Homeopathic treatment in acute gout · similimum treatment, resolution of all acute gout symptoms...
Transcript of Homeopathic treatment in acute gout · similimum treatment, resolution of all acute gout symptoms...
Homoeopathic Treatment in Acute Gout
A research report submitted to the faculty of Health Sciences,
Technikon Witwatersrand, Johannesburg, in partial fulfillment of the requirements
for the degree of Masters of Technology: Homoeopathy
by
Raakhi Cara
(Student number: 9614149)
Prof. M. Tikly
Supervisor
Dr. E. M. Solomon
Co-Supervisor
Johannesburg, 2003
DECLARATION
I declare that this research report is my own, unaided work. It is being submitted
for the Degree of Masters of Technology at the Technikon Witwatersrand,
Johannesburg. It has not been submitted before any degree or examination in any
other Technikon, or University.
su, (Signature of candidate)
13fh■ day of l'''Ec'"9' E2 a c' ° 3
ii
Dedicated to my loving,
husband Nilesh, and my parents, Pravin and Luxmi,
for enabling me to pursue my dreams
Ill
ACKNOWLEDGEMENTS
I would like to express my sincere gratitude to the following individuals for their
assistance in the completion of this dissertation.
Supervisor: Prof. M. Tikly (FRCP, PhD)
Co-Supervisor: Dr. E.M. Solomon (HD. ND.DO . (Lind), BA (Unisa)
Statistician: Lasath Pundyadeera
Technikon Witwatersrand for financial assistance
All the volunteers that participated in this trial
Dr. Bradshaw, Dr. Eden, Dr. Hardy and Dr Pellow from Weleda Pharmacy for
their guidance
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ABSTRACT
This research was conducted to determine the effect of homoeopathic treatment
on acute gout patients. Putterman (1994) conducted a research study on the effect
of the homoeopathic remedy Colchicum autumnale in gout, and found partial
improvement in the clinical picture of gout. No research has been conducted in
South Africa on the efficacy of homoeopathic medicines in acute gout patients.
This study focused on the homoeopathic Law of Similars, where a single most
similar homoeopathic remedy was chosen according to the unique characteristic
symptoms displayed by each participant suffering with acute gout.
This was a qualitative study that used ten subjects who presented within five days
of acute gout and participated in the fifteen-day study period. Participants that
complied with the American College of Rheumatology (formerly American
Rheumatism Association, ACR) criteria for gout were selected. Serum uric acid
tests were taken on day 0 and day 6 to assess hyperuricemia. On day 0 a thorough
case history and examination was taken followed by administration of the
indicated remedy. Treatment efficacy was evaluated on day 1, 3 and 6, based on
daily subjective impression of participant involvement, objective analysis and
comparative analysis of serum uric acid. Re-examination for relapses or rebound
attacks followed on day 15.
In a study using allopathic remedies in acute gout, resolution of all acute gout
symptoms occurred at an average of 8 days using indomethacin and 7 days using
triamcinolone (Alloway et. al., 1993). In this study using homoeopathic
similimum treatment, resolution of all acute gout symptoms occurred at an
average of 6 days. One episode of a rebound gout attack occurred and serum uric
acid decreased in 80% of patients. Homoeopathic similimum prescribing is an
effective alternative treatment for acute gout. Although more research is required,
the preliminary findings of this study suggest that the correct homoeopathic
similimum treatment is an effective treatment for the symptoms of acute gout.
TABLE OF CONTENTS Page no.
TITLE PAGE i
DECLARATION ii
DEDICATION iii
I ACKNOWLEDGEMENTS iv
ABSTRACT v
TABLE OF CONTENTS vi
APPENDICES xii
LIST OF TABLES xiii
LIST OF GRAPHS xv
LIST OF ABBREVIATIONS xvi
CHAPTER ONE: INTRODUCTION 1
1.1 General Introduction 1
I 1.2 Aim of study 1
CHAPTER TWO: LITERATURE REVIEW 2
2.1 Gout 2
2.2 Four stages of gout 2
2.2.1 Asymptomatic hyperuricemia 2
2.2.2 Acute gout 3
2.2.3 Recurrent attacks 4
I 2.2.4 Intercritical stage 4
2.2.5 Chronic stage 5
2.3 Hyperuricemia 6
2.3.1 Underexcretion of urate 7
2.3.2 Overproduction of urate 8
2.4 Pathogenesis 9
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2.5 Prognosis 10
2.6 Diagnosis 10
2.7 Risk factors 11
2.8 Epidemiology 12
2.9 Randomized studies on acute gout 12
2.10 Management of gout 13
2.10.1 Termination of the acute painful attack 13
2.10.2 Prevention of recurrences 13
2.10.3 Preventing urate deposition 13
2.10.4 Diet 13
2.10.5 Complications of allopathic treatment 14
2.10.6 Alternative approach 15
2.11 Homoeopathy 15
2.11.1 Preparation of homoeopathic remedies and potentization 16
2.11.2 Proving 17
2.11.3 Materia medica 17
2.11.4 Single remedy 18
2.11.5 Determination of homoeopathic remedies in acute cases 18
2.11.6 Repertorization 19
2.11.7 Responses that indicate cure 20
2.11.8 Aggravation 21
CHAPTER THREE: METHODOLOGY 22
3.1 Sample selection 22
3.2 Trial period 22
3.3 Homoeopathic repertorization and treatment 23
3.4 Medication 23
3.5 Subjective and objective assessment 23
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3.6 Questionnaires 24
3.7 Analysis of urate 25
3.8 Data interpretation and statistical analysis 25
CHAPTER FOUR: CASE STUDIES 27
4.1 Patient A 27
4.1.1 Homoeopathic treatment 28
4.1.2 Follow up cases 29
4.1.3 Discussion 30
4.1.4 Subjective improvement as a percentage 31
4.1.5 Objective improvement on day 0, 1, 3, 6 and 15 31
4.1.6 Change in SUA on day 0 and day 6 31
4.2 Patient B 32
4.2.1 Homoeopathic treatment 33
4.2.2 Follow up cases 34
4.2.3 Discussion 35
4.2.4 Subjective improvement as a percentage 36
4.2.5 Objective improvement on day 0, 1, 3, 6 and 15 36
4.2.6 Change in SUA on day 0 and day 6 36
4.3 Patient C 37
4.3.1 Homoeopathic treatment 38
4.3.2 Follow up cases 39
4.3.3 Discussion 40
4.3.4 Subjective improvement as a percentage 41
4.3.5 Objective improvement on day 0, 1, 3, 6 and 15 41
4.3.6 Change in SUA on day 0 and day 6 41
4.4 Patient D 42
4.4.1 Homoeopathic treatment 42
4.4.2 Follow up cases 43
4.4.3 Discussion 44
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4.4.4 Subjective improvement as a percentage 45
4.4.5 Objective improvement on day 0, 1, 3, 6 and 15 45
4.4.6 Change in SUA on day 0 and day 6 45
4.5 Patient E 46
4.5.1 Homoeopathic treatment 47
4.5.2 Follow up cases 48
4.5.3 Discussion 49
4.5.4 Subjective improvement as a percentage 50
4.5.5 Objective improvement on day 0, 1, 3, 6 and 15 50
4.5.6 Change in SUA on day 0 and day 6 50
4.6 Patient F 51
4.6.1 Homoeopathic treatment 52
4.6.2 Follow up cases 52
4.6.3 Discussion 53
4.6.4 Subjective improvement as a percentage 54
4.6.5 Objective improvement on day 0, 1, 3, 6 and 15 54
4.6.6 Change in SUA on day 0 and day 6 54
4.7 Patient G 55
4.7.1 Homoeopathic treatment 56
4.7.2 Follow up cases 57
4.7.3 Discussion 58
4.7.4 Subjective improvement as a percentage 58
4.7.5 Objective improvement on day 0, 1, 3, 6 and 15 58
4.7.6 Change in SUA on day 0 and day 6 58
4.8 Patient H 59
4.8.1 Homoeopathic treatment 60
4.8.2 Follow up cases 61
4.8.3 Discussion 61
4.8.4 Subjective improvement as a percentage 62
4.8.5 Objective improvement on day 0, 1, 3, 6 and 15 62
4.8.6 Change in SUA on day 0 and day 6 62
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4.9 Patient I 63
4.9.1 Homoeopathic treatment 64
4.9.2 Follow up cases 64
4.9.3 Discussion 65
4.9.4 Subjective improvement as a percentage 66
4.9.5 Objective improvement on day 0, 1, 3, 6 and 15 66
4.9.6 Change in SUA on day 0 and day 6 66
4.10 Patient J 67
4.10.1 Homoeopathic treatment 68
4.10.2 Follow up cases 68
4.10.3 Discussion 69
4.10.4 Subjective improvement as a percentage 70
4.10.5 Objective improvement on day 0, 1, 3, 6 and 15 70
4.10.6 Change in SUA on day 0 and day 6 70
CHAPTER FIVE: QUANTITATIVE ANALYSIS 71
5.1 Demographics 71
5.2 Clinical baseline data 72
5.3 Response to therapy 73
5.4 Compliance of patients 74
CHAPTER SIX: QUALITATIVE ANALYSIS 90
6.1 The correlation with other studies of acute gout 90
6.1.1 Diagnosis 90
6.1.2 Gender 90
6.1.3 Family history 91
6.1.4 Age related symptoms 91
6.1.5 Obesity 91
6.1.6 Alcohol abuse 91
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6.1.7 Diet 92
6.1.8 Allopathic drugs that increase urate 92
6.1.9 Renal excretion of urate 92
6.1.10 Other risk factors 93
6.1.11 Resolution of symptoms 93
6.2 Serum urate 93
6.3 Response to therapy 94
6.4. Homoeopathic treatment 94
6.4.1 Response to treatment 94
6.4.2 Characteristic symptoms of the modality of temperature 95
CHAPTER SEVEN: CONCLUSION 96
7.1 Limitations of this study 96
7.2 Conclusion 96
7.3 Recommendation 97
REFERENCES 98
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APPENDICES page no.
A ACR CRITERIA FOR GOUT 106
SUBJECT INFORMATION AND CONSENT FORM 107
C CASE TAKING 109
SUBJECT QUESTIONNAIRE 113
RESEARCH QUESTIONNAIRE 114
F PATIENT A 115
PATIENT B 130
PATIENT C 144
I PATIENT D 159
J PATIENT E 173
PATIENT F 188
PATIENT G 202
M PATIENT H 216
PATIENT I 232
PATIENT J 245
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LIST OF TABLES
Table Title
4.1.4 Subjective improvement as a percentage (Patient A) 31
4.1.5 Objective improvement on day 0, 1, 3, 6, 15 (Patient A) 31
4.1.6 Change in SUA on day 0 and day 6 (Patient A) 31
4.2.4 Subjective improvement as a percentage (Patient B) 36
4.2.5 Objective improvement on day 0, 1, 3, 6, 15 (Patient B) 36
4.2.6 Change in SUA on day 0 and day 6 (Patient B) 36
4.3.4 Subjective improvement as a percentage (Patient C) 41
4.3.5 Objective improvement on day 0, 1, 3, 6, 15 (Patient C) 41
4.3.6 Change in SUA on day 0 and day 6 (Patient C) 41
4.4.4 Subjective improvement as a percentage (Patient D) 45
4.4.5 Objective improvement on day 0, 1, 3, 6, 15 (Patient D) 45
4.4.6 Change in SUA on day 0 and day 6 (Patient D) 45
4.5.4 Subjective improvement as a percentage (Patient E) 50
4.5.5 Objective improvement on day 0, 1, 3, 6, 15 (Patient E) 50
4.5.6 Change in SUA on day 0 and day 6 (Patient E) 50
4.6.4 Subjective improvement as a percentage (Patient F) 54
4.6.5 Objective improvement on day 0, 1, 3, 6, 15 (Patient F) 54
4.6.6 Change in SUA on day 0 and day 6 (Patient F) 54
4.7.4 Subjective improvement as a percentage (Patient G) 58
4.7.5 Objective improvement on day 0, 1, 3, 6, 15 (Patient G) 58
4.7.6 Change in SUA on day 0 and day 6 (Patient G) 58
4.8.4 Subjective improvement as a percentage (Patient H) 62
4.8.5 Objective improvement on day 0, 1, 3, 6, 15 (Patient H) 62
4.8.6 Change in SUA on day 0 and day 6 (Patient H) 62
4.9.4 Subjective improvement as a percentage (Patient I) 66
4.9.5 Objective improvement on day 0, 1, 3, 6, 15 (Patient I) 66
4.9.6 Change in SUA on day 0 and day 6 (Patient I) 66
4.10.4 Subjective improvement as a percentage (Patient 1) 70
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4.10.5 Objective improvement on day 0, 1, 3, 6, 15 (Patient J) 70
4.10.6 Change in SUA on day 0 and day 6 (Patient J) 70
5.1.1 Table of demographics 71
5.1.2 Body mass index 71
5.2.1 Index joints affected 72
5.2.2 Number of total joints affected 72
5.2.3 Number of patients with tophi 72
5.2.4 Change in SUA of all patients 72
5.3.1 Response to therapy 73
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LIST OF GRAPHS
Graph page no.
1 Overall assessment 75
2 Subject assessment 76
3 Global patient assessment 77
4 Global clinician assessment 78
5 Pain assessment 79
6 Swelling assessment 80
7 Discoloration assessment 81
8 Sleep assessment 82
9 Activity assessment 83
10 Composite improvement 84
11 Subjective assessment 85
12 Observers joint improvement 86
13 Joint swelling 87
14 Degree of tenderness 88
15 Uric acid levels 89
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LIST OF ABBREVIATIONS
MSU monosodium urate
NSAID nonsteroidal anti-inflammatory drugs
SUA serum uric acid levels
ACR American College of Rheumatology (formerly American
Rheumatism Association)
> better for/ more than
< worse for/ less than
PRPP phosphoribosylpyrophosphate
HGPRT hypoxanthine-guanine phosphoribosyltransferase
mmol/ L millimoles per litre
mg milligrams
ATP adenosine triphosphate
AMP adenosine monophosphate
Mg/ dL milligrams per deciliter
C centesimal
X decimal
C degrees centigrade
kg kilograms
m meters
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CHAPTER ONE: INTRODUCTION
1.1 General Introduction
The peak incidence of gout occurs in patients 30 to 50 years old, and the condition
is much more common in men than in women. The National Health Survey (1983-
1985) determined the prevalence rate of self reported gout to be 13.6 cases per
thousand men and 6.4 cases per thousand women. These numbers reflect an
appropriate threefold increase in the prevalence of gout since 1969 (Harris et. al.,
1999). Acute gout is the second stage of gout and is caused by the precipitation of
monosodium urate (MSU) crystals in the synovial fluid, eliciting an inflammatory
response characterized by extremely painful red, hot and swollen joints (van
Doornum and Ryan, 2000). Acute gout subsides within five to ten days following
the onset of the attack (Tucker, 1999). Chronic tophaceous gout is a major
consequence of recurrent acute gout attacks especially if untreated (Harris et. al.,
1999).
Allopathic medication used in the treatment of acute gout, such as, nonsteroidal
anti-inflammatory drugs (NSAID) are contraindicated in patients with peptic ulcer
disease, renal insufficiency and bleeding dyscrasias (Alloway et. al., 1993).
Homoeopathic remedies could be used as an alternative treatment in such patients.
Putterman (1994) conducted a research study on the effect of the homoeopathic
remedy Colchicum autumnale in gout patients and showed partial improvement in
the clinical picture of gout, no research has been conducted in South Africa on the
efficacy of homoeopathic medicines in acute gout patients. Similimum treatment
allows each patient to be treated individually. Two people with the same disease
respond differently to that disease, therefore remedies that are similar to their
response may restore their health (Gunavante, 1998).
1.2 Aim of study
This study is aimed to determine the effect homoeopathic similimum remedies
have on acute gout patients.
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CHAPTER TWO: LITERATURE REVIEW
2.1 Gout
Gout is one of the oldest forms of arthritis and is characterized by multiple acute
episodes of monoarticular inflammatory arthritis, which is due to MSU crystals
accumulating in a joint (Till and Snaith, 1998). Urate is formed as a by-product of
purine metabolism. Alteration in normal purine metabolism results in the
elevation of serum uric acid levels (SUA). High SUA, also known as
hyperuricemia, can lead to formation of urate crystals and the precipitation of
urate (Howard, 1999) in the kidneys, articular cartilage and eventually in the
bone. MSU crystal formation is slow and it occurs on the surface of the articular
cartilage. Acute attacks occur when these crystals come away from the cartilage
and enter the synovial fluid, causing an inflammatory response (Hollingworth,
1998).
After an acute attack there is usually a long period of remission and in some cases
there will be no other attacks. In severe cases, the time between attacks reduces to
a point where multiple joints are chronically affected with tenosynovitis, bursitis
and cellulitis (Nuki, 1998). Chronic gout may progress to a point where tophi
develop in the ears, around joints and in bursae (Davies, 1994).
2.2 Four stages of gout
The four stages in the progression of gout include asymptomatic hyperuricemia,
acute gout, intercritical gout and chronic tophaceous gout (Tucker, 1999).
2.2.1 Asymptomatic hyperuricemia
Asymptomatic hyperuricemia is the term for abnormally high SUA, without gout
or nephrolithiasis (Harris et. al., 1999). It is a stage in and of itself that does not
constitute gout, however an asymptomatic phase of gout in which deposition of
MSU takes place (Tucker, 1999). Patients do not require treatment during this
stage, but efforts should be made to lower their SUA by encouraging them to
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make changes in their diet and lifestyles, (Harris et. al., 1999) thus preventing
gout.
2.2.2 Acute gout
Acute gout attacks may occur without an inciting factor, or they may be
precipitated by a number of conditions that raise SUA, such as, minor trauma,
alcohol use, surgery, fatigue, rapid weight loss, infection, drugs and high purine
diet (Tucker, 1999). Any abrupt change in the SUA may provoke an acute attack
of gout (Pittman and Bross, 1999).
Acute gout is characterized by: the sudden onset of pain, warmth, tenderness,
erythema, limited range of motion and swelling of the involved joint (Harris et.
al., 1999). An English physician Thomas Sydenham's classic description of his
gout suffering in the 17 th centaury, left this description of a typical attack of gout:
"the victim goes to bed and sleeps in good health. About two o' clock in the
morning he is awakened by a severe pain in the great toe, more rarely the heel,
ankle, or instep. This pain is like that of a dislocation. Then follows chills and a
little fever. The pain which was at first moderate becomes more intense... so
exquisite and lively meanwhile is the feeling of the part affected, that it cannot
bear the weight of bedclothes nor the jar of a person walking in the room. The
night passes in torture" (Flieger, 1998).
Joints are usually affected at night because water is reabsorbed from the joint
spaces, leaving a supersaturated concentration of MSU. Pain and inflammation are
produced when MSU crystals activate the humoral and cellular inflammatory
process (Pittman and Bross, 1999).
