A man of 45 years, came by way of a limp, because severe pain in the joints of the right big toe. Experienced by patients while awake this morning, according to the patient, last night he still had time shopping at the mall with friends. Medical history of reoccurens that happens often.

1. MEDICAL FACULTY
MUSLIM UNIVERSITY OF INDONESIA
2016

2. 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

3. A man of 45 years, came by way of a limp, because severe pain
in the joints of the right big toe. Experienced by patients while
awake this morning, according to the patient, last night he still
had time shopping at the mall with friends. Medical history of
reoccurens that happens often.

4. 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

5. A man 45
years
Limps
Severe
pain in the
joint of big
toe
Occurs
often

6. What are the
anatomy structure
involved?

7. (Ir. Suryo.2011)

8. MUSCLE

9. ARTICULATIO

10. INNERVATION

11. Explain the
mechanism of pain !

12. 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

13. Explain the patology
anatomy of the
scenario !

14. (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

15. The inflammation associated with rheumatoid
arthritis can lead to fibrosis (arrowhead) and
fusion of the joint (ankylosis).
(Hematoxylin and eosin, 40x.)
RHEUMATOID
ARTHRITIS

16. 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

17. What are the
differential diagnose
for this scenario?

18. GOUTYARTHRITIS
DEFINITION
Gouty arthritis or arthritis piral is an
inflammation of the joints as a manifestation of the
accumulation of monosodium urate crystals
precipitate, which is collected in the joint as a result
of 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

19.  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.

22. 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

23. 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.

26. RHEUMATOIDARTHRITIS
 Definition
Rheumatoid arthritis (RA) is a chronic infl
ammatory disease of unknown etiology
marked by a symmetric, peripheral
polyarthritis. It is the most common form of
chronic infl ammatory arthritis and often
results in joint damage and physical disability
http://www.thefitindian.com/wp-content/uploads/2013/11/Rheumatoid-Arthritis-Causes-and-Symptoms.jpg

27. DEFORMITIES
SEEN
RHEUMATOID
HAND

30. 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 - -

31. What are the
general examination
for this scenario?

32. 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

33. What are the additional
examination for the
scenario?

34. ANSWER
Laboratory
examination :
1. Serum calium and phosphate
2. The alkaline phosphate
3. Eritrocyte sedimentation rate
4. Serum muscle enzyme
5. Rheumatoid factor
6. FNA ( Fine Needle Aspiration)
Radiological
examination : 1. Rontgen photo
2. CT scan
3. Magnetic Resonance Imaging
4. Biopsy
5. Myelography (Myelogram)

35. What is the management
of disease based from
the scenario?

36. 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.

37. 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.

39. PHARMACOLOGY
ACUTE
1.NSAID
2.Colchine
3.Corticosteroid
CHRONIC
1.XOI
2.Allopurinol
3.Uricosuric Acid

40. What is the biochemistry
that occur?

41. STRUCTURE OF URIC ACID
Uric acid is actually an antioxidant from humans
and animals, but when in excessive amounts in the
blood will undergo crystallization and can lead to
gout.
Uric acid levels can be detected through blood tests
and 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.

42. METABOLISMOFURICACID
Intermediets from
glycolysis
IMP
PRPP
Adenosine
AMP
Uric acid
Inosine Guanosine
Hypoxanthine
GMP
Xanthine Guanin
Xanthin oxidase

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

44. Reduce alcohol consumption, especially
higher intake of beer and hard liquor
Reduce several dietary factors including
higher intake of meat, seafood, sugar
sweetened soft drinks and foods high in
fructose
Reduce dairy intake, folate intake, and
coffee consumption
PREVENTION AND
PROMOTION:
Avoid taking medicine that could heighten the risk of gout such as thiazide
and loop diuretics
Treatment 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

45. REHABILITATION :
By protecting and resting the area, icing, and elevating the affected
area
Relieving the cause of the bursitis by altering postures of modifying
environmental factors, for example if the olecranon is affected, trauma
on the area can be reduced by wearing protective elbow pads
Passive stretching exercises in flexion and extension are used to restore
range of motion to increase metabolism in the area and decrease
swelling

46. What are the prognosis
and complication?

47. ARTHRITIS GOUT
PROGNOSIS
• Foreseen 10-22% of patients with poor control or untreated will
develop tophi and 20% of nephrolithiasis in approximately 11 years
after the initial attack.
• On average, after the initial attack, predicted 62% of untreated will
have to attack in the first two years, 78% within 2 years,
89% within 5 years, 93% in 10 year.

48. 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)

49. RHEUMATOIDARTHRITIS
PROGNOSIS
• Therapeutic approach in the early diagnosis can reduce symptoms
such as inflammation of the joints, defects, joint destruction and
death
• Increased mortality due to infections and bleeding in the
gastrointestinal and cardiovascular disease risk.

50. RHEUMATOIDARTHRITIS
COMPLICATION
• Anemia
• Infection
• Gastrointestinal problems
• Osteoporosis
• Lung disease
• Heart disease
• Lymphoma and other cancer

51. OSTEOARTHRITIS
PROGNOSIS
• Depend on which joint is affected. When affected are the joints or
spine load buffer the possibility of morbidity and disability.
• Depends on the cause. Treatment of OA done relieve pain or
prevent the progression of the disease, but it can not restore the
pre-existing damage to the articular cartilage.

52. OSTEOARTHRITIS
COMPLICATION
• Decrease in the ability to perform daily activities, such as personal
hygiene, housework, or cooking
• Reduced ability to walk
• Complications of surgery

53. CONCLUSION
 The increased size on the big toe may indicate several diseases such as
arthritis gout, rheumatoid arthritis, and osteoarthritis. However, based
on the description, the man didn’t experience any morning stiffness
which is one of the main characteristics of rheumatic arthritis.
 The occurance of the swelling also didn’t appear in large articulation
such in osteoarthritis. This leaves arthritis gout as the most probable
cause of the swelling.
 To ensure this, several tests should be conducted, such as fine needle
aspiration (FNA) and CT scan.

54. • Gout occurs due to acculumation of uric acid, so
promotion and treatment in reducing the uric acid is
recommended.
• Administering the medication like NSAID, colchicine,
and corticosteroid are for accute gout, while
allupurinol is for chronic gout.
• If the disease is treated well, the result of the
prognosis will be good as well.
CONT..

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