. Rontgen photo2. CT scan3. Magnetic Resonance Imaging4. Biopsy5. Myelography (Myelogram)

What is the management of disease based from the scenario?

NONPHARMACOLOGY

(1) In overweight patients dietary modification to achieve ideal body weight should be

attempted, but ‘crash dieting’ and high protein/low carbohydrate (Atkins-type) diets

should be avoided.

(2) Inclusion of skimmed milk and/or low fat yoghurt, soy beans and vegetable

sources of protein and cherries, in the diet should be encouraged.

(3) Intake of high purine foods and red meat should be restricted.

(4) Patients with gout and a history of urolithiasis should be encouraged to drink >2 l

of water daily and avoid dehydration.

CONT..

(5) Alcohol consumption should be restricted to o <21 units/week (men) and 14

units/week (women)

(6) Patients should be discouraged from undertaking trials of herbal remedies

without medical consultation.

(7) Affected joints should be elevated and exposed in a cool environment. ‘Bed

cages’ and ice packs can be effective adjuncts to therapy.

(8) Trauma to joints and intense physical exercise should be avoided but moderate

physical exercise encouraged.

PHARMACOLOGY

ACUTE

1.NSAID2.Colchine3.Corticosteroid

CHRONIC

1.XOI2.Allopurinol3.Uricosuric Acid

What is the biochemistry that occur?

STRUCTURE OF URIC ACID

Uric acid is actually an antioxidant from humansand animals, but when in excessive amounts in theblood will undergo crystallization and can lead togout.

Uric acid levels can be detected through blood testsand urine.

Reference value normal blood levels of uric acid in men is 3.6 - 8.2 mg / dl, while the female is

2.3 - 6.1 mg / dl

Urate crystals under a microscope resembles a needle - sharp microscopic needle, white, and

malodorous.

ME

TAB

OL

ISM

OF

UR

IC A

CID

Intermediets from glycolysis

IMP

PRPP

Adenosine

AMP

Uric acid

Inosine Guanosine

Hypoxanthine

GMP

Xanthine Guanin

Xanthin oxidase

What are the prevention, promotion and rehabilitation for this scenario?

Reduce alcohol consumption, especiallyhigher intake of beer and hard liquor

Reduce several dietary factors includinghigher intake of meat, seafood, sugarsweetened soft drinks and foods high infructose

Reduce dairy intake, folate intake, andcoffee consumption

PREVENTION AND PROMOTION:

Avoid taking medicine that could heighten the risk of gout such as thiazideand loop diureticsTreatment of other chronic disease that may increase the incidence of gout,such as hypertension and diabetes

http://book-med.info/img/824/Smerete_foods_to_avoid_during_gout292.jpg

REHABILITATION :

By protecting and resting the area, icing, and elevating the affectedarea

Relieving the cause of the bursitis by altering postures of modifyingenvironmental factors, for example if the olecranon is affected, traumaon the area can be reduced by wearing protective elbow pads

Passive stretching exercises in flexion and extension are used to restorerange of motion to increase metabolism in the area and decreaseswelling

What are the prognosis and complication?

ARTHRITIS GOUT

PROGNOSIS

• Foreseen 10-22% of patients with poor control or untreated willdevelop tophi and 20% of nephrolithiasis in approximately 11 yearsafter the initial attack.

• On average, after the initial attack, predicted 62% of untreated willhave to attack in the first two years, 78% within 2 years,89% within 5 years, 93% in 10 year.

ARTHRITIS GOUT

COMPLICATION

• Disability• Tofi• Kidney illness• Calculi of uric acid (10-15%)• Chronic urate nephropathy• Acute urate nephropathy (usually secondary to chemotherapy)• The avascular necrosis of femur (femoral head)

RHEUMATOID ARTHRITIS

PROGNOSIS

• Therapeutic approach in the early diagnosis can reduce symptomssuch as inflammation of the joints, defects, joint destruction anddeath

• Increased mortality due to infections and bleeding in thegastrointestinal and cardiovascular disease risk.

RHEUMATOID ARTHRITIS

COMPLICATION

• Anemia• Infection • Gastrointestinal problems• Osteoporosis• Lung disease• Heart disease• Lymphoma and other cancer

OSTEOARTHRITIS

PROGNOSIS

• Depend on which joint is affected. When affected are the joints orspine load buffer the possibility of morbidity and disability.

• Depends on the cause. Treatment of OA done relieve pain orprevent the progression of the disease, but it can not restore thepre-existing damage to the articular cartilage.

OSTEOARTHRITIS

COMPLICATION

• Decrease in the ability to perform daily activities, such as personal hygiene, housework, or cooking

• Reduced ability to walk• Complications of surgery

CONCLUSION

The increased size on the big toe may indicate several diseases such asarthritis gout, rheumatoid arthritis, and osteoarthritis. However, basedon the description, the man didn’t experience any morning stiffnesswhich is one of the main characteristics of rheumatic arthritis.

The occurance of the swelling also didn’t appear in large articulationsuch in osteoarthritis. This leaves arthritis gout as the most probablecause of the swelling.

To ensure this, several tests should be conducted, such as fine needleaspiration (FNA) and CT scan.

• Gout occurs due to acculumation of uric acid, sopromotion and treatment in reducing the uric acid isrecommended.

• Administering the medication like NSAID, colchicine,and corticosteroid are for accute gout, whileallupurinol is for chronic gout.

• If the disease is treated well, the result of theprognosis will be good as well.

CONT..

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