In 90% of acute cases the first metatarsophalangeal joint is the initial joint
involved (Davies, 1994) a condition known as podagra (Harris et. al., 1999). This
is firstly because the extremities are cooler than other parts of the body, and MSU
crystallizes readily at lower temperatures and secondly because feet undergo
stress during normal walking or standing. Together, these factors explain why the
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metatarsophalangeal joint, forefoot, heel and Achilles tendon are attacked first.
Other targets, especially in untreated patients with recurrent attacks of gout, are
the knee, elbow, wrist, fingers and less often, the shoulders, pelvis, spine and
internal organs (Flieger, 1998).
Acute gout may be accompanied by leucocytosis, increased erythrocyte
sedimentation rate, and C reactive protein (Wood, 1999). Other symptoms include
post inflammatory desquamation and pruritus but are not always present (Tucker,
1999).
Acute attacks usually peak within one or two days of symptom onset. Without
treatment, an initial acute attack of gout will run its painful course within several
days or a few weeks, by which time all symptoms of the disease disappears
progressing to the intercritical stage (Flieger, 1998).
2.2.3 Recurrent attacks
The frequency of subsequent acute attacks of gout usually increases over time.
Approximately 60% of patients have a second attack within the first year
(Sturrock, 2000), only 7% of untreated patients never have a second attack
(Tucker, 1999) and 78% will have their second attack within two years (Harris et.
al., 1999). Subsequent attacks are likely to be more frequent, more severe, and
more destructive to joints and other tissues unless the problem is treated (Flieger,
1998). Polyarticular involvement also becomes more common over time and can
mimic other forms of arthritis. Left untreated, 60% of patients with recurrent gout
will develop tophi after a period of 10 years (Wood, 1999).
2.2.4 Intercritical stage
Following the recovery from acute gout, the patient re-enters an asymptomatic
phase of the disease. This phase is referred to as intercritical gout' or 'interval
gout' (Harris et. al., 1999). It is the interval between attacks of acute gout
whereby the patient is symptom free (Howard, 1999). The duration of the
intercritical stage can range from months to years. Some people may never have
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another attack. Treatment is required to ward off subsequent attacks (Howard,
1999). It is during the intercritical phase that the physician should focus on
secondary causes of hyperuricemia. Medications should be assessed to identify
those that may aggravate the patient's condition (eg. diuretics) and dietary
education regarding purine-rich foods (which contribute to higher SUA) should be
provided to the patient at this time. The patient should also be counseled about
limiting alcohol consumption and gradually losing weight if obese (Hams et. al.,
1999). In the untreated person, the frequency of acute attacks increases over time
and is often more severe and longer in duration (Howard, 1999). Crystal deposits
can persist despite the lack of symptoms (Tucker, 1999). Deposits can be
aspirated in up to 97% of cases (Tucker, 1999). The condition becomes chronic
when there is incomplete resolution of symptoms between attacks (Cohen and
Emmerson, 1998).
2.2.5 Chronic stage
Recurrent acute attacks of gout are followed by progressive cartilage and bone
erosion in association with deposition of tophi and secondary degenerative
changes. Severe functional impairment and gross deformities may occur (Haslett
et. al., 1999).
In a hospital-based study on urban Black South Africans 51.1% of gout patients
had tophi (Tikly et. al., 1998). Tophi are nodular masses of microcrystals of MSU
and amorphous urates, surrounded by histocytes, giant cells and fibrosis (Wood,
1999). Tophi appear in the periarticular and subarticular tissue of the joint (Perez-
Ruiz, 2002). If located superficially to the skin surface, tophi are visible and
appear nodular and white or yellow in colour. Ulceration of the skin can allow
crystallised exudates to develop. The exudates look like chalk and has a
consistency of toffee. Ulceration also increases the risk of superimposed infection
to the joint. The most common sites of urate deposition are the base of the great
toes, olecranon bursae, Achilles tendon, synovium, subchondral bone, extensor
surface of forearms, helix of the ears and joints (Tucker, 1999).
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Tophi rarely develop without acute gout (Pittman and Bross, 1999). The duration
of time between the first gout attack and recognisable tophaceous disease is highly
variable and may range from 3 to 42 years (mean: 11,6 years). The rate of urate
deposition and, consequently, the rate of tophi formation, correlate with the
duration and severity of hyperuricemia. Tophaceous disease is more likely to
occur in patients with the following: a polyarticular presentation, SUA higher than
0.53mmol/ L and a younger age at disease onset (i.e., 40.5 years or younger)
(Harris et. al., 1999).
Complications of tophi include pain, soft tissue damage and deformity, joint
destruction and nerve compression syndromes such as carpel tunnel syndrome
(Pittman and Bross, 1999).
2.3 Hyperuricemia
Urate remains in the plasma at normal levels. It moves through the circulation,
gets filtered by the kidneys and is excreted in the urine. When SUA rises above its
normal concentration it is known as hyperuricemia. Hyperuricemia, when varied
with temperature and blood acidity will form needle like crystals (Flieger, 1998).
Attacks of gout are caused by the body's inflammatory reaction to intermittent
precipitation of uric acid crystals into the joints.
Hyperuricemia is defined as SUA above 0.42mmol/ L in men (Schlesinger and
Schumacher, 2002) and above 0.35 mmol/ L in women (Putterman, 1994). This
concentration is also the limit of solubility for MSU in plasma. At levels of 0.48
mmol/ L or greater, MSU is more likely to precipitate in tissues. At pH of 7, more
than 90% of urate exists as MSU (Pittman and Bross, 1999), which is less soluble
than uric acid.
Hyperuricemia is a risk factor for gout and is one of the American College of
Rheumatology (formerly American Rheumatism Association, ACR) diagnostic
criteria for gout. Gout can be easily misdiagnosed as pseudogout in an
osteoarthritis patient or as a septic arthritis of the big toe. The presence of
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hyperuricemia in such cases confirms the diagnosis of gout together with five or
more of the ACR criteria for gout. Alternatively it is important to note that
hyperuricemia is common but not an obligatory feature and that SUA may be
normal in acute gout attacks (Sturrock, 2000).
Causes of hyperuricemia can either be primary or secondary in nature. Primary
hyperuricemia accounts for the majority of gout cases, and is linked to genetic
defects in purine metabolism. Abnormal metabolism of purines results in either;
underexcretion or over production of urate (Howard, 1999).
Factors that decrease renal excretion of urate
Drugs: low dose asprin, diuretics, anti-tuberculous drugs
Renal: hypertension, polycystic kidney disease, chronic renal failure
Metabolic \ endocrine: dehydration, lactic acidosis, ketosis
Genetic: reduced clearance of fractional excretion of urate
Miscellaneous: Obesity, sarcoidosis, toxaemia of pregnancy (Davis, 1999)
Factors that increase urate production
Nutritional: excess purine, ethanol, fructose consumption
Hematological: myeloproliferative and lymphoproliferative disorders,
polycythemia
Drugs: ethanol, cytotoxic drugs, vitamin B12
Genetic: enzyme mutations
Miscellaneous: obesity, psoriasis, hypertriglyceridemia (Davis, 1999).
2.3.1 Underexcretion of urate
Renal underexcretion of urate is considered to be the most frequent mechanism
for the development of hyperuricemia and gout (Perez-Ruiz et. al., 2002). Up to
90% of gout cases are due to underexcretion of urate. The remaining 10% of cases
are overproducers or a combination of both (Steven, 1998 and Davis, 1999).
Approximately two thirds of the urate produced each day is excreted in urine and
one third eliminated directly in saliva and intestinal secretions to undergo
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bacterial uricolysis (Smith, et. al., 1998 and Steven, 1998). Under normal
conditions, urate is filtered in the glomeruli of the kidney, reabsorbed in the
proximal tubule and secreted distally. Tubular secretion is almost entirely
responsible for the excretion of urate (Pittman and Bross, 1999).
Humans lack the enzyme uricase, an enzyme that breaks down urate into a more
water-soluble product called allantoin (Jones and Ball, 1999). The lack of this
enzyme subjects humans to the potential risk of tissue deposition of MSU crystals.
Unlike urate, allantoin is highly soluble and this lack is compounded by the
kidney's retention of more than 90% of the serum urate filtered at the glomerulus.
The balance of urate production to excretion with limits below the solubility of
MSU predisposes humans to form and deposit MSU crystals. The decreased urate
solubility at the lower temperatures of peripheral structures such as ears and toes
further complicates the delicate balance (Tucker, 1999).
Certain drugs can also cause hyperuricemia and precipitate gout. Loop and
thiazide diuretics, which inhibit distal tubular excretion of urate, are the most
common drugs that cause hyperuricemia. They rarely cause acute gout but may
encourage the formation of tophi. Low dose salicyclates, anti-tuberculous drugs
(pyrazinamide, ethambutol) and cyclosporin A have a similar effect on urate
excretion (Sturrock, 2000 and Steven, 1998).
2.3.2 Overproduction of urate
Overproduction occurs in 10%-15% of patients with primary gout (Davis, 1999)
and in 10% of patients the cause of overproduction is unknown (Stevens, 1998).
Purines, which are later metabolised to urate, enter a metabolic pathway by which
either nucleic acid or urate is produced (Pittman and Bross, 1999). Normal
production of urate is considered to be 600mg per day in men with normal renal
function on a purine free diet (Pittman and Bross, 1999). Overproduction of urate
may occur because of an abnormality in the enzymes that regulate purine
metabolism (Pittman and Bross, 1999). Two such abnormalities have been
documented. An increase in the activity of phosphoribosylpyrophosphate
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synthetase (PRPP) results in increased urate synthesis. A deficiency of
hypoxanthine-guanine phosphoribosyltransferase (HGPRT) also increases SUA
(Davis, 1999). These disorders may present with neurologic manifestations in
infancy or early childhood. HGPRT deficiency produces Lesch-Nyhan Syndrome,
which is characterized by sensorineural deafness and self-mutilation. PRPP
synthetase overactivity results in impaired neurologic development (Davis, 1999).
Overproduction of urate is most commonly associated with diseases that are
characterized by high cell turnover such as the myeloproliferative disorders and
some cancers (Wood, 1999). Cytotoxic drugs cause overproduction of urate from
cellular purines during the treatment of leukemias and lymphomas because they
increase the rate of cell death (Wood, 1999) a condition known as tumour lysis
syndrome.
Conditions that lead to increased degradation of adenosine triphosphate (ATP) to
adenosine monophosphate (AMP) involved in energy metabolism, which is not
re-used but degraded to adenosine and inosine and then to the purine bases and
urate will also result in overproduction (Emmerson, 1996). By this mechanism,
the ingestion of fructose or alcohol, sustained exercise, and tissue hypoxia from
any cause can result in overproduction of urate (Wood, 1999).
Gout is common in men with an alcohol intake in excess of 40 units per week,
especially in those who drink beer or lager, as these contain purines, such as
guanines, which are degraded to urate (Wood, 1999). Alcohol consumption and
obesity are associated not only with an increase in the production of urate but also
with a decrease in its excretion (Emmerson, 1996).
2.4 Pathogenesis
Solubility of MSU in plasma at pH 7.4 is approximately 6.7mg/ dL. Above this
concentration, plasma is supersaturated. Gout is due to the crystallisation and
deposition of poorly soluble MSU. Urate arises from abnormal metabolism of
purines. The purines are metabolised to hypoxanthine, which then undergoes
further metabolism, by the enzyme xanthine oxidase to xanthine, which is again
9
oxidized by xanthine oxidase to urate. Crystals of urate in the joint undergo
phagocytosis by local synoviocytes. Polymorphonuclear leukocytes ingest the
MSU crystals. Urate crystals damage leukocytes; they burst and empty contents
such as prostaglandins, lysosomes, and interleukin-1 into joint tissue. These
substances then cause the chemotaxis of leukocytes and macrophages to the joint,
magnifying the inflammatory response (Goodman and Gillman, 1999).
Alternatively the urate may be excreted. Urate is largely filtered through the
glomerulus. Additionally, it is actively secreted in the tubules. However, massive
tubular reabsorbtion of urate also occurs so that only about 10% of filtered urate is
actually excreted. If urinary conditions are conducive i.e acidic, the urate may
crystallise in the urine, forming urinary urate calculi (Goodman and Gillman,
1999).
2.5 Prognosis
Only 5% of patients with hyperuricemia develop gout (Stevens, 1998).
7% of patients will only have one arthritis attack (Stevens, 1998).
60% will have a recurrence within one year (Stevens, 1998).
With prolonged disease, frequency of attacks increases and may even
become chronic (Stevens, 1998).
Renal dysfunction is seen in many patients with gouty arthritis however,
severe renal dysfunction is uncommon. Renal dysfunction may not be due
to hyperuricemia, but rather may be due to other concomitant diseases, e.g.
hypertension and diabetes (Stevens, 1998).
2.6 Diagnosis
Gout is diagnosed according to the ACR criteria for gout. Patients must comply
with at least six of the ACR criteria for gout:
more than one attack of acute arthritis
maximum inflammation developed within one day
monoarthritis attack
redness observed over the joint
10
unilateral first metatarsophalangeal joint painful and swollen
unilateral tarsal joint attack
tophus (proven or suspected)
hyperuricemia
asymmetric swelling of joint x-ray
subcortical cysts without erosions on X-ray
monosodium urate monohydrate microcrystals in joint fluid during attack
joint fluid culture negative for organisms during the attack (Steward and
Silman, 1990).
2.7 Risk factors
About 90% of people afflicted with gout are men over 40 (Flieger, 1998).
Most of the affected females are postmenopausal, when SUA in women:
approach those in men. Park et. al., 2000 shows that female patients can
have a lower mean age onset of gout than in previous studies attributed to
the inclusion of renal transplantation patients.
Obesity in general (Lin et. al., 2000) and in particular excessive weight
gain in men between ages 20 and 40 has been shown to increase the risk of
gout (Flieger, 1998). About half of all gout sufferers are overweight
(Flieger, 1998). Rapid weight loss can also precipitate an acute attack.
Alcohol abuse or 'binge' drinking are associated with gout (Tang and Xia,
1998) as well as eating purine rich foods such as brains, kidneys, liver,
sardines and anchovies (Flieger, 1998).
Impaired renal function and use of thiazide diuretics and asprin to control
hypertension become important risk factors in the elderly (Chou et. al.,
2000 and Caspi et. al., 2000).
Other factors include occupational exposure to lead, surgery, family
history, trauma, infection, chemotherapy, fatigue and dehydration (Flieger,
1998).
The most common risk factor is failure of the metabolic process that
controls the amount of urate in the blood (Flieger, 1998).
11
2.8 Epidemiology
The incidence of gout is 0.1-0.3 % of adult population (Stevens, 1998).
Several British and American survey's have estimated the prevalence rate
of gout to be 2.6-8.4 per 1000 overall in adults (Sturrock, 2000), with the
prevalence increasing with age to rates 24 per 1000 in men and 16 per
1000 in women (Sturrock, 2000).
Gout occurs primarily in men older than 30 and is rarely found in men
before adolescence (Tucker, 1999). Children who have an attack should
undergo evaluation for a malignant or genetic cause (Davis, 1999).
Women account for approximately 10% of cases almost always
postmenopausal (urate levels remain constant until menopause) (Tucker,
1999). Affected women compared to men will more likely have coexistent
renal insufficiency, hypertension, polyarticular attacks, and a past history
of diuretic use (Davis, 1999).
Approximately 25% of patients with gout have a positive family history
(Stevens, 1998).
Compared with the classic manifestations in younger persons, gout in the
elderly is more evenly distributed between the sexes, more often affects
joints of the upper extremities, presents with fewer acute episodes, and has
a more indolent chronic clinical course (Fam, 1998).
2.9 Randomized studies on acute gout
In a study comparing triamcinolone acetonide with indomethacin in the treatment
of acute gout, resolution of all symptoms occurred at an average of eight days for
the indomethacin patients and seven days in the triamcinolone patients (Alloway
et. al., 1993). No side effects or episodes of rebound gout attacks occurred with
the triamcinolone acetonide therapy (Alloway et. al., 1993).
In a study using corticosteroid therapy in the treatment of acute gout, more than
21 of the 25 patients who were evaluated 24hours after therapy showed more than
50% improvement. Further improvement was noted on day 3, except in two
12
patients who developed early relapses. Overall subjective improvement was 90%
in 19 of the 25 patients evaluated on day 6 (Werlen et aL , 1996).
2.10 Management of gout
The three general goals of therapy in the management of gout are to terminate the
acute painful attack, prevent recurrences and prevent or reverse the complications
of urate deposition in the joints and the kidney or other involved sites (Emmerson,
1996).
2.10.1. Termination of the acute painful attack
During an acute attack, NSAID or Colchicines are the first drugs prescribed.
Bedrest is also important and should be continued for 24 hours after the acute
attack has been resolved. Early ambulation may precipitate recurrence. Hot or
cold compresses with elevation of the affected joint may offer some relief:
Appropriate footwear will also help relieve pain in acute attacks of the foot. A
rigid, open- type shoe is helpful; however, in general, shoes should have a low,
broad heel; strong counter; soft sole and upper; and most important a wide, deep
toe box (Emmerson, 1996).
2.10.2. Prevention of recurrences
Risk factors such as obesity, a high-purine diet, regular alcohol consumption, and
diuretic therapy may be correctable. The continuing challenge is to educate
patients about correctable factors and the importance of regular medication and
ensure their compliance so that attacks of gout do not recur (Emmerson, 1996).
2.10.3 Preventing urate deposition
In patients with persistent hyperuricemia, regular medication should lower the
SUA to an optimal level (Emmerson, 1996).
2.10.4 Diet
As urate is a by-product of purine, a partial treatment can be established by
limiting the amount of purine, in a patient's diet. This treatment is only partially
13
effective because two-thirds of the body's purine is endogenous and only one
third comes from food intake (Glynn, 1999).
A proper diet is helpful; however, it is not expected to significantly contribute to
the management of the disease (probably caused more from patient compliance
rather than dietary contribution). Nevertheless, patients should be advised to
follow a low-purine diet, which has been the standard gout therapy for many
years.
Foods high in purine that should be avoided include anchovies, organ and red
meat, gravies and broths, shellfish, herring, mackerel, sardines, and brewer's and
baker's yeast. Patients should avoid refined carbohydrates, particularly sugar and
white flour products, fried foods and most important alcoholic beverages, which
may precipitate attacks. Fat and protein intake should be reduced because they all
enhance insulin sensitivity and therefore may promote an increase in SUA
(Schlesinger and Schumacher, 2001).
A high fluid consumphon (more than 31_,Fda) will aidurate excretion and
minimize urate precipitation; optimal urine output is 2L or more. Alkalization of
the urine with sodium bicarbonate or trisodium citrate is also helpful (Tucker,
1999). If needed, weight loss is recommended; however, rapid weight loss and
gain may precipitate gouty attacks (Tang and Xia, 1998). Finally, certain
medications such as thiazide, loop diuretics, and low dose asprin should be
avoided because they inhibit renal excretion of urate.
2.10.5 Complications of allopathic treatment
Acute gout is treated allopathically by blocking the inflammatory response using
Colchicine, NSAID and intraarticular Corticosteroids (van Doornum and Ryan,
2000). Extreme caution is necessary when prescribing NSAID's in the elderly.
