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..
See you in the next panel
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