MEDICAL FACULTY HASANUDDIN UNIVERSITY MUSCULOSKELETAL

REPORT OF MODULE 1

GROUP 6 :
HANAN KHASYAWARI ABRAR FADHILLAH JULIANTY MIQDAD BIN MOHD SUBERI NORHANI AZURA BINTI MASHHOR SYAZWANI FARAIN BINTI ZAKARIA ZAFIRAH BINTI ROSHDI NAJIHAH BINTI WAHI ANUAR SYAZA NAQIBAH BINTI MOHAMED NOOR RAHIM NUR NABILAH BINTI ABDUL HAKIM SRI WAHYUNI R. VISHNU RAJ SAVUMTHARARAJ C111 11 805 C111 11 815 C111 11 826 C111 11 836 C111 11 846 C111 11 856 C111 11 866 C111 11 876 C111 11 887 C111 11 897 C111 08 757

SCENARIO 2
A man 45 year old come to Rheumatoid clinic with a lame walk, because of the great ache on the thumb joints on his right foot. He feels it when woke up this morning. According to the patient last night can still shop at mall with his family. This complaint seems always happened to the patient.

KEYWORD
y y y y y y y Man 45 year old Lame walk Great ache on the thumb joints on his right foot Feels it when wake up in the morning Still can shop at night The pain always happen

CLARIFICATION OF WORD
1. Lame walk difficulty in movement 2. Rheumatoid 3. Rheumatism resembling rheumatism any of a variety of disorders marked by inflammation, degeneration,

or metabolic derangement of connective tissue structures, especially the joints and related structures.

QUESTIONS AND ANSWERS

1. What is the musculoskeletal disorder related to 45 year old man?

The most likely musculoskeletal disorder that a 45 years old man will get is gout. Gout mostly affected by men rather than women at ratio 20:1 at the age of 40 to 50 years old. For women, they are prone to gout at the age of 60 and above. The second musculoskeletal disorder that a 45 years old man will get is rheumatoid arthritis. Women have higher chance to get rheumatoid arthritis compared to man as the ratio shows women to men is 3:1. But this ratio shows that men also can get affected by rheumatoid arthritis not that they will not have it. The typical age of a person that will experience the first stage of rheumatoid arthritis is 30-50 years old. The third musculoskeletal disorder that a 45 years old man prone to get is osteoarthritis. The ratio of women to men that will have osteoarthritis is 6:1. The typical age when a person started to experience the symptoms of osteoarthritis is 40 years old and above. The fourth musculoskeletal disorder is systemic sclerosis which has 3:1 ratio of women to men that has typical age of 20-50 years old when they get the systemic sclerosis. The fifth musculoskeletal disorder is psoriatic arthritis with equal number of women and men that can be afffected by this disorder at any age. The sixth musculoskeletal disorder is enteropathic arthritis that anybody can get at any age and the number of women and men that has this disorder is the same. These are the musculoskeletal disorders that a 45 years old man are prone to get. Maybe the possibilities are not limited by just these six disorders. There are so many other disorders that we have yet to find and learn about it.

2. Why the man has lame walk? According the scenario the man has lame walk caused by a great pain of a right thumb joint of foot . Dolor or great pain, in an inflammatory reaction apparently caused in various ways. Changes in local pH or concentration of certain ions can stimulate the nerve endings. The same, the release of bioactive chemicals can stimulate other nerves. In addition, the swelling of inflamed tissue leads to increased local pressure which undoubtedly cause pain, this great pain occur in a right thumb joint foot which resulted in unable to walk properly because of a problem with one's

feet or legs ,moving with pain or difficulty on account of injury, defect or temporary obstruction of a function .a lame leg, arm or muscle , crippled or physically disabled, especially in the foot or leg so as to limp or walk with difficulty.

3. Why the man has great ache thumb joint at right foot? Because it is an asymmetric disease and more often affects the small joints of my toes or metatarsalfalangeal. The pain is unilateral because most people are the dominant leg and right foot are more likely to be involved in bone fractures, muscle strain and sprains, especially those that occur due to overuse or as a result of physical activity stenuous. Another reason for the pain that occurs more frequently in the dominant leg is that the distribution of body weight tended to be on that side. 4. Why was the pain happened when he wake up? During night time, certain hormone released thus triggered enzyme formation that make the immune system to attack foreign substance which cause inflammation.

5. Why the joint pain always happen? In some people, the acute pain is so intense that even a bed sheet on the toe causes severe pain. The pain of the big toe is referred to as podagra. Even without treatment, the first attacks stop spontaneously after one to two weeks. While the pain and swelling completely go away, that pain commonly returns in the same joint or in another joint. With time, attacks of that pain can occur more frequently and may last longer. While the first attacks usually involve only one or two joints, multiple joints can be involved simultaneously over time.