These drugs are not recommended in patients with peptic ulcer disease, renal
failure, uncontrolled hypertension or cardiac failure (Fam, 1998). Colchicine may
be problematic in patients with gastrointestinal disease and may reach toxic levels
14
in patients with renal or hepatic insufficiency (Alloway et. al., 1993). Excessive
doses may also cause bone marrow failure and renal damage (Wood, 1999).
Intravenous Colchicine can result in myelosuppression, hepatic necrosis, renal
failure, seizures and death (Fam, 2002). Side effects of corticosteroids include
glucose intolerance, electrolyte shifts, hypertension, and increased susceptibility
to infection (John, 1999).
2.10.6 Alternative approach
Alternative approach strategies include a proper diet with the additional
consumption of flavonoids such as cherries, blackberries, and raspberries
(Whitaker, 1995). Flavonoid consumption should be the equivalent of a V2 lb of
fresh cherries per day to reduce SUA and prevent gout attacks.
A program of high potency vitamin and mineral supplementation is commonly
recommended. A typical formula consists of 500 to 1000mg of vitamin C, taken
three times daily. Supplementing with vitamin B complex and vitamin A may be
recommended. One study suggests that high dose folic acid reduces SUA by
inhibiting xanthine oxidase (Tucker, 1999).
Herbal remedies that contain flavonoids, including celery seed, birch, gravel root,
willow and wild carrots can also be used (Tucker, 1999).
2.11 Homoeopathy
Homoeopathy is a system of medicine founded by Dr. Samuel Hahnemann (1755-
1843) of Germany (Sankaran, 1995). The word itself is derived from Greek where
Homoios means 'similar', and Pathos means 'disease', (Speight, 1979).
Homoeopathy is a therapeutic method, which clinically applies the Law of
Similars and the Law of Infinitesimal Dose (Jouanny, 1994). The Law of Similars
may be described as "likes are cured by likes" and the Law of Infinitesimal Dose
involves prescribing weak or infinitesimal doses of a substance (Jouanny, 1994).
In other words, the crude agent that can cause a set of symptoms to occur in a
healthy person may be used therapeutically in infinitesimal doses in an ill patient
15
whose symptoms resemble those normally created by that agent (Eizayaga, 1991).
A similarity between the toxicological action of a substance and its therapeutic
action is therefore observed (Eizayaga, 1991). For example if a healthy person
takes a large dose of arsenic in its crude form, he will develop vomiting,
diarrhoea, a rapid pulse and prostration. His skin will become cold and his
expression anxious. When taken for a longer time, he will develop coryza like
symptoms, a headache, cough and bronchial catarrh. Later there will be specific
disturbances of skin and nerves, with sensations of burning often relieved by
warmth. He may desire sips of water, have a fear of death and experience
restlessness (Sankaran, 1995). According to the Law of Similars patients
displaying similar symptoms have been cured by weak or infinitesimal doses of
homoeopathically prepared arsenic called Arsenicum album, irrespective of the
name of the disease (cholera, colds, asthma, eczema) (Sankaran, 1995).
When homoeopathic remedies are applied correctly according to the Law of
Similars, it stimulates the natural healing ability of the individual, by enhancing
the elimination of toxins from the body and by restoring balance to the organ
systems (Van Wyk, 1998).
2.11.1 Preparation of homoeopathic remedies and potentization
Homoeopathic remedies are prepared from all kingdoms of nature: plant, animal
and mineral. First a solution of the active principles of a substance from the plant
kingdom for example is soaked in pure alcohol to obtain a mother tincture (Ray,
1994). The remedy is then prepared according to a process of serial dilution and
succussion (vigorously pounding the solution against a firm surface).
Homoeopathic remedies are always non-toxic due to these dilutions (Jouanny,
1994). The potencies can be prepared according to two scales, the decimal (X) or
the centesimal scale (C). Between each stage of dilution the diluted tincture is
succussed. The dilution factor for the decimal scale is 1:10 and for the centesimal
scale , is 1:100. To produce a 1 C potency of any remedy, one drop of the mother
tincture is added to 99 drops of an alcohol/ water mixture. The mixture is then
succussed a hundred times. One drop is then taken from this mixture and added to
16
99 drops of another alcohol/ water mixture, succussed to prepare a 2C potency
(Lockie and Geddes, 1995). According to Avogadro's constant, once a mixture
has been diluted beyond a "12C" or "24X" potency it is highly likely that nothing
of the original substance remains in the dilution (Lockie and Geddes, 1995).
Through succussion the remedies healing properties seem to increase and when
given to the patient it promotes healing (Lockie, 1990). This step-by-step dilution
and succusion of the medicinal substance releases latent energy making it
extremely powerful and at the same time renders it harmless. This is in direct
contrast to the toxic drugs of modern medicine, and their 'side effects' (Sankaran,
1995). The most common potencies used are 30C, 200C and 1M. 30C and below
are used for physical disturbances, 200C for emotional disturbances and 1M and
over for disturbances on the psychological plane (Kent, 1979) although there are
many variations.
2.11.2 Proving
Hahnemann carried out a series of controlled experiments which were known as
provings on himself and other volunteers. A proving of a remedy was obtained
when a substance was administered to a group of healthy individuals in
infinitesimal, repeated doses and every symptom elicited was eventually recorded
in the materia medica (Eizayaga, 1991). The action of a substance may have
affected each individual at every level, for example, it could have caused a change
in temperament, may have increased or decreased thirst or desire for certain foods,
changed the patients tolerance in temperature etc. The proving of a remedy
indicates what disease symptoms a healthy body is able to produce as well as the
symptoms that this medication is able to treat (Hahnemann, 1998). Therefore the
proving of a substance determined the curative power of a remedy (Gunavante,
1998).
2.11.3 Materia medica
Hahnemann originally published the results of his provings in the form of a book
called the materia medica. Under each remedy, he listed, the symptoms that the
remedy produced in healthy people. There are approximately 3000 remedies
17
listed. The materia medica contains details of symptoms from provings,
toxicological effects of these substances and clinical indications. A materia
medica is used to find out which symptoms a remedy might cause (Lockie, 1990).
The following information on each remedy is found in the materia medica: mental
symptoms, modalities, appetite, food, thirst, desires, and aversions as well as
physical symptoms observed in every system (Eizayaga, 1991). There are a
variety of materia medicas and it is important for the homoeopath to study several
of them before choosing the most similar or similimum remedy (Vithoulkas,
1998).
2.11.4 Single remedy
Provings were carried out using single substances rather than compounds of many
substances, therefore homoeopathic remedies are commonly given as single
remedies (Hahnemann, 1998, Gunavante, 1998). Reactions are then observed, and
a decision is made whether to wait, repeat the dose, choose a stronger dose, or
change the remedy altogether (Vithoulkas, 1998).
2.11.5 Determination of homoeopathic remedies in acute cases
The similimum remedy is the homoeopathic remedy, which most closely
resembles a person's symptoms. In order to find the similimum remedy "every
case must be individualised, every symptom from head to feet, must be given, and
every variation from positive health must be known. Whatever is not as it should
be is a symptom and must be recorded" (Kent, 1957). Prominent, marked, peculiar
and characteristic symptoms individualise a case. A general symptom e.g.
"headache" would not be a guide in the selection of a homoeopathic remedy,
because there are hundreds of remedies to choose from. Individual peculiarities
such as, "sharp shooting pains in the left side of the head", shorten the selection of
remedies. Additional symptoms such as, the pains are "less lying down and worse
for walking" further individualize the case and lessen the selection of remedies
(Kent, 1957).
18
The selection of symptoms differs in an acute case taking as compared to a
chronic case taking. The action of the homoeopathic remedy in an acute case is to
catalyse the natural process already produced by the body's defence mechanism.
The homoeopath therefore places more emphasis on recent symptoms produced in
the acute phase and less on the longstanding symptoms of the chronic state. "If the
acute local complaint is more pronounced, or the patient is more sensitive, it will
provoke a more intense general reaction" (Jouanny et. al., 1996). The following
symptoms in an acute prescribing are important: aetiology, pathological signs,
location, time of appearance, duration, pain sensation and modalities that make
symptoms better or worse (Vithoulkas, 1998). The concomitant symptoms should
include thirst, appetite, energy, sleep, urination, perspiration, temperature and
fever. Mental symptoms are only included if they are marked and clearly suggest
a change in the persons behavior (Jouanny et. al., 1996).
In acute disease the indicated remedy is usually prescribed in low or medium
potencies several times a day until improvement occurs (Jouanny et. al., 1996).
2.11.6 Repertorization
The repertory is used as a remedy finder. In a repertory, there is a series of
headings concerned with parts or systems of the body, such as mind, head, joints,
etc. Under each heading there is a list of symptoms, such as pain, redness or
swelling. Alongside each symptom all the remedies known to produce that
symptom are printed, together with any factors, which may affect it (Lockie,
1990). Each remedy is graded with a score. For example, the patient says he or
she has a sudden tearing pain in the knee. The homoeopath refers to the
extremities chapter, finds the rubric, 'pain' and the sub-rubrics, tearing—knee-
sudden' and a list of remedies with a grading or score will follow (Ray, 1994).
Following the completion of a thorough case history the homoeopath chooses
several important characteristic symptoms to repertorize (Ray, 1994). The
symptoms are found in the repertory using rubrics. A table with the most
prominent remedies in descending order will be generated. The score under each
19
remedy is then added. The remedy with a high score, covering all or most of the
rubrics and matching the symptom picture in the materia medica is chosen as the
similimum remedy for the patient.
2.11.7 Responses that indicate cure
"The highest ideal of cure is rapid, gentle and permanent restoration of
health, or removal and annihilation of the disease in its whole extent, in
the shortest, most reliable and most harmless way, on easy comprehensible
principles" (Hahnemann, 1998). Restoring health means that not only must
the physical symptoms improve but there must also be an inward
improvement and mentally the patient must feel better with more energy
and must be able to deal with life more effectively (Kent, 1979 and
Chappel 1994).
The behavior of cure flows in the stream of natural direction; "it adjusts
the internal disorder and the outermost of man returns to order" (Kent,
1979) therefore when physical symptoms disappear, changes may occur in
a patients life even though it may seem coincidental (Chappel, 1994).
A short aggravation (worsening of symptoms) during the first hours after
taking the remedy is a good prognosis, because 'the medicinal disease
must naturally be stronger than the patients disease in order to overpower
and extinguish the latter" (Gunavante, 1998), in the same way "as a natural
disease can remove and annihilate another one similar to it, only when it is
stronger than the latter" (Hahnemann, 1998).
By taking homoeopathic medication, treatment follows a natural direction,
such that, symptoms previously suppressed will manifest outward as a
physical symptom (Kent, 1979), therefore there can be a return of an old
symptom. Brief temporary return of old symptoms is good if they return in
the reverse sequence of the original occurrence. The law of cure indicates
that symptoms will be eliminated in an order, from serious to less serious,
from internal to external or less critical, from inside out and from above
down (Herring's law of cure) (Kent, 1979).
20
It is favorable if physical symptoms just become better, provided the
process fits the law of cure (Chappel, 1994).
Generally the sequence is that, the patient will feel better mentally but
physical symptoms will worsen because toxins are being eliminated.
Symptoms will subside once the body is rid of these toxins (Chappel,
1994).
2.11.8 Aggravation
An aggravation occurs when original symptoms of the patient get worse after
taking the remedy. An aggravation can mean improvement or is due to an error in
potency or the presence of marked pathology. Aggravation caused by a remedy is
a sort of house cleaning and is indicative to the prognosis of the case.
If the aggravation is showing improvement, the general rule is that the patient as a
whole, in himself, feels better.
The types of aggravation that may be observed are:
Aggravation, which is quick, brief, and vigorous, followed by speedy
relief of the patient. This type is much to be desired and is a sign that the
improvement will be of long duration and that structural changes are in
non- vital organs (Kent, 1979, Hubbard, 1997).
Practically no aggravation observed and yet the patient recovers steadily.
This is ideal and shows that there is no great organic disease and that the
potency chosen exactly fits the case, especially if during recovery the
symptoms follow Herring's law (Kent, 1979, Hubbard, 1997).
When physical symptoms stand out more clearly while the patient himself
feels better. This is followed by old symptoms reappearing in reverse order
of there coming. This is highly favorable (Kent, 1979, Hubbard, 1997).
An unnecessary severe aggravation is caused by too high or too low
potency (Kent, 1979, Hubbard, 1997).
Where brief amelioration comes first and aggravation afterwards. This
means that the remedy was only "palliative" (caused symptomatic relief)
21
and was not correctly prescribed, or else that the patient is incurable, or
that a deeper remedy is needed (Kent, 1979, Hubbard, 1997).
CHAPTER THREE: METHODOLOGY
3.1 Sample selection
Ten subjects two female and eight male over the age of eighteen years presenting
within five days of the onset of acute gout participated in the fifteen-day study
period. Each subject fulfilled the ACR criteria for gout (appendix A). These
patients replied to advertisements placed in health shops, pharmacies and medical
centers.
3.2 Trial period
The investigation schedule went as follows:
Each subject was given a consent form (appendix B) to certify that
participation is voluntary and that they were allowed to withdraw at
anytime.
Exclusion criteria included prior allopathic therapy, poorly controlled
diabetes mellitus, severe infection and anticoagulant therapy.
No anti-inflammatory or analgesic drugs other than the study medication
was permitted from the time of inclusion into the study (day 0) to the end
of the fifteen-day study period.
Subjects were not allowed to take urate-lowering agents including
Allopurinol, Sulfinpyrazone and Probenecid except for participants who
had been on such therapy prior to the onset of the attack and who had
experienced insufficient relief from their medication.
A thorough case history (appendix C) was performed by the researcher on
each subject, with more emphasis on recent acute symptoms.
For uniformity the study limited itself to evaluating only the index joint
(the worse affected joint) of each participant.
22
The researcher completed a questionnaire (appendix E) based on joint
appearance, improvement, swelling and tenderness of each subject.
SUA were determined on day 0 and day 6.
X-rays and synovial fluid aspiration were excluded in this study due to
budget constraints.
Each subject answered a daily questionnaire assessing joint symptoms
from day 0 to day 6 (appendix D).
3.3 Homoeopathic repertorization and treatment
The case histories of each subject were used as a base for repertorization. The
most recent acute symptoms and important phrases were extracted to construct
rubrics, which then could be located by using the Radar computer repertory. In
acute cases it was important to use characteristics such as location, time of
appearance and duration, type of sensation and modalities, which make symptoms
better or worse. The concomitant symptoms included thirst, appetite, energy,
sleep, urination, perspiration, temperature and fever. Mental symptoms were only
included if they were pronounced and clearly conveyed a change in the subjects
behaviour. For chronic gout patients, the approach to finding the remedy was to
treat the case as an acute exacerbation of a chronic condition. Tables with the
most prominent remedies in descending order were generated. This enabled the
researcher to concentrate on a small, very strong group of remedies with the aid of
various materia medicas to decide on the most appropriate remedy.
3.4 Medication
The researcher prepared the medication. Lactose tablets were triple impregnated
with a 90% alcohol solution of the homoeopathic remedy.
The remedy was taken three times a day until improvement was seen. The remedy
was prescribed in the 30CH potency.
3.5 Subjective and objective assessment
Day 0 A thorough case history and physical examination was performed by
the researcher. SUA was determined.
23
Day 1- 6 Subjects answered a questionnaire evaluating their symptoms.
Day 1, 3, 6 The researcher evaluated treatment efficacy on day 1,3 and 6.
Day 6 SUA was determined for the second time.
Day 15 Subjects were re-evaluated.
3.6 Questionnaires
The studies outcome measures were designed according to previous studies on
acute gout.
Joint improvement was graded on a scale of 0 - 4 (Alloway et. al., 1993)
0 = totally resolved
1= improved by > 50%
2 = improved < 50%
3 = no change
4 = unchanged or worse with either progression of symptoms or any involvement
of previously uninvolved joints
Swelling was classified as (Ritche et. al., 1968)
0 = no swelling
1 = swelling with some loss of joint contours
2 = complete loss of joint contours
3 = fluid
Tenderness was graded on a scale of 1 —3 (Ritche et. al., 1968)
0 = no tenderness
1 = tender
2 = tender and wince (involuntary facial expression suggesting discomfort)
3 = tender and wince and withdrawal (involuntary movement of the affected joint
away from the stimulus)
On examination 1= tender was marked when the patient felt an abnormal
sensitiveness to touch or pressure, 2= tender with wince was marked when the
joint was tender and the patient complained or made an involuntary facial
expression showing discomfort. Tender with wince and withdrawal was marked
24
when a tenderness with a wince occurred together with an involuntary movement
of the affected joint away from the pain stimulus.
Putermans (1994) questionnaire was used to assess subject improvement
(appendix D). It was based on a rating scale of 1- 10 and included
Joint pain intensity
Joint swelling
Joint discoloration
Sleep affected
Level of activity
% improvement.
3.7 Analysis of urate
Hyperuricemia was one of the ACR diagnostic criteria for gout therefore SUA
was drawn on day 0. A second SUA test was drawn on day 6. The values in
mmol/ L of day 0 were compared to the values found on day 6, to determine a
change in SUA after the administration of homoeopathic treatment. SUA was
analyzed by the Trinder enzymatic method using the trace 120 auto analyzer by
Lancet laboratories.
3.8 Data interpretation and statistical analysis
Improvement was then defined as a 50% drop in day 1, 3 and 6 in any of
the major outcome measures.
Subjective assessment was calculated using question 1 to 5 in the subjects
questionnaire. The baseline was calculated as the sum of questions 1- 5 on
day 0 divided by 2. The score less than the baseline indicated more than
50% improvement on day 1, 3 and 6.
A 50% improvement in observer's joint improvement, swelling and
tenderness was calculated using question 1, 2 and 3 in the researchers
questionnaire. The score 1 or 0 in the researchers questionnaire on day 1,3
or 6 indicated > 50% improvement.
25
For data with normal distribution, including the global patient, global
clinician and SUA, the mean and standard deviation were calculated. For
non-normal data, including the age, disease duration and number of joints
affected the median and interquartile (25 — 75) ranges were calculated.
Body mass index (BMI) was calculated by measuring the patient's weight
in kilograms and dividing it by his or her height in meters squared (kg/m 2).
Obese patients scored > 30, overweight patients scored between 24 and 30,
normal patients scored < 24.
Subjective improvement as a percentage from day 0 to day 6 was
calculated by taking the original score assessed by the subject subtracted
by 10 and multiplied by 100.
This information together with information obtained at each consultation
was used comparatively to analyse each patient's trend. It was important to
study each of the ten patients cases intensively to determine whether
treatment was effective.
26
CHAPTER FOUR: CASE STUDIES
4.1 Patient A
A 71-year-old Indian male pensioner has a weight 52 kg and a height of 1.60m.
