ARTHRITIS

GOUT
Natalia Christine Go
Awalul Ikhramiah
Tutor : dr.Arnis Fanasari

Patient Identity
Name
: Mr. ID
Age
: 45 years old
Occupation : Security
Religion : moslem
Address : Bone

Chief Complaint:
Pain on the right foot joint (big toe)
History taking:
Suddenly experienced since last 8 hours and
making him couldnt walk normally. The location
of pain felt warm, oedema and looks red. About
a year ago, he had experienced the same
complain and had consulted to a doctor, he got
diagnosed as arthritis gout (history of Serum
Uric acid was 9 g/uL) Since then, he routinely
consumed Allopurinol 100 mg once daily.
No fever,
No cough, no chest pain nor shortness of
breath. No Nausea, vomit nor epigastric pain.
Urination and defecation is normal.

History of recent diseases

O Heavy alcohol drinker (3x/week)
since high school
O History of hypertension with
consumption of Amlodipine 5mg
once daily.
O History of high cholesterolemia with
consumption of Simvastatin 20mg
once daily.
O No history of Diabetes Mellitus.

Vital sign
Blood Pressure: 150/90 mmHg
Heart Rate : 86x/minutes
Respiration : 18 x/minutes
Temperature : 36,5oC
VAS : 7/10
Weight : 82 kg
Height : 162 cm
BMI : 32.0 (obese II)

Physical Examination
O Head : Anemia (-) , icterus (-)
O Neck
O Thorax

: DVS R+2 cmH20

: Rhonki -/- , wheezing

-/O Heart
: SI/SII Regular, murmur
(-)
O Abdomen
: Peristaltic normal, hepar
and lien impalpable, epigastric pain
(-)

Rheumatology Status
Gait
: Antalgic
Arms
: Tenderness (-), Effusion (-),
Eritema (-), Oedema (-)
Legs : 1)MTP 1 Sinistra:
Tenderness (-), Effusion (-),
Crepitation (-), Tophus (+)
2) MTP 1 Dextra:
Tenderness (+), Eritema (+),
Swelling (+)
Spine : Normal

Laboratory Examination
WBC

7.8 [103/Ul]

4.00-10.0
[103/Ul]

Hb

14.2 [g/dl]

12.0-16.0 [g/dl]

HCT

42%

37.0-48.0%

MCV

80.1

80.0-97.0

MCHC

32

31.5-35.0

PLT

182 [103/Ul]

150-400 [103/Ul]

Ur/Cr

51/0.9

10-50/P(<1.1)

SGOT/SGPT

32/38

<38/<41

GDS

127

140

LED I/II

47/51

Problem List

1. CHRONIC GOUT
ARTHRITIS ACUTE
EXACERBATION
O Presence of thophus

on MTP 1 sinistra
O Pain and swelling in
the first MTP 1 dextra
O Unilateral attack
involving the first MTP
joint

TREATMENT /
PLANNING

O Low purine diet

O Stop alcohol intake
O Cold compression
O Colchisine 0,5 mg/6

hours/oral
O Allopurinol 100 mg/24
jam/oral
Planning :
O Uric acid serum
O Uric acid urine 24
hours collection
(urinalysis)

Meet the ACR 1977 Diagnostic criteria

for Gout Arthritis
OSuspect there is presence of tophus
OHyperuricemia
OUnilateral arthritis involve MTP-1
OJoint eritem
OSwelling and pain on MTP-1
OThere is more than one acute arthritis
attack

Problem List
2. HYPERTENSION
GRADE 1
O Blood pressure:

150/90 mmHg
O History taking
amlodipine 5mg once
daily

TREATMENT /
PLANNING
O Low salt diet
O Switch oral anti

hypertension to
Valsartan 80 mg (ARB)
once daily

Problem List
3.DYSLIPEDEMI
A
O History taking

simvastatin

TREATMENT /
PLANNING
O Low fat diet
O Reduce body weight
O Simvastatin 20 mg

once daily
Planning:
O lipid profile

Differential Diagnosis
Gout

Osteoarthritis

Presence of symptoms
affecting the whole body
(systemic)

Chills and a mild fever

along with a general
feeling of malaise may also
accompany the severe pain
and inflammation.

Systemic symptoms are not

present. Localized joint
pain (Knee and hips) but
NO swelling Pain severity
is important (mechanical,
inflammatory, nocturnal,
sudden)

Associated symptoms

Tophi may form. These are

large masses of uric acid
crystals, which gets
collected in the joints and
damage it.They also gets
collected in the bone and
cartilage, such as in the
ears.

(no systemic symps)

fatigue, muscle weakness,
fever, organ involvement;
Bony enlargement,
deformity, instability,
restricted movement, joint
locked, sleep
dist,depression, comorbid
conditions (bursitis,
fibromyalgia, gout)

Treatment

Resting the joint and

applying ice, NSAIDS,
corticosteroids, colchicine (a
painkiller), medications that
target uric acid production or
excretion, healthy diet low
in purines (from alcohol,
meat, fish).

NSAIDs (short term use)

Acetaminophen, Analgesics,
exercise

Disease Process

Metabolic Disease

Normal wear and tear

(chronic degenerative)

Pattern of joints that are

affected

Joint of the big toe most

commonly affected. other
joints affected are of ankle,
heel, knee, wrist, fingers,
elbow

Asymmetrical & may spread

to the other side. Symptoms
begin gradually and are often
limited to one set of joints,
usually the finger joints
closest to the fingernails or
the thumbs, large weightbearing joints,

Cause

Hyperuricemia
overabundance of
crystalline monosodium
urate (uric acid) deposits in
the blood and joint fluid.

Wear and tear associated

with aging or injury, also
caused by injuries to the
joints, obesity, heredity,
overuse of the joints from
sports

Age of onset

Usually over 35 years of

age in men and after
menopause in females

Over 60

Speed of onset

Sudden onset

Slow, over years

Further Anamnesis
O Family history of disease

Family history of disease is important to

eliminate the possibility of hereditary diseases
and diseases that infected from family members.
O Psycho-socio-economy history

Psycho-socio-economy need to be asked for the

treatment option or therapy that suit the patient
until we get the optimal results.

Discussion
Gout Arthritis

Definition
An excess of uric acid (Monosodium
urate monohydrate crystals) in the
blood and tissues of the body which if
present long enough may form into a
needle like crystals which can inflame
your joints and cause severe pain and
swelling (UK GOUT Society, 2016)

Etiology
O Too much uric acid in the blood

( hyperuricemia)
O High purine diet ( too much meat and seafood)
or drinking too much alcohol.
O Drugs that increase uric acid concentration
(aspirin or niacin) or drugs that reduce the
amount of salt and water in the body
( diuretics)
O Genetic conditions ( Kelley seegmiller
syndrome or Lesch Nyhan syndrome)

Patophisiology of Gout
Arthritis

DIAGNOSTIC CRITERIA

Management
Pharmacology Therapy

Management
Non-pharmacologic teraphy:
Education
O Diet
O Rest

CLINICAL MANIFESTATION