6. What is the anatomy related to this case?

7. What is the histology related to this case?

8. What is the pathomechanism of joint pain? Joint pain may due to several disorders and those disorders have different pathomechanisms.  The first disorder is gout. The pathomechanisms of gout is uric acid is the byproduct of cell nucleic acid breakdown, is present in small amounts in the blood because body continually breakdown cells and forms new cells. Also, the body readily transforms substances in foods called purines into uric acid. Most often, the uric acid level in the blood becomes abnormally high when the kidneys cannot eliminate enough uric aid in the urine. Too much uric acid in the bloodcan result in urate crystals being formed and deposited in joints.  The second disorder of joint is rheumatoid arthritis. The pathomechanism of rheumatoid arthritis is affected joints enlarge because of swelling of the soft tissue and can quickly deformed. These symptoms may due to TH lymphocytes trigger proliferation of lymphocytes resulting TC lymphocytes (cellular immuneresponse) destroy antigen bearing and B lymphocytes (humoral immuneresponse) become plasma cells. Thus, activating the macrophages. Macrophages play a crucial role in nflammation and rheumatoid arthritis. Macrophages are activated in two ways. First,by TH lymphocytes, which in turn produce IFN

. IFN

is a potent macrophage activator. Second, by immune

complexes. Activated macrophages produce various cytokines which can have either pro- or inhibitory inflammatiory actions. Among the pro inflammatory cytokines are TNF and IL-1.  The third disorder is osteoarthritis. The pathomechanism of osteoarthritis is normally, joints have such a low friction level that they are protected from wearing out, even after years of use. Osteoarthritis probably begins most often with an abnormality of the cells that synthesise the components of cartilage, such as collagen and proteoglycan. Next, the cartilage may swell because of water retention, become soft, and develop cracks on the surface. Tiny cavities form in the bone beneath the cartilage, weakening the bone. Bone can overgrow at the edges of joint, producing bumps that can be seen and felt. Ultimately, the smooth, slippery surface of the cartilage becomes rough and pitted, so that the joint can no longer move smoothly and absorb impact. 9. Does he felt any pain when he walk? Yes, he does. Because there is swelling on the right big toe, redness, and sudden onset of a hot, then the suffered will feel pain when walking. In addition, because of swollen joints, can make suffered feel uncomfort dan difficult to walk. He felt the pain spontaneously in the morning, but over time the pain will go away slowly.

DIFFERENTIAL DIAGNOSE Symptom

A. Joint y y y y y y Joint place Characteristic Joint Structure Stiffness Pain Pain characteristic Mechanic Female > Male > 50 years Chronicle Female > Male 30 50 years Chronicle Acute Male > Female Inflammation Inflammation Big Joint Asymmetric Cartilage < 20 minutes Small Joint Symmetric Cavum Sinovial > 30 minutes Small Joint Asymmetric Cavum Sinovial -

RA

OA

GA

B. Fever C. Gender D. Age E. Trip

DIAGNOSE
Great pain 45 year Man old Rheumatoid arthritis W>M Yes walk joint No Yes morning No No Lame of thumb the pain Pain in Intermittent

Osteoarthritis

W>M

No

Yes

Yes

Yes

No

Gout arthritis

M>W

Yes

Yes

Yes

Yes

Yes

GOUT
Gout Overview
Gout is a disease characterized by an abnormal metabolism of uric acid, resulting in an excess of uric acid in the tissues and blood. People with gout either produce too much uric acid, or more commonly, their bodies have a problem in removing it. There are a number of possible consequences of the building up of uric acid in the body, including acute and chronic gouty arthritis, kidney stones, and local deposits of uric acid (tophi) in the skin and other tissues. Gout may occur alone (primary gout) or may be associated with other medical conditions or medications (secondary gout). Gouty arthritis is a common cause of a sudden onset of a painful, hot, red, swollen joint, particularly in the foot at the big toe. Gouty arthritis is reportedly the most common cause of inflammatory arthritis in men over the age of 40. It is definitively diagnosed by detecting uric acid (monosodium urate) crystals in an aspirated sample of the joint fluid. These uric acid crystals can accumulate in the joint and tissues around the joint over years, intermittently triggering repeated bouts of acute inflammation. Repeated "attacks" of gouty arthritis, or "flares," can damage the joint and lead to chronic arthritis. Fortunately, while gout is a progressive disease, there are effective medications to treat gout.