His complaint began with a fever the night before. He was burning hot, restless
and alternated between hot and cold with the fever. His heater did not provide
enough heat when he got cold and he could not bear the heat of the blanket when
he got hot. His sleep was disturbed by a constant urge to urinate. He became
worried when he noticed his urine was dark, burnt like "vinegar", smelt like
"Handy Andy" and passed in drops. This was accompanied by a lower back pain
in the left kidney area. He usually has a sensitive bladder and finds that his urine
dribbles out involuntary but the night of the onset of symptoms this did not
happen. Towards the early hours of the morning he woke up with an unbearable
tearing pain in his right knee. The pain radiated to the right big toe (index joint),
which got swollen. His joint pain was worse for motion, at night and lying on the
painful side. It was better for heat, rest and holding the joint with his hands. He
bandaged his foot to keep it warm, and to prevent movement. During examination
of the joint, the patient winced as bandages were being removed and touching the
skin caused pain. The joint was red, hot and swollen with some loss of joint
contours. On touch the joint was tender and the patient winced. There was no
numbness; and when examined the patient could feel a light touch and a pain
sensation. No perspiration was found on the joint. The joint was stiff, worse for
motion and better for rest. His feet were abnormally cold. He felt pain on
standing and when walking. The patient limped to avoid pain on his affected
joints when walking short distances. He used crutches to walk longer distances
because of the gout. Other findings on examination included temperature 38°C,
left lumbar sacral pain with renal angle tenderness. Noticeable changes
accompanying the acute gout attack were pyrexia, malaise, insomnia, general joint
stiffness, nausea and loss of appetite. No change in thirst occurred; the patient is
normally thirstless, does not drink water and prefers tea. He had hyperuricemia
with SUA of 0.52mmol/L.
27
He takes Saw palmetto for his enlarged prostate, Panado for headaches and
bodyaches, and usually Corticosteroid, Brufen or Arthrexin for joint pain. He was
on no gout medication on day 0. In 1986 he had renal calculi removed and had
raised SUA. Three months later a sharp pain experienced in his foot radiated to
his knee. Gout occurred at the knee joint and was treated with infra-articular
steroids. Consumption of red meat at barbeques provoked his gout attacks. There
was no family history of gout and he has never consumed alcohol in his life. Gout
affects his knee, sometimes the shoulders or toe at least once a year. Dietary
habits have changed to chicken instead of red meat, which he eats on occasion but
finds that red meat aggravates his gout.
4.1.1 Homoeopathic treatment
Benzoicum acidum 30CH was prescribed three times daily. The following
symptoms of Benzoicum acidum from different materia medica's match the
symptoms described by patient A:
It is clinically indicated for gout (Clarke, 1997 and Vermeulen, 1997)
in patients suffering from urinary troubles (Khaneja, 2001) with uric
acid diathesis (Agrawal, 1997).
Gout occurs especially in the knee or big toe (Morrison, 1993), on the
right toe (Vermeulen, 1997 and Agrawal, 1997).
Pains tearing in large joints of big toe, with redness and swelling of
joints (Allen, 2001 and Vermeulen, 1997).
Joint symptoms aggravated at night and on motion (Vermeulen, 1997).
Joint symptoms relieved by rest and heat (Vermeulen, 1997).
Benzoicum acidum is useful in gout when it has a pathogenic action on
the bladder causing irritation with dark coloured urine smelling
strongly of ammonia (Jouanny, 1984, Khaneja, 2001 and Farrington,
1995).
The typology of these patients is generally gouty rheumatic individuals
suffering from uricemia and lithiasis. The rheumatic symptoms are
inversely proportional to the flow of urine (Jouanny, 1984).
28
There are often kidney complaints especially inflammation of the left
kidney (Moiloa, 2000).
Morrison, 1998 states that when joint pains are suppressed
allopathically, rheumatic heart disorders may occur. Alternatively he
says that urinary tract symptoms such as kidney stones (uric acid) may
develop.
Other symptoms indicating this remedy are dribbling of urine in old
men with enlarged prostate (Allen, 2001).
4.1.2 Follow up cases
Day 1: All joint symptoms worsened; pain, swelling, tenderness, discoloration,
and mobility. On examination the joint was dark red, hot, smooth, inflamed with
complete loss of joint contours, tender with wince and withdrawal and numb with
loss of light touch sensation. The index joint was incapable of flexion and
extension with pain on least motion. The patient depended on crutches to stand
and walk. Back pain, renal symptoms, energy level, sleep, general joint stiffness,
restlessness, nausea and appetite had also worsened. His fever reduced to 36.8 °C.
Mentally he could handle the pain but said that he would be forced to take other
medication if it got worse. The patient became thirsty but did not drink water.
Medication continued three times daily.
Day 3: subjective and objective improvement of < 50% occurred. The patient got
thirsty and drank four glasses of water. Urinary symptoms improved to profuse,
burning and odorous urine. Joint pain, swelling, discoloration tenderness and
flexibility improved after urination. Modalities of heat, rest and motion improved.
On examination the joint was light red, warm, smooth, swollen with some loss of
joint contours, tender and not numb. The patient winced on flexion and extension
of the joint. He was able to stand without crutches. Energy, appetite and nausea
resolved. The pain and range of motion in all the other joints improved. No pain
was experienced in the lumbar sacral area and no renal tenderness was observed.
The medication continued until his symptoms resolved completely.
Day 6: Total resolution of joint symptoms occurred. On examination the joint was
pink and cool with no pain, inflammation, tenderness or numbness. Mobility was
29
resolved with normal flexion and extension. The patient was able to stand and
walk normally without crutches. His urine was light yellow and odorless. No pain
on urination and no kidney pain were experienced. SUA decreased by 0.11mmol/
L. Medication discontinued.
Day 15: Total resolution with no relapses.
4.1.3 Discussion
A type of aggravation to the remedy had taken place in which the individual
symptoms stood out more clearly while the patient himself felt well. The
worsening of symptoms is often due to toxins being eliminated from the body.
The stimulation of the thirst centre produced by the remedy on day 1 shows that
the remedy acts as a catalyst to stimulate the natural process of the bodies own
defence mechanism. The natural process being that by getting thirsty, the patient
would drink more water thus allowing the urinary system to eliminate more
toxins. The rapid response in joint improvement by day 6 after the aggravation
proved the remedy chosen best fitted the symptom picture. The patients
improvement in consumption of water aided the elimination of toxins.
30
4.1.4 Subjective improvement as a percentage from day 0 to day 6 occurred
as follows:
Day 1 2 3 4 5 6 Joint pain 20% 0% 0% 50% 60% 80% 100%
Joint swelling 20% 0% 0% 50% 60% 90% 100%
Joint discoloration 30% 0% 0% 50% 60% 80% 90%
Sleep affected 30% 0% 0% 50% 70% 100% 90%
Level of activity 40% 0% 0% 40% 70% 80% 100%
Overall
Improvement
0% 0% 0% 30% 50% 80% 90%
4.1.5 Objective improvement on day 0, 1, 3, 6 and 15 occurred as follows
Day 0 1 3 6 15
a) Joint improvement 4 4 2 0 0
b) Severity of swelling 1 2 1 0 0
c) Degree of tenderness 2 3 1 0 0
4.1.6 Change in SUA on day 0 and day 6
Day 0 6
SUA 0.52mmol/ L 0.41mmol/ L
Normal values: < 0.42 mmol/L in males
< 0.35 mmol/L in females
31
4.2. Patient B
This 60-year-old Indian housewife, 1,63m in height and 86 kg in weight, has
diabetes mellitus and is presently on diabetic and antihypertensive medication.
She consumes no alcohol, and eats small meals throughout the day. For supper
she eats salads with meat curry (red or white meat). She avoids sugar and has
fructose in its place. Her gout began two years ago and she has already suffered
two attacks since then. Gout had previously attacked her first metatarsophalangeal
joint, knee and shoulder. Her present attack, started two days ago from walking a
long distance in uncomfortable shoes. When she got home, she immediately took
off her shoes because her feet were burning. The left toe felt as if she sprained it
and was very painful to touch. That night she argued with her husband that she
was fine but her left toe was incredibly painful and swollen. The right foot was
normal. She realised then that it was a gout attack and hoped it would go away by
the next day, but it didn't. Her left first metatarsophalangeal joint felt sore with a
slight throb as if someone hammered her toe. The pain improved with heat packs,
got worse with movement and on touch. On examination she complained of pain
when the examiner approached the joint. Her joint was blue-purple in colour,
tender with wince and withdrawal and oedematous. She had numbness with a loss
of light touch and pain sensation over the joint. Her joint felt hot but her feet were
cold.
The joint could not be flexed or extended on account of the pain aggravated by
touch. She walked on the unaffected limb and placed pressure on her left heel
when stepping. Her left toe was untouched and immobile while walking. She felt
exhausted; her body felt tired and sore as if she ran a marathon. Her leg muscles
were sore from all the walking and generally her muscles are getting weak. She
had a restless sleep. She kept tossing and turning, to get rid of the pain. The pain
was relieved temporarily in a certain position but returned shortly compelling her
to move. Patient B had a fever; her temperature was 38.2°C and her head felt hot.
She had a dull feeling in her head and could not concentrate properly. No change
in urination was noted. She normally urinates frequently, profusely and wakes up
at night. Her appetite was normal, with no loss or gain. She is thirsty normally and
drinks more than 8 glasses of water daily. She craves sugar and gets diarrhoea
32
when she eats anything sweet. Mentally she is healthy. She is tired of taking
medicines, so she avoids it if she can. She believes in natural healing like home
remedies, reflexology, herbs and homoeopathy. She is independent, confident and
friendly. She complained of losing feeling in her fingers and toes and of sinusitis.
SUA was 0.4 mmol/L and she was hyperuricemic.
4.2.1 Homoeopathic treatment
Arnica montana 30CH was prescribed three times daily. The following symptoms
of Arnica montana in different materia medica's match the symptoms described
by Patient B:
Arnica montana is the great 'injury remedy'. Boyd, 1989 suggests that if
injury precedes the development of arthritis or gout always start with a
dose of Arnica montana, even if the injury has occurred a long time
before.
This remedy is particularly indicated in gout attacks, which occur
following physical effort or repeated micro-trauma: e.g. badly fitted
shoes (Jouanny, 1994), a fall or severe wrench (Khaneja, 2001).
Violent burning in the feet (Hahnemann, 1996).
Joints feel as if they were sprained (Burt, 1995).
Sudden swelling of the affected foot (Hahnemann, 1996).
Towards evening a gouty numb pain as from a dislocation in the joint of
the big toe, with some redness occurs (Hahnemann, 1996).
In one of the toes a dull throbbing pain (Hahnemann, 1996).
Single blows in the big toe (Hahnemann, 1996).
Pain < touch (Jouanny, 1994).
Pain < movement (Burt, 1995).
Pain > hot application (Jouanny, 1994).
Pain < night (Burt, 1995).
Purplish edema of the affected joint (Jouanny, 1994).
Gout, with great fear of being touched or struck by persons coming near
him (Allen, 2001).
33
Fear from being approached in gout (Farrington, 1995).
Generally feels bruised or sore all over as if suffering from multiple
blows and knocks. Moreover the bruised sensation is accompanied by
great exhaustion and weariness (Burt, 1995).
Restless patients must keep changing position. The soreness is improved
in a new position (Boyd, 1989).
Rheumatic pain in the foot with a slight fever toward the evening
(Hahnemann, 1996).
Indescribable pain in the affected foot, as from internal uneasiness, and
as if he were lying on something hard, which compels him to lay the part
here and there and to move it about, in the evening (Hahnemann, 1996).
With fever the head feels hot when the body is cold, with great thirst
during the chill and the heat (Burt, 1995).
Discharge of a large quantity of urine, which he cannot retain especially
at night (Hahnemann, 1996).
Arnica montana patients are quarrelsome, up against the whole world.
He wants to know better than everybody and no one can take him up, is
disdainful and imperious (Gibson, 1987).
Says there is nothing the matter with him (Allen, 2001).
4.2.2 Follow up cases
Day 1: Slight to no improvement of joint symptoms occurred. On examination the
joint was blue, hot, tender with wince and withdrawal and inflamed with complete
loss of joint contours. There was numbness with loss of pain and light touch
sensation. She complained of an unbearable bruised pain on moving the joint and
on touching the affected area. She was unable to walk or put pressure on the
affected area. Sleep, energy levels and muscle pain improved. Her fever reduced
to 36.4°C and she was not as thirsty as before. Mentally she became more
irritated. Her medication and dosage continued.
Day 3: Joint improvement of < 50% had occurred. On examination the joint was
pale, warm, tender with a wince and inflamed with some loss of joint contours.
The joint was able to flex and extend with pain on touch and movement. The
34
patient could not walk or apply pressure on the affected area. The right unaffected
foot was also numb with loss of pain and light touch sensation, suggesting that
this was a symptom of diabetes mellitus and not due to gout. Subjective
improvement of energy, sleep, muscle ache occurred. Medication and dosage
continued until better.
Day 6: Joint improvement of > 50% was observed. Joint colour, pain,
temperature, tenderness, inflammation, modalities and mobility had improved.
On examination the joint was pink, warm, with no tenderness and inflammation.
No change in numbness occurred. The patient was able to flex and extend the
joint with no pain. She could walk short distances with a slight pain on walking.
Other symptoms such as energy levels, sleep, perspiration and bodyache resolved.
SUA showed a slight decrease of 0.02mmol/L since day 0.
Day 15: The patient complained that even though her pain and swelling was gone,
she could not move the affected joint as well as all the others. She felt tired and
had a light sleep. Her muscle aches resolved. A 90% resolution of all her
symptoms with no relapses had taken place.
4.2.3 Discussion
Patient B had complications of diabetes mellitus and hypertension. It was
important to distinguish her acute symptoms from her chronic symptoms.
Symptoms such as polyuria, polydypsia, paresthesia, craves sugar and diarrhoea
were common symptoms of diabetes mellitus and not taken into account. Her
slow reaction to medication could have been due to her complications of diabetes
and hypertension. Arnica montana produced a > 50% improvement by day 6 and
90% improvement by day 15. The patient's uric acid remained above 0.35mmol/L
on day 0 and day 6 indicating that she has hyperuricemia. Diuretic therapy and
anti-hypertensive medication could be the cause of her hyperuricemia.
35
4.2.4 Subjective improvement as a percentage from day 0 to day 6 occurred as follows:
Day 0 1 2 3 4 5 6
Joint pain 0% 10% 30% 50% 80% 80% 90%
Joint swelling 0% 20% 30% 50% 90% 90% 100%
Joint discoloration 0% 20% 30% 70% 80% 90% 90%
Sleep affected 0% 30% 60% 80% 80% 100% 100%
Level of activity 0% 30% 50% 70% 90% 100% 100%
Overall
Improvement
0% 20% 30% 50% 70% 90% 90%
4.2.5 Objective improvement on day 0, 1, 3, 6 and 15 occurred as follows
Day 0 1 3 6 15
a) Joint improvement 4 3 2 1 1
b) Severity of swelling 3 2 1 0 0
c) Degree of tenderness 3 3 2 0 0
4.2.6 Change in SUA on day 0 and Day 6
Day 0 6
SUA 0.4mmol/ L 0.38mmol/ L
Normal values: < 0.42 mmol/L in males
< 0.35 mmol/L in females
36
4.3. Patient C
This 31-year-old white male entrepreneur is 1.64m in height and 83 kg in weight.
He has a family history of gout, drinks socially once in two months and eats red
meat several times during the week. His gout started in 2001 and he already
experienced three gout attacks, two of which were in the same year. Only the first
metatarsophalangeal joint had been affected. Consumption of red meat and
alcohol at a barbeque the night before triggered his gout attack. The next morning
his toe was too painful to move or touch, so he screamed for his wife. She helped
him soak his feet in ice water, which provided temporary relief. He complained of
a tearing pain in the right metatarsophalangeal joint, which felt stiff The pain was
worse for touch, any motion, and thinking about it. It was better for soaking it in
cold water or ice packs and when bandaged tightly to prevent slight movement
and increase pressure. Temporary relieve was found keeping the joint still and
pain returned in a short while. On examination the affected foot was bandaged
with no socks and shoes. The patient complained of pain while removing
bandages. The joint was red, hot, oedematous and tender with wince and
withdrawal. No perspiration and numbness were found. The joint was immobile
due to pain, with an inability to flex and extend the affected joint. The patient
walked with the help of crutches to avoid the affected foot touching the floor.
Other symptoms occurring with the gout attack were: a pounding toxic headache
from the alcohol, worse for alcohol, moving his eyes and talking too fast and
better for pressing the temples. A change in temperament occurred he became
angry, irritated and restless because his work involved driving, which he could not
do. He felt hot but not feverish, and perspired over his whole body, his clothes got
damp. His temperature was 38°C. He felt hungry but could not eat. He had no
thirst and normally drinks 8 glasses of water daily. He had an urge to urinate this
morning but was only successful later after drinking water. ,SUA was 0.32mmol/L
and he was not hyperuricemic.
37
4.3.1 Homoeopathic treatment
Bryonia alba 30CH was prescribed three times a day until better. The following
symptoms of Bryonia alba from different materia medica's match the symptoms
described by Patient C:
It is indicated for acute gouty arthritis (Jouanny, 1994 and Khaneja,
2001).
The action of Bryonia alba upon the serous and fibrous tissue, shown by
the stitching tearing pains, makes this one of the important remedies in
arthritis (Burt, 1995).
+It's action upon the joints shows it to be still more appropriate to
articular arthritis (Burt, 1995).
The joints are swollen, hot, red (Boericke, 1998), < motion (Burnett,
1998), < touch (Vermeulen, 1997), > pressure because it keeps the
affected part still (Tyler, 1998), > rest (Jouanny, 1994).
Symptoms tend to be right sided (Gibson, 1987).
Causation: alcohol (Vermeulen, 1997).
Headache as if it would burst open, greatly aggravated by motion,
opening the eyes, relieved by pressure and closing the eyes (Burt, 1995).
The typical Bryonia alba personality is the businessman, without much
imagination but with "calculation", a dry fellow, sober, reliable,
methodical, concerned with everything he does with safety, stability,
security. Lacking a safe bases for his economic existence he becomes
irritable, angry, anxious and depressed. In illness the individual
characteristics are often exaggerated, so it is not surprising that the
Bryonia alba patient is anxious both about his condition and current
affairs. He becomes irritable, morose, angry if crossed, his poise and
sense of stability being upset (Gibson, 1987).
Sweat is easy and profuse, over the whole trunk and head, but not on parts
affected, in the rheumatic attack (Vermeulen, 1997).
38
4.3.2 Follow up cases
Day 1: Less than 50% improvement in the patient's gout pain, temperature,
tenderness, inflammation and modalities occurred. On examination the joint was
red, less hot than day 0, tender with wince and withdrawal, inflamed with a
reduction of fluid although contours were not visible. The joint became numb
with a loss of light touch and pain sensation. Joint pain was bearable on touch.
The joint was incapable of flexion and extension and the patient could not walk
without crutches. Sleep, energy, fever, perspiration, headache, bowel movements
and neck tension had improved. His temperature was 37°C He felt calmer and
stopped worrying about work. A change in urinary symptoms occurred. Urine
previously clear in colour was passed yellow even though he drinks lots of water.
His headache got worse after the first dose of medication, and disappeared after
half an hour. After a bowel movement he gained his appetite. His medication and
dosage continued.
