PBL 1: PAINFUL BIG TOE

VITALS:

B/P: 130/80 (Normal range: 120/80-140/90)

R/R: 18/min. ( Normal range: 12-20/min for males)
BMI: 30.4 ( OBESITY)
Temp: 99.6 F ( Normal: 98.6 F)

LAB INVESTIGATION:

HB: 12gm/dl. (Normal range:13.5-17.5 for males)

(12-15.5 for females)
ESR: 35mm/hr. (Normal range:0-22mm/hr for males)
(0-29mm/hr for females)
Serum uric acid: 8.5mg/dl. (Normal range:2.4-6.0mg/dl male
3.4-7.0mg/dl female)

SYNOVIAL FLUID ASPIRATE ANALYSIS:

WBC: 10,000/mm3. (200-2000/mm3 non inflammatory)

( >2000 inflammation)
Polymorphs: 95%. ( Normal: <50%)

LEARNING GOALS:
1-ESR: Erythrocyte sedimentation rate is a blood test usually
done to measure how quickly the erythrocytes settle at the
bottom of test tube. In normal they settle slowly.

2-SYNOVIAL TAP: A fluid is present between the bones to

lubricate them and prevents them from getting damage.
It is a test done to take out a sample of that synovial fluid
during a process called arthrocentosis.

3-HYDROCHLOROTHIAZIDE: It is diuretic medication used

to treat high blood pressure and swelling due to fluid build
up.

4-BIFRIGENT NEEDLE: Urate crystals are shaped like

needles of toothpicks with pointed ends. Under polarizing
light microscopy, urate crystals are yellow when aligned
parallel to axis and blue when aligned perpendicular to axis.
5-INDOMETHACIN: It is a nonsteroidal anti-inflammatory
drug commonly used as a prescription medication to reduce
fever,pain,stiffness and swelling from inflammation. It works
by inhibiting the production of prostaglandins and
endogenous signaling.

6-PURINE CATABOLISM:
1- An amino group is removed from AMP to produce IMP
by AMP (adenylate) deaminase or from adenosine to
produce inosine (hypoxanthine-ribose) by adenosine
deaminase.
2- IMP and GMP are converted into their respective
nucleoside forms, inosine and guanosine, by the action
of 5-nucleotidase.
3- Purine nucleoside phosphorylase converts inosine and
guanosine into their respective purine bases,
hypoxanthine and guanine.
4- Guanine is deaminated to xanthine.
5- Hypoxanthine is oxidized by molybdenum- containing
xanthine oxidase to xanthine which is further oxidized
by XO to uric acid the final end product of purine
degradation. Uric acid is excreted primarily in the urine.
7-DRUG PRESCRIPTION IN GOUT:
1-A drug named Allopurinol is given which is xanthine
oxidase inhibitor the enzyme responsible for conversion of
hypoxanthine to xanthine.
2-For acute gout nonsteroidal anti-inflammatory drugs are
prescribed colchine or corticosteroids and indomethacin, as
these drugs shows rapid symptomatic relied within 24 hours.
Colchine works as an anti-inflammatory agent by blocking
microtubule assembly in neutrophils.

8-PREVENTIVE MEASURES DURING GOUT: Factors that

increase the risk of of gout are alcohol intake, diet rich in
meat and existence of metabolic syndrome such as obesity,
hypertension and renal disease So a patient needs to modify
it’s lifestyle by avoiding alcohol intake, limit consumption of
meat and ensure adequate hydration.

9-COMPETITIVE INDIGENOUS: Organic acids present in

our body are reabsorbed from two sides present in proximal
convuated tubule. These two positions are apical and basal
lateral side.
90% of urea is absorbed at apical side and is return to kidney
from where it comes back to basal lateral side and when we
take diuretics, these diuretics competes with remaining urea
for excretion and so is this how uric acid gets accumulated.
This process is called competitive indigenous.