Causes
Uric acid is generated as we metabolize the food we eat and as the body's tissues are broken down during normal cell turnover. Some people with gout generate too much uric acid (10% of those affected) and are medically referred to as "over-producers." Other people with gout do not effectively eliminate their uric acid into the urine (90%) and are medically referred to as under-excreters. Genetics (our inherited genes), gender, and nutrition (alcoholism, obesity) play key roles in the development of gout. Gout is not contagious. If your parents have gout, then you have a 20% chance of developing it. Intake of alcoholic beverages, especially beer, increases the risk for gout. Diets rich in red meats, internal organs, yeast, and oily fish increase the risk for gout. Uric acid levels increase at puberty in men and at menopause in women, so men first develop gout at an earlier age (after puberty) than do women (after menopause). Gout in premenopausal women is distinctly unusual. Attacks of gouty arthritis can be precipitated when there is a sudden change in uric acid levels, which may be caused by overindulgence in alcohol and red meats, trauma, starvation and dehydration, IV contrast dyes, chemotherapy, medications, diuretics and some other anti-hypertensive medications, aspirin (Bayer, Ecotrin), nicotinic acid (B-3-50, B3-500-Gr,

Niacin SR, Niacor, Niaspan ER, Slo-Niacin),cyclosporin A, allopurinol (Zyloprim) and probenecid (Benemid), others.

Symptoms and Signs

The first symptom of gouty arthritis is typically the sudden onset of a hot, red, swollen joint. The most common joint involved is at the base of the big toe where swelling can be associated with severe tenderness, but almost any joint can be involved (for example, knee, ankle, and small joints of the hands). In some people, the acute pain is so intense that even a bed sheet on the toe causes severe pain. Acute gouty arthritis at the base of the big toe is referred to as podagra. Even without treatment, the first attacks stop spontaneously after one to two weeks. While the pain and swelling completely go away, gouty arthritis commonly returns in the same joint or in another joint. With time, attacks of gouty arthritis can occur more frequently and may last longer. While the first attacks usually involve only one or two joints, multiple joints can be involved simultaneously over time. It is important to note that unrecognizable (subclinical), potentially damaging inflammation in joints can occur between attacks of obvious flares of gouty arthritis. Kidney stones are more frequent in people with gout. Uric acid crystals can form outside joints. Collections of these crystals, known as tophi, can be found in the earlobe, elbow, and Achilles tendon (back of the ankle), or in other tissues. Typically, these tophi are not painful but can be a valuable clue for the diagnosis as the crystals that form them can be removed with a small needle for microscopic examination. Microscopic evaluation of a tophus reveals a nest-like accumulation of uric acid crystals embedded with white blood cells of inflammation.

Diagnosis
1. Joint aspiration This is the most important diagnostic test. It is the ultimate method of being certain of a diagnosis of gouty arthritis, as opposed to other causes such as an infection in the joint. A needle is inserted into the joint to withdraw a sample of fluid for testing. The fluid is examined under a microscope to see if there are gout crystals or signs of a bacterial infection present. Sometimes other crystals can be found in the joint fluid, such as calcium pyrophosphate, which is caused by an entirely different condition called pseudogout ("like gout"). Gouty arthritis is sometimes diagnosed based on the typical clinical presentation without a joint aspiration. 2. Blood tests Your doctor may obtain a blood sample to look at your cell counts, uric acid levels, kidney function, etc. Unfortunately, the level of uric acid in your blood cannot be reliably used to make a diagnosis of gout. It is normal in approximately 10% of people during an acute attack of gouty arthritis. Moreover, uric acid levels are elevated in 5%-8% of the general population, so the presence of an elevated level does not necessarily mean that gout is the cause of an inflamed joint. Interestingly, the uric acid is typically lowered during a flare of inflammatory gouty arthritis. Therefore, the optimal time to measure the uric acid is after a flare has resolved when acute inflammation is not present. 3. Radiographs X-rays are primarily used to assess underlying joint damage, especially in those who have had multiple episodes of gouty arthritis.

When to Seek Medical Care

Anyone who has a sudden onset of a hot, red, swollen joint should seek medical care, either with a primary-care physician, at an emergency department, or with a rheumatologist (arthritis specialist). These symptoms can also be due to an infection, loss of cartilage in the joint, or other reasons. It is important to make an accurate diagnosis of gouty arthritis as the treatment ultimately is guided by the cause of the inflammation.

If you have been diagnosed with gout and have more than one attack of arthritis, you should take the medication prescribed by your physician for these attacks. You should be seen by your physician, in the emergency department, or urgent care center if your attack does not respond to this treatment. You may need medications to prevent further arthritis flares. Attacks of abdominal pain due to kidney stones (renal colic) may be related to uric acid kidney stones from gout.