Day 3: A 50% subjective improvement occurred. On examination the joint was
light red, warm, tender, swollen with complete loss of joint contours and not
numb. Extension and flexion of the toe without pain was accomplished. Patient
complained of pain and inability to walk on his foot. Other accompanying
symptoms had also improved. He felt calmer and made alternatives to get his
work done. His sleep was restful. The colour of his urine changed to light yellow.
He did not experience another headache. He had no thirst but continues to drink 2
liters of water daily. His appetite was normal. Overall the patient was improving
and continued medication.
Day 6: Improvement of >50% occurred. On examination the joint was pink, cool,
with no inflammation, no tenderness and no numbness. The patient was able to
drive and walk with a slight pain. He was not angry or irritable and felt more
controlled and focused. His sleep patterns, urination, appetite, thirst and bowel
movements were normal. SUA was normal on day 0 with no hyperuricemia and
increased on day 6 by 0.02mmol/ L (no hyperuricemia).
Day 15: Total resolution of acute gout symptoms with no relapses occurred.
Mentally the patient felt that even though he was stressed he was able to cope
with work better than before and was able to accomplish more.
39
4.3.3 Discussion
Although Bryonia alba tends to be better for warm application in joint pain
(Jouanny, 1994) it is also known that cold ameliorates in general (Schroyens,
1997). Even though a key symptom of Bryonia alba is thirst (Vermeulen, 1997),
Bryonia alba can also be thirstless (Schroyens, 1997). The change in urine from
clear on day 0 to yellow on day 6 could have been due to something the patient
ate or it could have been an elimination of toxins. His headache could have been
the reappearance of an old suppressed headache or a new symptom or caused by
the elimination of toxins. Dietary habits were not questioned during follow up
cases and the increase of SUA by 0.02mmol/ L could have been caused by
consumption of purine rich foods. Progress was slow, improvement of > 50%
objective and 90% subjective improvement of joint symptoms occurred by day 6.
Bryonia alba was one of the similar remedies that fitted this patient picture, other
remedies that could have been considered are Nux vomica and Ledum palustre.
40
4.3.4 Subjective improvement as a percentage from day 0 to day 6 occurred
as follows:
Day 0 1 2 3 4 5 6
Joint pain 0% 20% 30% 50% 50% 70% 90%
Joint swelling 0% 20% 30% 50% 50% 60% 90%
Joint discoloration 0% 20% 40% 60% 80% 90% 100%
Sleep affected 30% 50% 60% 100% 80% 90% 100%
Level of activity 0% 0% 30% 50% 50% 80% 90%
Overall
Improvement
0% 20% 30% 50% 70% 90% 90%
4.3.5 Objective improvement on day 0, 1, 3, 6 and 15 occurred as follows
Day 0 1 3 6 15
a) Joint improvement 4 2 2 1
b) Severity of swelling 3 2 2 0 0
c) Degree of tenderness 3 3 1 0 0
4.3.6 Change in SUA on day 0 and day 6
Day 0 6
SUA 0.32 mmol/ L 0.34 mmolJ L
Normal values: < 0.42 mmol/L in males
< 0.35 mmol/L in females
41
4.4. Patient D
This 66-year-old Indian salesman, height 1.73m, weight 57 kg, had a car accident
in 1991 and suffers from back problems ever since. He lost both parents in a car
accident at the age of sixteen. He uses Arthrexin and deep heat for joint pain and
cannot afford other medication. When he gets home he drinks brandy and later has
a nightcap to sleep. For lunch he eats takeaway meat specials and for supper red
or white meat or fish with rice. His gout started twenty years ago. He did not
know how many gout attacks he gets every year. Gout has previously affected his
shoulders, fingers, toes and knees. His gout attack started the night before when a
cold draft kept him awake and caused his feet to cramp. His right first
metatarsophalangeal joint was affected, with a burning, tearing pain worse for
stretching his toes and worse thinking about the pain. The joint felt better when
covered by a blanket. On examination his joint was red, warm, tender with a
wince response, swollen with complete loss of joint contours and numb with loss
of light touch. Other important findings were tophi on his finger joint and
contraction of the toes on his affected foot. The patient was very restless, and
movement did not relieve the pain. He had no fever with a temperature of 36 °C,
no thirst and did not feel like eating. Generally he enjoys salty and spicy food.
The typology of the patient is very weak. He walks with crutches on a daily bases
and can not do with out them. He is unable to lift heavy parcels and complains
that all his joints are sore and stiff with neck and back pain. He has urinary
incontinence especially at night since last year, loss of smell, hearing and vision
difficulty. Mentally he feels lonely at home and better working around people.
SUA was 0.53mmol/L and he had hyperuricemia.
4.4.1 Homoeopathic treatment
Causticum 30CH was prescribed three times daily until better. The following
symptoms of Causticum from different materia medica's match the symptoms
described by Patient D:
• It is a remedy of paralysis and contractures. It affects the muscular and
fibrous tissues. Indicated in arthritis where there is contracture of the
42
tendons, drawing pain, restlessness < night, < dry cold, > warm wet
(Boyd, 1989).
Gouty tearing in small joints of foot and swelling of parts (Vermeulen,
1997).
Worn out from work and suffer from stiff joints (Jouanny, 1984).
< thinking about symptoms (Jouanny, 1984 and Tyler 1998).
> warmth especially heat of bed (Vermeulen, 1997).
Pain and shriveling of joints, which become tightened up and
ankylosed (Tyler, 1998).
Must move constantly but motion doesn't relieve (Allen, 2001).
Rheumatic affections, with contraction of the flexors and stiffness of
the joints; tension and shortening of the muscles (Allen, 2001).
The sufferer looks weary, weak and wasted. Symptoms develop slowly
and progressively, with an accompanying deterioration and increasing
weakness (Gibson, 1987).
Paralysis; of single parts e.g., vocal cords, eyelids, face, extremities,
bladder, generally right side (Allen, 2001).
Weakness of bladder sphincter, urine passes involuntarily (Allen,
1994).
Causticum picture may be derived from sudden emotional stress, or
long lasting grief or worry (Gibson, 1987 and Allen, 2001).
4.4.2 Follow up cases
Day 1: The toes on the affected foot that were immobile on day 0 were able to
flex with a wince but could not extend. Slight to no improvement of gout
symptoms had taken place. The first metatarsophalangeal joint could not be flexed
or extended. On examination joint colour, temperature, tenderness, inflammation
and numbness remained the same as day 0. He continued the medication
administered.
Day 3: The toes of the affected foot relaxed and were capable of flexion and
extension with no pain. Gout pain and discoloration improved by < 50%. Slight to
43
no change occurred in other gout symptoms. On examination the joint was
maroon, hot, tender with a wince and inflamed with complete loss of joint
contours. Numbness improved with loss of light touch sensation. Pain reduced
although joint was incapable of flexion and extension. The patient could not stand,
walk or wear closed shoes. Tophi remained the same. Medication continued.
Day 6: > 50% improvement occurred. On examination the joint was pale, cool
with no tenderness, swelling or numbness. Pain occurred when the joint was
overexerted. The patient was able to flex and extend his joint voluntarily without
pain and walked normally on crutches. Crutches were used daily due to arthritis
not only because of gout. Mentally the patient felt good, general joint and body
aches improved. SUA reduced by 0.09mmol/L.
Day 15: Total resolution with no relapses. Tophi did not undergo change or
improvement.
4.4.3 Discussion
Patient D reacted slowly to the medication; this could have been due to his gout
being chronic or because of his weak defense mechanism.
44
4.4.4 Subjective improvement as a percentage from day 0 to day 6 occurred
as follows:
Day 0 1 2 3 4 5
Joint pain 30% 30% 40% 50% 70% 80% 80%
Joint swelling 30% 30% 30% 30% 50% 70% 80%
Joint discoloration 30% 30% 30% 30% 50% 80% 80%
Sleep affected 30% 30% 30% 30% 60% 60% 70%
Level of activity 0% 0% 0% 10% 50% 70% 80%
Overall
Improvement
0% 0% 30% 30% 50% 70% 80%
4.4.50bjective improvement on day 0, 1, 3, 6 and 15 occurred as follows
Day 0 1 3 6 15
a) Joint improvement 4 3 3 1 0
b) Severity of swelling 2 2 2 0 0
c) Degree of tenderness 2 2 2 0 0
4.4.6 Change in SUA on day 0 and day 6
Day 0
SUA 0.53 mmol/ L 0.44 mmol/ L
Normal values: < 0.42 mmol/L in males
< 0.35 mmol/L in females
45
4.5 Patient E
This 59-year-old Indian lady sells vegetables for a living. She is 1.64m in height
and 91kg in weight suffering from gout, anaemia and low blood pressure. She has
a family history of gout, is allergic to fish and takes vitamin B, folic acid and iron
tablets daily. She eats red or white meat for breakfast, lunch and supper and feels
weak without it. She does not consume alcohol. Her gout began 5 years ago, she
knew she would inherit it from her mom but did not take dietary precautions to
avoid it. She was treated with a Voltaren injection after her first attack. Only her
first metatarsophalangeal joint has been affected since then and she gets one
attack per year. Her present attack was triggered after walking long distances
selling vegetables in the rain. After work her feet felt sore and heavy as if
sprained, she soaked it in cold water, which did not help. She was restless and
tossed and turned the whole night; her fever broke and her right first
metatarsophalangeal joint began to pain. On examination her joint was dark red,
hot, tender with wince and withdrawal, swollen with complete loss of joint
contours and numb with loss of pain and light touch sensation. The right heel, sole
and digits of her foot were sore. The pain radiated to her whole foot, which felt
bruised and stiff. Her pain was better for stretching the joint and moving slowly.
Keeping busy took her mind off the pain. It was worse when tired, at rest, sitting,
rising to walk, lying down and at night. The patient winced on initial movement
during flexion and extension of the affected joint. Pain reduced on continuous
rotation of the joint. The patient was able to limp slowly on the affected joint but
complained of pain on standing or sitting too long, her temperature was 39°C.
She complained of symptoms related to an acute respiratory infection such as
fatigue, restless, insomnia, pyrexia, bodyache, dull headache, rhinitis, earache,
tight chest, dry cough and red dry throat with a dry tongue. That morning she did
not feel like eating even though she was hungry and very thirsty. Drinking water
did not ameliorate her thirst or sore throat. Her urination is usually dark and
scanty. Mentally she was restless; could not sit still and anxious about getting
back to work. She had hyperuricemia with SUA of 0.4mmol/L.
46
4.5.1 Homoeopathic treatment
Rhus toxicodendron 30CH was prescribed three times daily until better. The
following symptoms of Rhus toxicodendron from different materia medica's
match the symptoms described by Patient E:
Rhus toxicodendron is administered to acute gout patients when there is a
dark red swelling of joint (Jouanny et. al., 1994). The sensation is of a
painful articular stiffness, which is relieved by motion, the pain persists
when the patient begins to move and then fades away. Pain reappears
when patient is tired. The pain is aggravated by humidity. These
symptoms may occur during an attack of rheumatism or after violent
exercise (Jouanny et. al., 1984).
The attack can be caused by bad effects of getting wet (Allen, 2001).
Feet painful as if sprained (Vermeulen, 1997 and Burt, 1995).
Heaviness of lower limbs feel bruised (Vermeulen, 1997).
< night (Allen, 2001).
Great restlessness, anxiety and apprehension, cannot remain in bed, must
change position (Allen, 2001).
Fever with stiff joints (Burt, 1995).
Intermittent fever with chill, dry cough and restlessness (Vermeulen,
1997).
< cold, wet rainy weather (Morrison, 1998).
< sitting (Morrison, 1998).
< rest (Allen, 2001).
< first motion (Vermeulen, 1997).
continued motion (Morrison, 1998 and Allen, 2001).
change in position (Allen, 2001).
> moving affected parts (Allen, 2001).
Dullness in the head (Hahnemann, 1996).
Hungry without appetite (Hahnemann, 1996).
Great thirst (Burt, 1995).
Dry tongue (Jouanny, 1984).
47
Throat red, dry (Vermeulen, 1387).
Nose: nasal mucus runs in profusion involuntarily out of nose
(Hahnemann,1996), severe sneezing (Hahnemann, 1996).
Earache (Hahnemann, 1996).
Tension in chest and shortness of breath (Vermeulen, 1997).
Dark urine (Vermeulen, 1997).
Influenza (Jouanny, 1984).
4.5.2 Follow up cases
Day 1: Rhus toxicodendron produced a 30% subjective improvement and no
objective improvement in gout symptoms. On examination the joint was sore not
bruised compared to day 0, warm and tender with a wince. No change in colour,
swelling, numbness and mobility occurred. Accompanying symptoms of sleep,
energy, fever, body ache, appetite and respiratory symptoms improved. The
patient was able to sit still with out feeling restless. Medication and dosage
continued three times daily.
Day 3: No marked change was shown from day 1 compared to day 3.
Improvement of < 50% took place. Subjective assessment of pain increased by
10%. On examination no change in colour, swelling, tenderness, numbness,
mobility and modalities took place. The patient returned to work and continued to
worsen symptoms by walking on the affected foot. Medication and dosage
continued.
Day 6: The patient's joint pain, colour, temperature, tenderness, and joint
mobility worsened. On examination the joint was dark red, hot and tender with
wince and withdrawal. Numbness and swelling remained the same. Pain on initial
flexion and extension had increased and felt bruised since day 3. Continued
motion relieved the joint pain Pain on rest returned. Walking relieved the pain,
but over exertion produced pain. Other symptoms such as muscle ache, energy,
sleep and restlessness also worsened. Medication and dosage continued. SUA
reduced by 0.05mmo1/L.
Day 15: Total resolution of symptoms subjectively occurred by day 10 with no
relapses.
48
4.5.3 Discussion
"Bedrest is an important treatment and should be continued for 24 hours after the
acute attack has been resolved". This patient failed to see the importance of
resting the joint and therefore had a slow response to the medication and self
induced an aggravation by walking on the joint.
The symptoms mentioned above show that Rhus toxicodendron has similar
symptoms to the patient although one of the key symptoms of Rhus toxicodendron
is > warmth (Allen, 2001) and < cold (Allen, 2001) and patient E said that "cold
application did not help" but did not say that cold application worsened
symptoms. Most of the patient's joint symptoms were similar to Rhus
toxicodendron except this symptom. The researcher failed to ask about warm
application and therefore there is a possibility that a similar remedy but not the
most similar remedy was prescribed.
A gradual joint improvement was taking place from day 0 to day 3 and symptoms
aggravated on day 6. The short amelioration of symptoms followed by an
aggravation could indicate that the remedy was only palliative and was incorrectly
prescribed. Pulsatilla pratenis was a remedy that came up second during
repertorization and could have been considered.
49
4.5.4 Subjective improvement as a percentage from day 0 to day 6 occurred
as follows:
Day 0 1 2 3 4 5 6
Joint pain 0% 30% 40% 50% 30% 30% 40%
Joint swelling 10% 10% 20% 20% 10% 20% 30%
Joint discoloration 10% 10% 20% 20% 20% 20% 30%
Sleep affected 0% 80% 50% 70% 60% 50% 50%
Level of activity 50% 50% 40% 50% 30% 40% 40%
Overall
Improvement
0% 30% 40% 40% 30% 40% 40%
4.5.5 Objective improvement on day 0, 1, 3, 6 and 15 occurred as follows
Day 0 1 3 6 15
a) Joint improvement 4 3 2 4 0
b) Severity of swelling 2 2 2 2 0
c) Degree of tenderness 3 2 2 3 0
4.5.6 Change in SUA on day 0 and day 6
Day 0 6
SUA 0.4 mmol/ L 0.35 mmol/ L
Normal values: < 0.42 mmol/L in males
< 0.35 mmol/L in females
50
4.6 Patient F
A 42-year-old white male, manages a clothing store. He weighs 98 kg and is 1,7m
in height. He has a medical history of stomach ulcers, irritable bowel syndrome,
depression and gout. The medication he takes is: Colchicum, Brufen, Arthrexin
or any anti inflammatory medication from a chemist for his gout, St John's wort
for depression, panado for headaches and cimetidine for stomach ulcers. He
consumes; 3-6 beers at night while watching television, hot shots daily, whisky as
a nightcap, wine with supper and does not keep count on weekends because he
can handle alcohol. He lives alone and eats takeaways. Some of the food he eats
is chicken livers, steak, kidneys and sardines. His first gout attack started five
years ago due to excessive drinking and mixing with bad company. He was told
to avoid alcohol and red meat but instead learn't to get use to the gout pain. His
first metatarsophalangeal joint is usually affected two to three times a year. His
present complaint was triggered from drinking alcohol at a nightclub two days
ago. He woke up groggy, with a heavy head and a throbbing, tearing pain in the
base of the right toe. The joint pain was worse for motion, touch, heat and night
and better for ice-cold application and rest. The patient wore sandals with the
strap away from the affected joint avoiding touch. The affected foot had no sock.
He limped to avoid pressure on his affected joint. The presence of a tophus on his
first metatarsophalangeal joint was observed. On examination the joint was pale
and hot to touch compared to his cold feet. His joint was oedematous, numb with
loss of pain and light touch sensation and tender with wince and withdrawal on
touch. The joint was stiff and incapable of flexion and extension. His energy
levels were low, he became hot and cold and had a temperature of 36°C. He was
dressed warmly with layers of clothes and looked chilly. He had a headache two
days ago with the gout attack and was not experiencing one at the present time.
His head felt heavy, he could not lift it of the pillow and pressure ameliorated the
headache. He gets dizzy on rising from sitting. He eats according to his hunger
sometimes three times a day and other times a toast for the entire day. He gets
thirsty and craves cold beer's especially after work. He hates water and will not
drink it. He likes to be alone because he feels that people are judgmental,
51
superficial and always gossiping. He often wishes his life was different and
drinking makes him forget. He had hyperuricemia with SUA of 0.61 mmol/L.
4.6.1 Homoeopathic treatment
Ledum palustre 30CH was prescribed three times a day until better. The following
symptoms of Ledum palustre from different materia medica's match the
symptoms described by patient F:
Rose (1999) and Allen (2001) state that Ledum palustre is a very useful
remedy in the treatment of acute gout. It is prescribed when the ball of the
big toe becomes swollen, sore and painful on walking. The pain is worse
from warmth, pressure and motion. Gouty nodules may develop in the
joints affected. Because Ledum is such a cold remedy, the patient is
continually chilly It is said that this remedy is given if colchicum has been
given allopathically on several previous occasions.
Jouanny (1984) prescribes Ledum palustre for acute gout when the joint is
swollen, hot to touch and pale. Pain is worse at night and by the warmth of
the bed and is improved by cold applications and rest.
Joints are very stiff, can only be moved after bathing with cold water;
there is a desire to put feet in ice cold water (Gibson, 1987).
The remedy is indicated in patients who have a history of alcohol abuse
(Moiloa, 2001).
Bad effects from alcoholic drinkers (Vermeulen, 1997).
Pains are tearing and throbbing (Allen, 2001).
4.6.2 Follow up cases
Day 1: No objective improvement had taken place. On examination the joint was
pale, hot, tender with wince and withdrawal, oedematous and numb with loss of
light touch and pain sensation. The pain was worse on flexion and extension of
the joint compared to day 0. The patient could not-stand or walk without limping.
