[Expert Solution]: SUBJECT: PHARMACOLOGY

SUBJECT: PHARMACOLOGY. Chief Complaint: “My toe is on fire” HPI Roy Huff is a 78-year-old man who presents to the emergency department complaining of significant toe pain. Mr. Huff states, “I think I’m paying the price for my fun at Oktoberfest”. He reports having spent the weekend indulging in beer and sausage at the local Oktoberfest festival. In the early hours of Monday morning (approximately 2 hours ago), he awoke to sudden excruciating pain in his right big toe. Over the last hour, this toe has become red, swollen, and so painful that he cannot walk. He has not experienced any trauma or injuries. He also denies having experienced these symptoms previously. PMH HTN PUD Obesity FH The patient typically drinks “”a can of beer or two” daily but drank significantly on Friday, Saturday, and Sunday. He does not smoke or use illicit drugs. Medications Chlorthalidone 25 mg po daily, started 1 month ago Omeprazole 20 mg po daily All NKDA (no known drug allergies acc. to google) SUZROS Other than feeling somewhere dehydrated from all of his drinking, the patient has no major complaints prior to this ED visit. No chest pain, nausea/vomiting, or respiratory symptoms. Bowel habits are normal. He has no prior history of arthritic symptoms or joint problems. PHYSICAL EXAMINATION Gen: A healthy-appearing, obese, white man in acute distress VS: BP : 120/60, P 110, RR 19, T37.50C; Wt 88 kg. Ht 5’6 (Compute for BMI) HEENT PERRLA, dry mucous membranes, throat / ears clear of redness or inflammation NECK/LYMPH NODES: Negative for lymph node swelling or masses Lungs/Thorax: Clear to auscultation bilaterally, symmetric movement with inspiration CV: Tachycardic, normal rhythm, normal S1 and S2 ABD: Obese, but soft, nontender. Positive bowel sounds in all quadrants. Genit/Rect: Deferred MS/Ext Erythematous, edematous right first metatarsophalangeal joint, which is very warm to touch. Joint pain is exquisite with patient relating the pain as currently as 10/10 (on a 1-10 scale with “0” being no pain and “10” being the worst pain the patient has ever suffered). No swelling of any other joints. No signs of tophi present. Neuro: A & O x.3 CN II-XII grossly intact, no focal neurologic deficits. increased = BUN, serum creatinine, WBC, neutrophils, triglyceride (borderline high), ESR, SUA decreased = lymph azotemia BUN = 40mg/dL (5-25) SCr = 3 mg/dL Leukocytosis with predominance of neutrophilia WBC = 12.8×10^3 mm^3 (4-10) Hypertriglyceridemia = 190 mg/dL (<150) Lymphopenia = 10% (25-35) Increased ESR =45 mm/hr (0-20) Hyperuricemia = 11.6 mg/dL (3.6-6.8). ASSESSMENT: Primary presentation of acute gouty arthritis, Acute renal failure secondary to dehydration and diuretic use, Probable adverse drug reaction: drug induced gout ,Hypertension: currently well controlled, History of duodenal ulcer or maintenance antisecretory therapy. CLINICAL COURSE:The patient responded to the therapy you recommended, and within 96 hours his pain has subsided significantly. Toe redness and swelling have decreased to near normal. Additionally, with fluids, his SCr has returned to baseline (0.8 mg/dL). After consultation with you, the patient’s physician decides against maintenance therapy to decrease serum uric acid levels. The patient, remembering the severe pain this episode caused, follows your recommended lifestyle Changes and is adherent to the new medication you recommended for his hypertension. At his 6-month follow-up appointment, he reports no more attacks of gout. He has lost 20 lb and no longer drinks ethanol. His serum uric acid level has decreased to 6.9 mg/dL, and his BP is 130/80 mm Hg.1. Create a list of all the patient’s drug therapy problems. EXPLAIN EACH DRUG TO WHY THAT IS THE PROBLEM 2. What risk factors in this case could contribute to or cause gouty arthritis? EXPLAIN AND LIST ALL IN FULL DETAIL. 3. EXPLAIN IN FULL DETAIL THE PATHOGENESIS OF GOUTY ARTHRITIS USING THE IMAGE PROVIDED