Treatment
1. Self-Care at Home Take medications as prescribed. While a joint is hot and swollen, you may want to use a cane or similar support to keep your weight off that joint. It may be helpful to keep the swollen joint elevated above your chest as much as possible. Ice packs can be helpful in relieving pain and reducing inflammation. Maintaining adequate hydration is key for minimizing the frequency and intensity of attacks. Cherry juice may decrease the intensity and severity of attacks. 2. Medications While some medications are used to treat the hot, swollen joint, other medications are used to prevent further attacks of gout. With any of these medications, call your doctor if you think you are having problems from them or if they are not working. Medicines used to treat acute gout and/or prevent further attacks are as follows: y Nonsteroidal anti-inflammatory drugs (NSAIDs)

Examples include indomethacin (Indocin), ibuprofen (Advil), and naproxen (Aleve). Newer drugs such as celecoxib (Celebrex) can also be used. Aspirin should not be used for this condition. High doses of anti-inflammatory medications are needed to control the inflammation and can be tapered off within a couple of weeks. Tell your doctor about your other health problems, particularly if you have a history of peptic ulcer disease or intestinal bleeding, if you are taking warfarin (Coumadin), or if you have problems with your kidney function. The primary complications of these medications include upset stomach, bleeding ulcers, and decreased kidney function. y Colchicine (Colcrys)

This medication is given in two different ways, either to treat the acute attack of arthritis or to prevent recurring attacks. To treat the hot, swollen joint, colchicine is given rapidly (generally, two tablets at once followed by another tablet an hour later). To help prevent an attack from coming back, colchicine can be given once or twice a day. While the chronic use of colchicine can reduce the attacks of gout, it does not prevent the accumulation of uric acid that can lead to joint damage even without attacks of hot, swollen joints. y Corticosteroids

Corticosteroids such as prednisone (Meticorten, Sterapred, Sterapred DS) are generally given when your doctor feels this is a safer approach than using NSAIDs. Some complications with the short-term use of corticosteroids include altered mood, elevated blood pressure, and problems with control of glucose in patients with diabetes. Corticosteroids can also be injected into the swollen joint. Resting the joint temporarily, after it is injected with steroids, can be helpful. Occasionally, corticosteroids or a related compound, corticotropin (ACTH), can also be injected into the muscle or given intravenously. Medicines in addition to low-dose colchicine used to prevent further attacks of gout and lower the level of uric acid in the blood include the following. y Probenecid (Benemid)

This medication helps the body eliminate excess uric acid through the kidneys and into the urine. You should drink at least 2 liters of fluid a day while taking this medication (to help prevent uric acid kidney stones from forming). y Allopurinol

This medication decreases the formation of uric acid by the body and is a very reliable way to lower the blood uric acid level. Allopurinol is currently the gold standard of maintenance therapy. Common side effects include stomach pain, headache, diarrhea, and rash. y Febuxostat (Uloric)

Febuxostat is first new medication developed specifically for the control of gout in over 40 years. It may decrease the formation of uric acid by the body and is a very reliable way to lower the blood uric acid level. This type of medication can be used in patients with mild to moderate kidney impairment. They should not be taken with 6mercaptopurine (6-MP), or azathioprine.

3. Surgery Surgery is rarely needed for gout unless significant joint damage has occurred from lack of effective treatment.

CONCLUSION
Gout is a metabolic disease most often affecting middle-aged to elderly men and postmenopausal women. Gout is due to the excessive amount of uric acid accumulate either because of the unable to remove it or over production. Hyperuricemia is the biologic hallmark of gout. When present, plasma and extracellular fluids become supersaturated with uric acid, which under the right conditions, may crystallize and result in a spectrum of clinical manifestations that may occur singly or in combination.

REFERENCES
Beers M.H., Fletcher A.J., & Jones T.V.(2003). The merck s manual of medical information. 2nd edition. Pp.330. New York:Pocket Books. Chris.(2010). Causes of right, left leg and foot pain. Date of retrieval February 12, 2012. Retrieved on http://www.healthype.com/causes-of-right-left-leg-and-foot-pain.html#causeof-unilateral-one-side-foot-pain-right-or-left Fauci A.S., Braunwald E., & KasperD.L.(2009). Harrison s manual of medicine. 17th edition. Pp. 900. United Kingdom:McGraw Hill. Murtagh J.(1995). General practice. Pp. 248. New York:McGraw Hill. Shier Jr.W.C., & Conrad M. (). Gout. Date of retrieval February 14, 2012. Retrieved on http://www.emedicinehealth.com/gout/page3_em.htm#Gout%20Symptoms