His body felt sore and heavy worse than day 1. He woke up with a headache that
left within 10 minutes. His temperature was 37°C. Subjective improvement of
sleep and level of activity by 10% occurred. The patient did not crave alcohol but
52
continued to drink it His mind felt clear. Medication and dosage continued three
times daily.
Day 3: Objective improvement of >50% occurred. There had been a change in
gout pain, temperature, tenderness, inflammation, numbness, modalities and
mobility. On examination the joint was pale, warm, tender, swollen with some
loss of joint contours and not numb. The joint was not stiff and capable of flexion
and extension with slight pain. The patient was able to stand but continued to limp
when walking. Touching the joint was bearable and the patient was wearing shoes
and socks on both feet. Bodyaches resolved. He became thirsty, drank cool drinks
and felt more energetic. Mentally he seemed indifferent toward life and said that
he was neither happy nor depressed and took each day as it came. Medication and
dosage continued.
Day 6: Total resolution of gout pain, temperature, tenderness, inflammation,
numbness, modalities and mobility had occurred. His energy was better than
normal. The patient admitted that he had an alcohol addiction and was asked to
attend counseling. SUA reduced by llmmol/L.
Day 15: Total resolution with no relapses. A favorable change in diet occurred;
the patient's appetite increased, he began to eat more food and drank fruit juice.
He did not seek counseling for alcohol addiction.
4.6.3 Discussion
Although joint symptoms showed no change on day 1, a dramatic subjective and
objective improvement of > 50% occurred on day 3 with total resolution of
symptoms on day 6. This favorable improvement indicates that Ledum palustre
was correctly prescribed.
53
4.6.4 Subjective improvement as a percentage from day 0 to day 6 occurred
as follows:
Day 0 1 2 3 4 5 6
Joint pain 0% 0% 0% 50% 50% 80% 100%
Joint swelling 0% 0% 0% 50% 50% 80% 100%
Joint discoloration 0% 0% 20% 60% 70% 100% 100%
Sleep affected 20% 20% 40% 70% 100% 90% 100%
Level of activity 20% 10% 30% 60% 70% 80% 100%
Overall
Improvement
0% 0% 30% 50% 50% 70% 80%
4.6.5 Objective improvement on day 0, 1, 3, 6 and 15 occurred as follows
Day 0 1 3 6 15
Joint improvement 4 3 1 0
Severity of swelling 3 3 1 0 0
Degree of tenderness 3 3 1 0
4.6.6 Change in SUA on day 0 and day 6
Day 0 6
SUA 0.61 mmol/ L 0.50 mmol/ L
ormal values: < 0.42 mmol/L in males
< 0.35 mmol/L in females
54
4.7 Patient G
This is a 42-year-old Black male who delivers furniture as an occupation. He is
1,79m tall and 75 kg in weight. He has a past medical history of sinusitis and
backache. His mother suffers from high blood pressure and father has gout. He
consumes alcohol on weekends about 12 beers, and does not drink during the
week. He only eats red meat and does not enjoy eating white meat. His first gout
attack started in 1998, after his brother's funeral. He had one or two attacks every
year since then affecting his ankle, big toe or knee. His complaint began two days
ago with a back pain so bad he was bedridden. He got worse during the day with a
fever and had painful joints in the leg. Joint pain started in his left ankle first, to
which he applied rough salt with hot water, the pain in his ankle subsided but
began in his left big toe the day after to which he applied a traditional remedy
Mtlabelo. The gout then radiated to his left knee and the pain in his big toe
subsided. He described the pain in his knee (index joint) as burning, stitching,
cutting, tearing, shooting and pressing with a sensation as if somebody hit his
legs. The joint pain was worse when standing, sitting, walking, and applying
pressure. He did not know what made the pain better. On examination the joint
was red, cold, oedematous and tender with wince and withdrawal. The patient
complained of pain on rising from sitting, he could not walk or stand due to joint
stiffness not pain on pressure. The knee was unable to bend/ flex. He limped on
his right leg and dragged his left leg. Surrounding areas affected were the ankle
and sole. The patient complained of pain in his heel when standing and therefore
required the use of crutches. His back pain was worse for motion, walking and
touching the painful area. Left kidney tenderness and pain on fist percussion was
found. He had insomnia and fatigue. He felt feverish the day before and took a
panado, which reduced the fever. His temperature was 37°C. He usually perspires
a lot, everywhere, anytime. He had a problem emptying his bladder completely.
He described his urine as hot, thick, light in colour and smelt like "sulfur" with a
burning pain radiating from the groin down the legs. He urinated tiny particles he
called "sout" (salt). He lost his appetite and did not want food. He was thirsty, but
avoided drinking to prevent dysuria. He had hyperuricemia and his SUA was
0. 5 9mmol/L.
55
4.7.1 Homoeopathic treatment
Berberis vulgaris 30CH was prescribed 3 times daily until better. The following
symptoms of Berberis vulgaris from different materia medica's match the
symptoms described by patient G:
Rheumatic and gouty complaints, with diseases of the urinary organs
(Allen, 2001).
Acute pain moves from joint to joint; now worse here and now there.
Sudden twitches of pain; stitching pain, < motion and < pressure, any
location (Morrison, 1998).
Tearing, burning joint pain (Farrington, 1995).
Burning, stinging, tearing, pressing joint pain, < stretching leg
(Vermeulen, 1997).
All Berberis vulgaris joint pains radiate (Boericke, 1998).
Intense lameness and weariness of legs after walking a short distance.
Lower legs as if beaten and heaviness, can scarcely rise from a seat
(Vermeulen, 1997).
Renal colic, < left side (Allen, 2001).
Cold feeling in feet as if frozen (Vermeulen, 1997).
Pain in the balls of the heels on standing (Vermeulen, 1997).
Burning pain in urethra, < when passing urine and after stream has
finished, pain radiates. Pale yellow urine with transparent, gelatinous
sediment, which floats in the urine, (Blackie, 1990). Urine thick, turbid,
yellow with sandy or slimy sediment (Vermeulen, 1997).
Acute pain in renal angle worse deep pressure (Blackie, 1990).
Pain in small of back, very sensitive to touch in renal region; < when
sitting and lying, jarring, fatigue. Burning and soreness in region of
kidneys. Numbness, stiffness and lameness with pain in renal and lumbar
regions. Stitching, cutting pain from left kidney following course of ureter
into bladder and urethra (Allen, 2001).
Everything excites sweating (Vermeulen, 1997).
Appetite either increased or decreased (Vermeulen, 1997).
56
• Great thirst, aversion to drink (Vermeulen, 1997).
4.7.2 Follow up cases
Day 1:
On examination there was slight to no change of the knee joint. It was bright red,
cold, tender with wince and withdrawal, swollen with some loss of joint contours
and numb with loss of light touch. The patient could not flex or extend the joint.
He was unable to walk or stand. Pain in the heel persisted. The fever reduced but
he was very tired and sleepy. He was thirsty but did not drink water because of the
pain experienced during urination. Back pain reduced although pain during
urination increased. There was an increase in small sandy particles passed in the
urine. His urine was burning, hot and worse than day 1. The patient was advised
to drink more water to facilitate the elimination of toxins. Mentally the patient felt
incurable. Medication and dosage continued.
Day 3: < 50% improvement took place subjectively and objectively. On
examination the joint was red, cold, tender, swollen with complete loss of joint
contours, with pain on motion. The knee joint was able to flex and extend with
pain, but the patient could not stand or walk. The patient increased his intake of
water and drank 5-6 glasses on day 2. There was no change in renal pain or
tenderness objectively although subjectively the patient felt an improvement in
back pain. Urinary symptoms improved; urine was profuse with no burning and
contained small particles. Mentally he felt the medication cleansed his kidneys.
The patient improved in energy, and sleep.
Day 6: Total resolution of symptoms with no pain, swelling, tenderness and
discoloration. Mobility of joint was normal with ability to flex, extend, sit and
walk normally. Energy improved, he felt brand new. Urine did not burn, but was
profuse with a reduction of particles passed. SUA decreased by 0.19 mmol/L.
Day 15: Total resolution of symptoms in all joints affected with no relapses. Urine
passed was yellow, not burning, with no particles. No renal angle tenderness or
pain.
57
4.7.3 Discussion
An aggravation of urinary symptoms occurred indicating that toxins were being
eliminated. These particles could have been the presence of urate, the decrease of
SUA by 0.19mmol/L could confirm this statement. No aggravation of joint
symptoms occurred and the patient recovered steadily with total resolution by day
6 indicating that the remedy and potency chosen fitted the case.
4.7.4 Subjective improvement as a percentage from day 0 to day 6 occurred
as follows:
Day 0 1 2 3 4 5 6
Joint pain 20% 20% 30% 30% 50% 70% 100%
Joint swelling 10% 20% 30% 40% 50% 80% 100%
Joint discoloration 20% 20% 30% 30% 40% 80% 100%
Sleep affected 10% 0% 60% 70% 70% 50% 90%
Level of activity 10% 10% 30% 40% 50% 80% 100%
Overall
Improvement
0% 10% 30% 40% 50% 70% 100%
4.7.5 Objective improvement on clay 0, 1, 3, 6 and 15 occurred as follows
Day 0 1 3 6 15
a) Joint improvement 4 3 2 0 0
b) Severity of swelling 3 2 2 0 0
c) Degree of tenderness 3 3 1 0 0
4.7.6 Change in SUA on day 0 and day 6
Day 0 6
SUA 0.59 mmol/ L 0.40 mmol/ L
Normal values: < 0.42 mmol/L in males
< 0.35 mmol/L in females
58
4.8. Patient H
This 65 year old black retired male, height 1,65m, weight 80 kg, is hypertensive
and stopped taking medication a week ago because he did not fetch more from the
clinic. He drinks African beers (nkomboti), and eats red meat with no salt or
spices. His gout began in his early 30's, when he over indulged in drinking a lot of
beers and eating red meat. His doctor warned him to change his diet but at that
time he felt that if he stopped drinking his friends would have left him and he
would be bored every weekend. He takes Brufen for any joint pain and therefore
does not know how many attacks he gets per year. His says that his last attack was
two years ago. His first metatarsophalangeal joint, shoulder joint and knee joint
have already been affected during previous attacks. The present gout attack started
the day before during his afternoon sleep. He felt feverish and drank water but it
didn't help. He began to perspire on his face. When his daughter came home from
work, he complained that his shoulder was sore. In the evening he screamed
because his left first metatarsophalangeal joint (index joint) pained more, it was
unbearable. He had no medication at home and suffered throughout the night. The
next morning his left toe was dark red and hot with a burning, tearing, sore pain. It
was so painful he couldn't touch it. Joint symptoms were worse for movement,
cold, touch, pressure, evening and better for rest. On examination the joint was
dark red, hot, tender with wince and withdrawal, oedematous and not numb.
Movement was unbearable; the patient winced on approach to touching the
affected joint. The surrounding areas of the foot were cold. The patient used a
wheel chair to move around, he was unable to stand or put any pressure on the
affected joint and had no shoes on the affected foot. The patient felt weak and
tired and could not sleep on account of pain. His fever reduced as compared to the
night before. His temperature was 38.3°C. He complained that his body pains all
the time and that his joints and muscles are getting weaker. That morning his
urination was burning, dark and scanty. Normally he urinates frequently and
profusely. He was hungry but the smell of food made him "want to vomit". He
only drank milk and juice for energy. He had no thirst and craved sand. He is
usually constipated but noticed a loose stool that morning. His memory is failing
59
and it makes him sad because he depends on his daughter to do everything and
can't depend on himself. SUA was 0.47mmol/L indicating hyperuricemia.
4.8.1 Homoeopathic treatment
Colchicum autumanale 30CH was prescribed 3 times daily until better. The
following symptoms of Colchicum autumanale from different materia medica's
match the symptoms described by Patient H:
Colchicum autumnale 30CH is one of the conventional drugs used in the
treatment of an acute gout attack but it can also be used homoeopathically
if the symptoms match (Rose, 1999).
Colchicum autumnale fits into many conditions of gout but conventional
medicine does not tell us what kind of gout to give it in. It is merely a
medicine of experience (Tyler, 1998).
Agrawal (1997) administers Colchicum autumnale when the following
symptoms appear: gouty rheumatism, erratic pains, extremely painful,
worse at night and by movement. Gout attacking many joints, shifting
from one to another, with burning and tearing pains, worse from external
pressure, odors or touch. The joint becomes inflamed, dark red, hot and
intensely painful, urine acid, dark and scanty; smell of food nauseates,
urate diathesis. Gout in persons of vigorous constitutions. Gout associated
with gastric disturbances.
> rest, < cold (Vermeulen, 1997)
Arthritic pains in joints; patient screams with pain on touching a joint or
stubbing a toe (Allen, 2001).
GIT: smelling painfully acute; nausea and faintness from the odor of
cooking food (Allen, 2001). No thirst (Tyler, 1998).
Urine dark, scanty, burning or suppressed (Vermeulen 1997).
Energy: great weakness and exhaustion (Tyler, 1998)
Sleep: At night, disturbed sleep or driven away by pains. Sleeplessness
from restlessness of limbs.
Fever: intermittent and sensitive to odor of food (Vermeulen, 1997)
60
4.8.2 Follow up cases
Day 1: Patient improvement was < 50% in gout pain, tenderness, and
inflammation. On examination the joint was red, hot, tender with a wince, swollen
with complete loss of joint contours and not numb. The patient was able to touch
and bend the toe with less pain. The patient could not stand or walk on the
affected area. No pain was experienced extending the joint. Subjective
improvement in energy and sleep occurred. Urination was more profuse, dark and
not burning. The smell of food still made him ill. He was hungry and ate with his
nose closed. His fever reduced to 37°C. His blood pressure was 160mmHg/ 100
mmHg and he was advised to go to the clinic and continue with antihypertensive
medication. Medication continued three times daily.
Day 3: Patient showed > 50% objective improvement in joint symptoms. The
patient used crutches to walk and wore sandals on both feet. On examination the
joint was pink, warm, tender, swollen with some loss of joint contours and not
numb. The joint was able to flex and extend with no pain. Pain occurred on
walking. The patient felt energetic, had a good sleep and urinates normally with
no pain. He regained an appetite and was not affected by the smell of food.
Medication and dosage continued.
Day 6: Blood pressure improved to 150/ 80mm/Hg with total resolution of acute
gout symptoms. Urination was profuse, not burning and yellow. On examination
the joint was not swollen, tender, numb or painful. The patient wore socks and
shoes, and resumed walking normally without crutches. SUA decreased by
0.07rnmol/L and he was still hyperuricemic.
Day 15: Total resolution of gout symptoms with no relapses. His blood pressure
was 150/ 80mmHg.
4.8.3 Discussion
Patient H had a craving for sand, which was a strange, rare and peculiar symptom.
Colchicum autumnale does not crave sand but other remedies that do are Silica
and Tarentula hispanica, which may have been interesting remedies to pursue.
Improvement began to take place from day 1, with > 50 % improvement of joint
symptoms on day 3 and total resolution of symptoms by day 6. No aggravation of
61
symptoms occurred and the patient recovered steadily indicating that the remedy
and potency chosen fitted the case. The gradual improvement when compared to
other cases was due to his underlying pathology. His hyperuricemia could be
caused by taking anti-hypertensive medication.
4.8.4 Subjective improvement as a percentage from day 0 to day 6 occurred
as follows:
Day 0 1 2 3 4 5 6
Joint pain 0% 10% 20% 20% 40% 70% 100%
Joint swelling 0% 10% 20% 30% 40% 70% 100%
Joint discoloration 10% 30% 50% 50% 60% 100% 100%
Sleep affected 0% 70% 70% 70% 100% 100% 90%
Level of activity 0% 10% 50% 50% 50% 80% 100%
Overall
Improvement
0% 20% 30% 30% 50% 60% 90%
4.8.5 Objective improvement on day 0, 1, 3, 6 and 15 occurred as follows
Day 0 1 3 6 15
a) Joint improvement 4 2 1 0 0
b) Severity of swelling 3 2 1 0 0
c) Degree of tenderness 3 2 1 0 0
4.8.6 Change in SUA on day 0 and day 6
Day 0 6
SUA 0.47 mmol/ L 0.40 mmol/ L
Normal values: < 0.42 mmol/L in males
< 0.35 mmol/L in females
62
4.9 Patient I
This 32-year-old Indian male shopkeeper, 1,58m in height, weighing 83 kg is
allergic to Sulphur Dioxide and is on no present medication. He is a social drinker
that indulges on weekends. The alcoholic beverages he drinks are: breezers, beers,
tequila, cocktails, wines and shooters. He loves to try new drinks on the market
and feels his tolerance of alcohol is good because he does not get drunk quickly.
He is not health conscious and has an appetite for anything tasty. He eats red or
white meat for lunch and supper with no vegetables. Drinking too much alcohol
caused his gout. He has been through two acute gout attacks in his life, which
were treated with a Voltaren injection and Cataflam. He gets acute attacks once a
year. Only his first metatarsophalangeal joint had been previously affected. His
present attack happened suddenly with a burning fever. He had no sleep and
became chilly with the fever. He screamed from a sharp, tearing pain in his toe,
which was relieved temporarily with ice-cold application. The patient did not feel
well and suffered with an unbearable pain he described it as "the worst pain in his
life". He had a very high temperature of 40°C with hot burning skin and a
headache. He described his headache as "burning up" and "the throbbing gets
bigger and bigger as if it's going to burst". His head and body were wet with
perspiration. His right tarsal and first metatarsophalangeal joints (index) were
affected, with a "beating sensation in his toe, like a heartbeat". The pain was
worse for movement and touch, and better for cold application, pressure and rest.
On examination the joint was very bright red, very hot to touch, oedematous and
immobile with pain on least motion.
His joint was tender and he winced and withdrew his foot on approaching to touch
it. His joint was immobile and the slightest movement caused pain. His feet were
cold. He walked with the assistance of a stick. His ear felt blocked and full of
pressure. His energy levels were depleted. He noticed that he did not urinate that
morning and had no urge to go. He felt very hungry but not thirsty. He craved salt
and vinegar chips. He was in a lot of pain, felt ill, tired and restless. SUA was
0.33mmol/ L and he did not have hyperuricemia.
63
4.9.1 Homoeopathic treatment
Belladona atropa 30CH was prescribed every hour until better. The following
symptoms of Belladona atropa from different materia medica's match the
symptoms described by patient I:
The constitutional type is healthy, vital and robust. It is well known for it's
usefulness in acute disorders and febrile conditions. In all forms of
disorders, the conditions are congestive, intense and often characterized by
pain and throbbing or pulsation (Morrison, 1993).
Sudden, severe inflammation of the joints. Joint is swollen, red, and
exquisitely sensitive. < touch, < motion, > pressure, > cold. Location:
more often right side (Morrison, 1998).
Tearing in metatarsal joint of great toe (Allen, 1994).
At the affected site there is inflammation, bright redness, throbbing pain,
intense heat around the congested area with a burning feeling, which
almost seems to scald the examiners hand (Morrison, 1993 and Jouanny,
1984. Joint is tender (Rose, 1999).
Fever: Head hot and painful, face flushed, pulse full and bounding, sleepy
but can't sleep (Allen, 2001). Fever commencing at night, much chilliness,
followed by much heat, high temperature, intense burning heat. Generally
heat without thirst (Burt, 1996). The patient exudes hot perspiration
particularly noticeable on the face (Jouanny, 1984).
If headache is present, it is of the throbbing kind, patient is exhausted and
restless (Jouanny, 1984).
4.9.2 Follow up cases
Day 1: the fever reduced to 37.5° C. > 50% objective and 90% subjective
improvement of gout symptoms occurred. On examination the joint was pink and
warm with no swelling, tenderness or numbness. Range of motion was normal
with no pain and he was able to walk. Patient resumed normal activity, energy
levels improved and he did not feel sick or tired. Medication discontinued.
Day 3: Gout symptoms resolved completely with no change from day 1. No
medication was being taken.
64
Day 6: Relapse of gout symptoms occurred on day 5. The gout symptoms
experienced during the relapse were less serious than day 0. The patient continued
with medication and symptoms resolved within a short while. On examination
gout symptoms were resolved totally. The joint was pink and warm with no
swelling, tenderness or numbness. Range of motion was normal with no pain and
he was able to walk. No medication was necessary. SUA increased by
0. 05mmol/L.
Day 15: Total resolution of acute symptoms with no other relapses.
4.9.3 Discussion
Patient I had a very high fever and therefore symptoms of the fever took
precedence over the joint symptoms. Belladonna atropa was very indicated in this
patient's symptom picture especially because of the sudden, violent onset and
congestive fever. Aconitum napellus is also a remedy that could have fitted this
picture although Belladonna atropa is used in place of Aconitum napellus when
there is an onset of sweating (Jouanny, 1984). The dosage of Belladonna atropa
increased to every hour instead of three times a day compared to other cases
because of the seriousness of the fever. It was very important to bring the fever
down to prevent further complications. Joint symptoms of the patient also fitted
the Belladonna atropa joint picture and therefore a quick recovery of both fever
and joint symptoms had taken place. This case is a good indication of how the
homoeopathic remedy treats the patient as a whole system and does not localize
itself to only the fever symptoms or only the joint symptoms. It also shows that a
well-indicated similimum remedy acts fast and effectively. The relapse is seen in
homoeopathic terms as an indication that a repeat dose of the remedy is required.
The rapid response after the remedy was repeated is a clear indication that the
remedy chosen was the similimum. The slight increase of SUA by 0.05 mmol/L
could have been due to a diet high in purines during trial. The researcher
questioned the patients alcohol intake but failed to question diet. The patient did
not consume alcohol during the trial period.
65
4.9.4 Subjective improvement as a percentage from day 0 to day 6 occurred
as follows:
Day 0 1 2 3 4 5 6
Joint pain 0% 90% 100% 100% 100% 20% 100%
Joint swelling 0% 90% 100% 100% 100% 30% 100%
Joint discoloration 0% 100% 100% 100% 100% 40% 100%
Sleep affected 0% 70% 100% 90% 80% 40% 90%
Level of activity 0% 80% 100% 100% 100% 70% 100%
Overall
Improvement
0% 90% 100% 100% 100% 30% 100%
4.9.5 Objective improvement on day 0, 1, 3, 6 and 15 occurred as follows
Day 0 1 3 6 15
Joint improvement 4 1 1 0 0
Severity of swelling 3 0 0 0 0
Degree of tenderness 3 0 0 0 0
4.9.6 Change in SUA on day 0 and day 6
Day 0 6
SUA 0.33mmol/ L 0.38 mmol/ L
Normal values: < 0.42 mmol/L in males
< 0.35 mmol/L in females
66
4.10 Patient J
This 45 year old white male height 1.59m and weight 90 kg is a manager of a
bakery. He suffers with gout, anaemia, asthma and has renal stones. His gout is
hereditary. He loves to overindulge in food and alcohol. He drinks two beers daily
with lunch or supper, six beers on a weekend with other hot shots. He loves food
and has large servings during meal times. Two pork sausages, three eggs, six
slices of bread, tea and biscuits for breakfast, family meal take ways (steak and
spare ribs) for lunch, cakes and pastries during the day and two or three helpings
of whatever is on the table, usually red meat for supper. His gout was caused from
family history, diet and excessive alcohol. He was a rebel as a youngster and
started drinking in school. He continued drinking daily thereafter out of
enjoyment. His first gout attack started in his thirties. His big toe, knee, fingers
and shoulders have been affected in previous attacks. He has between one or two
attacks per year.
His present gout attack started two days ago, after walking in the rain his joints
felt cold and stiff and his feet got ice cold. He immediately had a hot bath and
wrapped himself in blankets. He had a restless sleep and broke out into a fever.
He was shocked in the morning when he woke up with gout because he didn't eat
any red meat for supper or drink more than his usual beer. His left knee was
affected with a stitching burning pain. The symptoms were worse for rainy
weather, night, lying down and movement and better for rest and sitting. He felt
the pain in his bone. He was weak and tired with no energy or strength to pick
himself up. His body felt lame and lifeless and he did not want to do anything. He
got tired walking up stairs to his room on the second floor. He couldn't sleep the
night before. He had no fever but sweats a lot under his arms. He was not feeling
hungry and did not want to eat red meat because it made his gout symptoms
worse. He was not thirsty and does not drink water. On examination the patient's
joint was dark red-purple, cold, tender with wince and withdrawal, oedematous
and numb with loss of light touch and pain sensation. The foot was covered in
cold profuse perspiration that had an offensive smell. The joint affected was able
to flex and extend with pain on motion. The patient had shoes and socks over the
affected joint. The patient was unable to walk due to the weakness of his joint and
67
not because of pain. He was able to bear the pain. Other noticeable symptoms
were obesity with lack of muscle strength, weak joints, renal pain on right side
and temperature of 38°C. His SUA was 0.56mmol/ L indicating hyperuricemia.
4.10.1 Homoeopathic treatment
Calcarea carbonica 30CH was prescribed three times daily until better. The
following symptoms of Calcarea carbonica from different materia medica's
match the symptoms described by patient J:
This remedy can be indicated for it's tendency to gout and renal lithiasis
(Jouanny, 1984).
Aversion to meat (Morrison, 1993)
Fat, flabby, lethargic, pale, slow walking, slow talking. Fatness without
fitness, sweating without heat, bones without strength. Tissues plus
quantity, minus quality'. Mentally and physically slow. (Blackie, 1990)
Chilly and generally worse for cold (Morrison, 1993).
General aggravation from cold wet weather (Morrison, 1993).
General aggravation from exertion (Morrison, 1993)
Knee joints cold (Schroyens, 1997)
Poor stamina (Morrison, 1993)
Perspiration and odor from feet (Vermeulen, 1997) and feet are cold
(Morrison, 1998)
Burning, swelling of knee, comes over night. (Vermeulen, 1997)
Rheumatic pains are sharp and stitching, and come on after exposure to
cold, wet weather (Khaneja, 2001).
Renal stones (Vermeulen, 1997)
4.10.2 Follow up cases
Day 1: objective improvement of < 50% occurred. On examination the joint was
dark red, cold, tender with wince and withdrawal, inflamed with complete loss of
joint contours, numb with loss of pain and light touch sensation. The patient
winced on flexion and extension of the joint. Joint pain was < movement > rest.
68
He felt as if his "toe was on fire". The joint felt stronger than day 0 but the pain
felt worse at night and he could not sleep. He felt a burning pain at the beginning
of urination, which reduced after urinating frequently. He drank three glasses of
water and was not thirsty. On day 0 he was not thirsty and drank no water. His
temperature reduced to 37° C. Medication continued.
Day 3: > 50 % subjective and objective improvement took place. Gout pain,
temperature, tenderness, inflammation, numbness, perspiration and modalities
improved. On examination the joint was light red, warm, tender, swollen with
some loss of joint contours, not numb. His urine was more profuse, burnt less and
he drank more water. He felt calmer than usual and stayed calm in a situation
where he would normally get worried. Medication and dosage continued.
Day 6: Total resolution of gout symptoms with no burning on urination. SUA
decreased by 0.14 mmol/L.
Day 15: Total resolution of gout symptoms.
4.10.3 Discussion
Blackie, 1990 sums up the typology of a Calcarea carbonica patient " Fat, flabby,
lethargic, pale, slow walking, slow talking. Fatness without fitness, sweating
without heat, bones without strength. Tissues- plus quantity, minus quality.
Mentally and physically slow." Patient J's acute gout symptoms did not stand out
as clearly as his typology therefore both his typology and acute gout symptoms
were considered when choosing the most similar remedy. Most of the patients
acute gout symptoms fitted the symptom picture of Calcarea carbonica except the
purple discoloration of patient J's joint. Calcarea carbonica's joints are usually
red (Vermeulen, 1997).
An aggravation of physical symptoms on day 1 could have been due to the body
eliminating toxins. An aggravation of urinary symptoms occurred and a decrease
in serum uric acid by 0.14mmol/L confirms that toxins were eliminated.
Initial improvement was gradual on day 1 and 2, > 50% improvement occurred on
day 3 and total resolution of symptoms occurred on day 6. These results show that
Calcarea carbonica was a well indicated remedy.
69
4.10.4 Subjective improvement as a percentage from day 0 to day 6 occurred as follows:
Day 0 1 2 3 4 5 6
Joint pain 10% 0% 0% 40% 60% 70% 100%
Joint swelling 10% 10% 20% 40% 40% 80% 100%
Joint discoloration 20% 30% 50% 50% 60% 100% 100%
Sleep affected 0% 0% 70% 70% 80% 90% 90%
Level of activity 0% 0% 0% 30% 50% 70% 100%
Overall
Improvement
0% 0% 30% 50% 50% 80% 90%
4.10.5 Objective improvement on day 0, 1, 3, 6 and 15 occurred as follows Day 0 1 3 6 15
a) Joint improvement 4 2 1 0 0
b) Severity of swelling 3 2 1 0 0
c) Degree of tenderness 3 3 1 0 0
4.10.6 Change in SUA on day 0 and day 6
Day 0 6
SUA 0.56mmol/ L 0.42 mmol/ L
ormal values: < 0.42 mmol/L in males
< 0.35 mmol/L in females
70
CHAPTER FIVE: QUANTITATIVE ANALYSIS
5.1 Demographics
5.1.1 Table of demographics
No of
Patients
Median Quartile
25%
Quartile
75%
Age 30- 40yrs: 2 patients
40- 50yrs: 3 patients
50- 60yrs: 1 patients
60- 70yrs: 3 patients
> 70yrs: 1 patients
52 yrs 42 yrs 63.75 yrs
Duration
Of disease
1 day: 1 patient
3 days: 3 patients
6 days: 5 patients
10 days: 1 patient
5 days 3 days 6 days
Male
Female
8 male > 3 0yrs
2 female > 55 yrs
Postmenopausal
Black
Indian .
White
2 patients
5 patients
3 patients
5.1.2 Body mass index
Body mass index Obese
(> 30)
Overweight
(24- 30)
Normal
(< 24)
Number of
Patients
6 adults 2 adults 2 adults
71
5.2 Clinical baseline data
5.2.1 Index joints' affected
Index joint Metatarsophalangeql Knee
Number of
patients
8 patients 2 patient
5.2.2 Number of total joints affected
Median Quartile Quartile
25% 75%
Number of total joints 4.5 2.5 6
Affected
5.2.3 Number of patients with tophi
Tophi Number
of patients
Tophi 2
No tophi 8
5.2.4 Change in SUA of all patients
Patient SUA (mmol/L)
Day 0
SUA (mmol/L)
Day 6
Gender
A 0.52 0.41 Male
B 0.4 0.38 Female
C 0.32 0.34 Male
D 0.53 0.44 Male
E 0.4 0.35 Female
F 0.61 0.5 Male
G 0.59 0.4 Male
H 0.47 0.4 Male
I 0.33 0.38 Male
72
J 0.56 0.42 Male
Mean 0.47 0.40
SD 0.11 0.05
Normal values: < 0.42 mmol/L in males
< 0.35 mmol/L in females
5.3 Response to therapy
According to the graphs 5, 6, 7, 8 and 9 resolution of symptoms took place in the
following order:
Discoloration
Joint pain
Joint tenderness
Joint swelling
Level of activity
Overall joint improvement
5.3.1 Response to therapy
Graph Response
to therapy
>50%
improvement
within 24 hours
>50%
improvement
within 72 hours
>50%
improvement
within 144hours
10 Overall
Improvement
1 patient 3 patients 5 patients
11 Subjective
Assessment
1 patient 2 patients 7 patients
12 Observers
joint
improvement
1 patient 3 patients 4 patients
13 Swelling 1 patient 4 patients 4 patients
14 Tenderness 1 patient 6 patients 2 patients
73
5.4 Compliance of patients
Non-compliance of patients was an important factor. Initially 24 patients were
treated; 14 had not complied; 7 continued with other allopathic medication, 4 did
not return and had given the wrong contact details and 3 were unable to attend
follow up sessions. It is possible that the wrong similimum remedy was given
forcing patients to use alternative medication or that patients could not tolerate the
aggravation of symptoms.
74
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CHAPTER SIX: QUALITATIVE ANALYSIS
6.1 The correlation with other studies of acute gout
This study correlates with the findings of other studies on acute gout in the
following ways:
6.1.1 Diagnosis
The patients selected were fairly typical of gout (appendix A) all of which had
more than one attack of acute arthritis, maximum inflammation developed within
one day, a monoarthritis attack and redness observed over the joint. Eight out of
ten patients had podagra and two patients had gout affecting the knee joint (Table
5.2.1). One out of ten patients had a unilateral tarsal joint attack, two out of ten
had tophi and eight out of ten had hyperuricemia. Due to financial constraints x-
rays and synovial fluid aspiration were not taken. Patients were accepted if these
tests were done previously and indicated gout.
6.1.2 Gender
Gout affects adult men more than women (Sturrock, 2000). This study correlates
with the findings of other studies in that all ten patients were adults affecting eight
men and two women (Table 5.1.1) Gout occurs primarily in men older than 30
and is rarely found in men before adolescence (Tucker, 1999). About 90% of
people afflicted with gout are men over 40 (Flieger, 1998). The eight men chosen
in this study were all adults over the age of thirty. Of the eight men two were
above thirty and six above forty.
Women account for approximately 10% of cases almost always postmenopausal
(urate levels remain constant until menopause) (Tucker, 1999). The two female
participants were both postmenopausal.
Affected women are more likely than their male counterparts to have coexistent
renal insufficiency, hypertension, polyarticular attacks, and a past history of
diuretic use (Davis, 1999). In this study both females had renal problems, one
90
female participant had hypertension and diabetes and one male patient had
hypertension. Five participants had polyarticular gout; only one was female.
6.1.3 Family history
Approximately 25% of patients with gout have a positive family history (Steven,
1998). In this study four out of ten patients had a positive family history for gout
and two patients did not know their family history.
6.1.4 Age related symptoms
Compared with the classic manifestations in younger persons, gout in the elderly
is more evenly distributed between the sexes, more often affects joints of the
upper extremities, presents with fewer acute episodes, and has a more indolent
chronic clinical course (Fam, 1998). Four patients were over 60 years, one female
and three male; all of them had experienced gout in their knee and shoulder, with
approximately one to two attacks per year of a more chronic appearance. Joint
pain becomes generalized in the elderly as compared to local joint pain in younger
patients. Gout in the two patients who were in there thirties experienced more
acute, painful, violent attacks of the metatarsophalangeal joint.
6.1.5 Obesity
Obesity in general (Lin et. al., 2000) and in particular excessive weight gain in
men between ages 20 and 40 has been shown to increase the risk of gout (Flieger,
1998). About half of all gout sufferers are overweight (Flieger, 1998) therefore it
is essential to educate patients on the importance of losing weight.
Eight out of ten patients were overweight in this study of which six were obese
(Table 5.1.2). The patient should also be counseled about gradually losing weight
if obese.
6.1.6 Alcohol abuse
Alcohol abuse or 'binge' drinking are associated with gout (Tang and Xia, 1998).
Seven out of ten patients consumed alcohol on a daily basis of which three
patient's acute attack was caused by excessive intake of alcohol. An alcoholic
91
addiction was observed in one patient who was asked to attend counseling at
alcoholics anonymous. Acute attacks can be prevented if patients control their
alcohol intake. The patient should be counseled about limiting alcohol
consumption.
6.1.7 Diet
Urate is a by-product of purine and therefore a partial treatment can be established
by limiting the amount of purine, in a patients diet (Glynn, 1999).
Eating purine rich foods such as brains, kidneys, liver, sardines and anchovies can
precipitate a gout attack (Flieger, 1998). All ten patients had a high purine diet
and mainly ate red meat. Acute gout attacks could have been prevented if patients
controlled their diet. Dietary education regarding purine-rich foods (which
contribute to higher SUA) should be provided to the patient at this time.
6.1.8 Allopathic drugs that increase urate
Impaired renal function and use of thiazide diuretics and asprin to control
hypertension become an important risk factor in the elderly (Chou et. al., 2000
and Caspi et. al., 2000) because it causes an increase in SUA by decreasing renal
excretion of urate. Six patients had high blood pressure two of which were taking
antihypertensive medication. The continued uses of such drugs further aggravate
gout symptoms, for these patients alternate anti-hypertensive therapy should be
considered.
6.1.9 Renal excretion of urate
The most important risk factor is failure of the metabolic process that controls the
amount of urate in the blood (Flieger, 1998). Renal management of urate is
defective in many patients with primary hyperuricemia and gout (Pittman and
Bross, 1999). Four out of ten patients had renal problems in this study. Lowering
SUA through diet, urate-lowering drugs, herbal and homeopathic medication is a
good preventative measure.
92
6.1.10 Other risk factors
Other risk factors include occupational exposure to lead, surgery, trauma,
infection, chemotherapy, fatigue and dehydration (Flieger, 1998). One patient's
gout attack was caused by trauma in the foot from walking in uncomfortable
shoes. This attack could have been avoided if proper shoes were worn. It is
advisable to educate gout patients on these causes of gout and how to avoid them
in order to prevent acute gout attacks.
6.1.11 Resolution of symptoms
In a study comparing triamcinolone acetonide with indomethacin in the treatment
of acute gout resolution of all symptoms occurred at an average of eight days for
the indomethacin patients and seven days in the triamcinolone patients (Alloway
et. al., 1993). Nine out of ten patients gout symptoms resolved by day six in this
study. No side effects or episodes of rebound gout attacks occurred with the
triamcinolone (Alloway et. al., 1993). Gout symptoms were aggravated
temporarily in two patients and one patient had a minor relapse of symptoms in
this study but quickly resolved thereafter. The relapse is seen in homoeopathic
terms as an indication that a repeat dose of the remedy is required. The rapid
response after the remedy was repeated is a clear indication that the remedy
chosen was the similimum.
6.2 Serum urate
Eight out of ten patients had hyperuricemia on day 0 and showed a reduction of
SUA on day 6 between 0.02 mmol/L and 0.19mmol/L (Table 5.2.4 and Graph 14).
A decline in serum uric acid after the administration of homoeopathic treatment
indicates that it could be used as a urate-lowering agent. These values support the
need for further research to establish the effect homoeopathic remedies have on
serum and urine urate.
Two out of ten patients SUA increased: patient C by 0.02mmol/L and patient I by
0.05 mmol/L. The small increase could have been due to a consumption of food,
medication or alcohol that increased urate production or decrease renal excretion
93
of urate. It is important to note that both patients were not hyperuricemic on day
0, and although SUA increased both these patients were not hyperuricemic on day
6.
6.3 Response to therapy
Graph 1-4: Subjective (graph 1 and 3) and objective (graph 2 and 4) assessment of
improvement correlated with each other, showing that the researchers clinical
examination compared to the subjects evaluation was fair and unbiased.
Graphs 5-9: The decline in the scores from day 0 to day 6 indicates that
improvement progressed on a daily basis with an average total resolution by day
6. When describing acute gout: excruciating, unbearable pain is almost always the
first symptoms that gout sufferers will relate to. In this study the reduction of pain
is second on the list of improvement. Therefore we can say that homoeopathic
remedies act as effective analgesics in the treatment of acute gout. This is
advantageous in that the patient feels better when pain disappears thus lessening
the discomfort of acute gout.
Graphs 10-14: The overall improvement of nine out of ten patients by more than
50% by day 6 indicates that homoeopathic similimum treatment is an effective
treatment for acute gout. Five out of ten patients swelling improved within 3 days
and nine out of ten by the sixth day, indicating that homoeopathic remedies are
effective in treating the swelling of joints affected in acute gout. The rapid relief
of pain in seven patients by day three and nine patients by day six further
indicates the effectiveness of homoeopathic remedies and its effect as an analgesic
in acute gout (Table 5.3.1).
6.4. Homoeopathic treatment
6.4.1 Response to treatment
Rapid response occurred in Patient I, with a total resolution of symptoms by day
one. The symptom picture of patient I was very similar to the symptom picture of
the homoeopathic remedy and therefore the researcher concluded that this
supports the principles that the closer the similitude the more dramatic the
response. Recovery was quick and the patient had no side effects after the
94
homoeopathic medication was administered. This supports Hahnemann's
principles of cure being rapid and gentle. It also shows that homoeopathic
medication works immediately and is fast acting.
Slow response occurred in three patients; two of which had underlying pathology.
Patient B had diabetes mellitus and hypertension and patient D had chronic gout.
Patient C responded slowly to the remedy possibly because a more similar remedy
could have been chosen.
Aggravation of symptoms occurred in four patients. In three of these patients (A,
G, SUA decreased in all three patients suggesting that the aggravation was
caused due to an elimination of toxins and support Hahnemann's responses to
treatment. Patient E 's aggravation was self-induced by walking long distances on
the affected joint.
6.4.2 Characteristic symptoms of the modality of temperature
Patient A, B, and D had joint symptoms > hot but there amelioration for hot
differed in that patient A preferred the warmth of a bandage compared to patient B
who felt better from heat packs and D from the warmth of a blanket. This is in
direct contrast to patient C, F, H and I whose joint symptoms were > cold. Patient
F and I preferred ice packs. Each of these patients symptoms were considered and
a remedy individually prescribed. This is only one symptom showing the depth
involving homoeopathic prescribing. It indicates the individuality of each patient
and finally the importance of prescribing one similimum remedy.
95
CHAPTER SEVEN: CONCLUSION
7.1 Limitations of this study
X-rays and synovial fluid aspiration were not taken due to financial
constraints.
24-hour urine samples were not used as diagnostic criteria, this limited the
ability to test renal insufficiency and the possibility of uric acid excretion
during treatment.
Before, during and after an acute gout attack serum uric acid levels
fluctuate and therefore homoeopathic remedies may not have been
responsible for the decrease in uric acid levels during treatment. It is
advisable to do future studies to determine the effect of homoeopathic
remedies on serum uric acid during the intercritical phase of gout.
Aggravation of gout symptoms caused by homoeopathic treatment is a
disadvantage in that gout pain is unbearable and patients seek immediate
pain relief
Foods, beverages and medication affecting SUA should have been avoided
during the trial period to avoid the fluctuation of SUA.
The researcher failed to ask how long previous attacks had lasted, which
could have formed a baseline of the study.
7.2 Conclusion
The main aim of this study was to treat acute gout and its presenting symptoms
using homoeopathic similimum remedies. Total resolution of acute gout
symptoms took place within six days with a 50% improvement of swelling and
70% improvement of pain within three days showing that homoeopathic treatment
responds immediately and rapidly. Under optimal conditions when the similimum
remedy was found, response was extremely rapid. These values therefore
conclude that homoeopathic similimum remedies are an effective alternative in
the treatment of acute gout. The research findings support Hahnemanns highest
ideal of cure being rapid and gentle.
96
Twenty-four volunteers were recruited for this study but only ten completed the
study. It is therefore concluded that the skill of the prescriber in discerning the
correct remedy and patient compliance are the most important factors for success.
7.3 Recommendation
A very important aspect to consider in future studies is similimum treatment on
urate level in gout patients during their intercritical phase using 24hr urine
samples and SUA. Patients should be monitored for a longer period of time to
assess the effect of future relapses. Homoeopathic remedies could be used as an
alternative treatment in acute gout patients experiencing side effects to allopathic
drugs, however further studies to confirm findings are required.
97
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APPENDIX A
American College of Rheumatology (ACR) criteria for gout
Participants must comply with at least six of the (ACR) criteria for gout to be
chosen.
Mark with an 4 where applicable
A B C D E F G H I J
More than one attack of acute arthritis -4 4 4 4 4 4 4 4 4 4 Maximum inflammation developed within
one day
4 4 4 4 4 4 4 4 4 4
Monoarthritis attack 4 4 4 4 4 4 4 4 4 4 Redness observed over the joint 4 4 4 4 4 4 4 4 4 Unilateral first metatarsophalangeal joint
painful or swollen
4 4 4 4 4 4 4 4 4
Unilateral tarsal joint attack 4
Tophus (proven or suspected) 4 4 Hyperuricemia 4 4 4 4 4 4 4 4 Asymmetric swelling of a joint x-ray
Subcortical cysts without erosions on X-ray
Monosodium urate monohydrate
microcrystals in joint fluid during attack
4 4 4 4 4
Joint fluid culture negative for organisms
during the attack
106
APPENDIX B
SUBJECT INFORMATION AND CONSENT FORM
Homoeopathic Treatment in Acute Gout
Dear Participant
The purpose of this study is to determine the effect of homoeopathic remedies in
acute gout.
You will be chosen if you comply with the ACR criteria for gout. A blood sample
will be taken on day 0 and day 6 of the study. The researcher will take a thorough
case history and evaluate your joints using a questionnaire. You will be required
to take the medication and answer a questionnaire daily from day 0 to day 6. No
anti-inflammatory or analegesic drugs other than the study medication will be
permitted from the time of inclusion into the study (day 0) to the end of the sixth—
day study period (Werlen et. al., 1996). It is requested that you do not take uric
lowering agents including allopurinol, sulfinpyrazone and probenecid except if
you have been on such therapy prior to the onset of the attack and your drugs are
not relieving your symptoms.
You are also requested to make no changes to your current diet and lifestyle for
the duration of the study. A follow up will take place on day 15.
The potential benefits for those who receive the study medicine are that the
homoeopathic treatment may reduce symptoms experienced during the attack and
thereby improve the quality of life. Irrespective of the treatment assigned, all
patients who participate in this study will contribute to medical knowledge,
resulting in a greater efficacy in the therapeutic management of gout patients.
Participation in the study is voluntary and you are free to refuse to participate or
to withdraw your consent and to discontinue participation at any time. Such
107
refusal or discontinuance will not effect your regular treatments or medical care in
any way. A signed copy of this consent form will be made available to you.
I have fully explained the procedures, identifying those, which are investigational,
and have explained their purpose. I have asked whether any questions have arisen
regarding the procedures and have answered these questions to the best of my
ability.
Date: Researcher:
I have been fully informed as to the procedures to be followed, including those,
which are investigational and have been given a description of the attendant
discomforts, risks, and benefits to be expected and the appropriate alternate
procedures. In signing this consent form I agree to this method of treatment and I
understand that I am free to withdraw my consent and discontinue my
participation in this study at any time. I also understand that if I have any
questions at any time, they will be answered.
Date: Patient:
108
APPENDIX C CASE TAKING
Age:
Sex:
Occupation:
Past medical history:
Past surgical history:
Family history:
Vaccination:
Allergies:
Present medication:
Alcohol:
Diet:
History of gout:
When did it start?
How did it start?
Cause:
Number of joints affected:
Number of attacks during the year:
Main complaint
When did it start?
Location:
Side:
Type of pain:
Radiation of pain:
S ens ation:
Modalities: <
Concomitant symptoms:
109
Have you noticed a change in any of the following?
Energy:
Sleep:
Body perspiration:
Bodyaches:
Urination:
Headache:
Appetite:
Thirst:
Cravings/ aversions:
Bowel movements:
Mental symptoms:
Nose:
Ear:
Throat:
Eyes:
Neck:
Respiratory:
Heart:
Nervous system:
Female:
PHYSICAL EXAMINATION
1.General survey
1.1 Height:
1.2 Weight
1.3 General state:
1.4 Dress:
1.5 Grooming:
1.6 Personal hygiene:
1.7 Breath and body odors:
1.8 Facial expression and manner:
110
Main complaint
2.1 Examination of joint
2.2 Overlying skin: Color-
Temperature-
Texture-
Tenderness-
Inflammation-
Numbness-
Perspiration
Mobility of joint-
Surrounding areas affected-
Skin
3.1 Abnormal lesions:
3.2 Color:
3.3 Nails:
3.4 Conjunctiva:
Head
4.1 Scalp:
4.2 Hair:
4.3 Skull:
4.4 Face:
4.5 Headache:
Eyes
5.1 Visual acuity:
5.2 Visual fields:
5.3 Compare pupils:
5.4 Light reaction:
5.5 Retinoscopy:
Ears
6.1 Auricle:
6.2 Ear canal:
111
6.4 Eardrum:
6.5 Hearing:
6.6 Vertigo:
Nose and sinuses
Mouth and pharynx
Neck
Thorax and lungs
Cardiovascular
11.1 Heart sounds and radiation:
11.2 Jugular venous pressure:
11.3 Apex beat:
Abdomen
12.1 Abdominal masses:
12.2 Bowel sounds:
12.3 Liver:
12.4 Spleen:
Peripheral vascular system
Musculoskeletal system
14.1 Muscle:
14. 2 Joints:
14.1 Back:
Nervous system
Vital signs
16.1 Blood Pressure:
16.2 Pulse (bilateral) all seven:
16.3 Respiratory rate:
16.4 Temperature:
112
APPENDIX D
SUBJECTS QUESTIONNAIRE Day 0 1 2 3
1.What would you rate your pain intensity as?
0 = minimum 10 = maximum
Level of swelling of joints?
0 = minimum 10 = maximum
Is there discoloration of the joint?
0 = minimum 10 = maximum
Is your sleep affected?
0 = minimum 10 = maximum
Level of activity?
0 = minimum 10 = maximum
Rate your improvement as a %
0= 100% improvement
10= 0% improvement
113
APPENDIX E
RESEARCHERS QUESTIONNAIRE
Day 0 1 3 6 15
Joint improvement?
0= total resolution
1= improvement of > 50%
2= improvement of< 50%
3= no change
4= worsening of symptoms or involvement
of previously uninvolved joints
Severity of swelling?
0= no swelling
1= swelling with some loss of joint contours
2= complete loss of joint contours
3= fluid
Degree of tenderness
0= no tenderness
1= tender
2= tender and wince
3= tender + wince+ withdraw
114
APPENDIX F
Patient A
Age: 71yrs
Race: Indian
Sex: Male
Occupation: Pensioner.
Past medical history: Medication for enlarged prostate and saw palmetto
Panado's for body aches and pains as well as headaches
Cortizone and Brufen or Arthrexin for gout
Past surgical history: Kidney stones removed in 1986
Family history: Stroke on mother 's side
Vaccination: All done
Allergies: Sulphur
Present medication: none
Alcohol: I don't drink alcohol at all, I never did.
Diet: Bread and tea for breakfast.
For lunch and dinner: red meat with rice or bread usually but I tried to cut
down to chicken because the red meat aggravates my gout.
No dairy products.
History of gout
When did it start? 13- 14 years ago, I found out I had gout after my kidney stone
was removed. They said the uric acid was high on my blood test
and I was prone to getting an attack.
How did it start: About three months later a sharp pain in my foot traveled to my
knee. My knee got swollen and was relieved by a cortisone
injection.
Cause: it started from going to a lot of braai's, we only braai red meat because
it's the tastiest.
Number of joints affected: knee mostly sometimes the shoulders or toe.
Number of attacks during the year: once a year, it used to be twice a year. It's not
as painful as before.
115
Main complaint
When did it start? First I got a fever last night, then I couldn't sleep because I
needed to urinate. I got worried because my urine was dark,
burning, and smelt strong like that detergent handy andy. I want
to urinate but it comes out in drops like a tap dripping. It burns
so bad; it feels like I'm passing vinegar. I usually have a
bladder problem at night; my urine drops out when I 'm sleeping
but last night it did not. Very early in the morning I got a pain
in my right knee, now the pain is worse in my big toe.
Location: Big toe and knee
Side: Right
Type of pain: Unbearable tearing at night, during the day not so bad.
Radiation of pain: Started in the knee but went to the toe. Then the toe got
swollen.
Sensation: As if someone is tearing my toe from inside out.
Modalities: < Motion
> holding my toe
>Heat and rest, I bandaged my foot to keep it warm, so the cold
doesn't go in and so my foot doesn't move.
< Night, the pain is ok now, but it gets worse at night and when I lie
on the side that's painful
Have you noticed a change in any of the following?
Energy: yes, I don't feel too well with this pain.
Fever: burning hot, restless, I couldn't decide whether I was hot or cold.' When I
got hot threw the blanket off and then I got so cold the heater wasn't helping
Sleep: I had a restless sleep last night, I kept waking up to urinate but nothing
came out and my fever also kept me up.
Body perspiration: none
Bodyaches: My lower back pains on the left especially when my
urine comes out dark and it is very difficult to urinate at
this time. (Patient points out the area of pain, which is
observed to be the left kidney region.)
116
Urination: it's burning as if I 'm passing vinegar and is a dark color. It has a
strong, bad handy andy smell. I have an urge to go, but only drops come
out.
Appetite: I lost my appetite this morning and feel sick in my stomach.
Thirst: no change, I don't get thirsty and I don't like drinking water. I normally
drink tea.
Cravings/ aversions: none
Bowel movements: no change, once a day
Mental symptoms: I'm in pain and restless at the moment. I went through a male
menopause in my late 40 's. I didn't care, I was depressed and
disappointed with life and the past. I slowly learn't to deal with
life and now am content.
Head: I occasionally get left sided pain in the temples. It throbs especially when I
think a lot.
> Brufen,
< night,
> rest, no radiation,
Nose: no problem
Ear: I can hear very well, but I loose balance when I stand up and my ears ring all
the time.
What does it sound like? Ssssssssss,
When do you hear the ringing? On and off during the day.
Modalities? > jumping on one leg or swallowing, to balance the pressure
< daytime
Eyes: I wear bifocals and can't see near. I must wear glasses when I'm reading
and driving. I can't read for long because my eyes pain.
Neck: my neck and shoulders pain but I feel better after stretching them.
Respiratory: I'm a smoker with bronchitis. I cough up green mucus in the
morning.
How many cigarettes do you smoke daily? About 5 daily, I started smoking as a
teenager.
Heart: I experience pain sometimes in my heart region near my breast bone.
117
Type of pain: sharp
Radiation: left
Modalities: < night with a heart palpatation
> rest, goes away after a few minutes
< gardening
Nervous system: no problem
Male: enlarged prostate with dribbling of urine.
PHYSICAL EXAMINATION
1. General survey
1.1 Height: 160 cm
1.2 Weight: 52 kg
1.3 General state: thin
1.4 Dress: normal
1.5 Grooming: well
1.6 Personal hygiene: clean
1.7 Breath and body odors: breathe- cigarette smoke
1.8 Facial expression and manner: friendly and smiling
2.1 Index joint
2.1 Observation: (Patient winced on removing bandage, touching his skin caused
pain)
2.2 Color- red
Temperature -feet cold, joint hot
Texture - smooth
Tenderness - tenderness and wince
Inflammation- swelling with some loss of joint contours
Numbness - light touch and pain sensation are normal
Perspiration- none
2.3 Mobility of joint- stiff,
< motion
> rest
pain on standing and walking
2.4 Surrounding areas affected - very cold feet (not normally cold but today it
118
suddenly is).
Skin
3.1 Abnormal lesions: none
3.2 Color: normal
3.3 Nails: long and unkempt
3.4 Conjunctiva: normal
Head
4.1 Scalp: normal, no tenderness
4.2 Hair: baldness and hair loss
4.3 Skull: normal
4.4 Face: wrinkled, unshaven
4.5 Headache: temporal, left side, throbbing. Patient is feeling nauseous
No visual disturbances, neurological symptoms, nasal congestion,
muscle tension, vomiting or vertigo.
Eyes
5.1 Visual acuity: normal with glasses
5.2 Visual fields: normal
5.3 Compare pupils: equal
5.4 Light reaction: normal
5.5 Retinoscopy: no abnormalities
Ears
6.1 Auricle: normal, no tophi
6.2 Ear canal: presence of cerumen, no redness, swelling.
6.4 Eardrum: normal
6.5 Hearing: sensory neural loss
6.6 Vertigo: on standing, lasts for a few seconds, has been happening for past 3
years.
Nose and sinuses: sense of smell diminished, mucopurulent nasal mucosa,
no nasal polyps, no sinus tenderness.
Mouth and pharynx: nicotine stains on teeth, tonsils removed
Neck: limited range of motion with pain on certain movements and local
muscle tenderness
119
Thorax and lungs: decreased fremitus on both upper lobes of lungs, presence
of wheeze on expiring which cleared on coughing
Cardiovascular
11.1 Heart sounds and radiation: normal and no abnormal radiation
11.2 Jugular venous pressure: 3.5 cm at an angle of 45°
11.3 Apex beat: localized at the point of 5 th left intercostals and midclavicular
line
Abdomen
12.1 Abdominal masses: none
12.2 Bowel sounds: normal
12.3 Liver: normal
12.4 Spleen: normal
12.5 Aorta: normal
Peripheral vascular system: cold feet, poor circulation
Musculoskeletal system
14.1 Muscle: atrophy and weakness
14.2 Joints: decreased and limited range of motion of all joints with pain in
certain joints, crepitus of left knee
14.1 Back: lumbar sacral pain on left side with renal tenderness, no hypertrophy
Nervous system
15.1 Cranial nerves: slow reaction
15.2 Motor system, muscle tone, strength and bulk: poor
15.3 Gait and co -ordination: poor co-ordination, limps to avoid pain on affected
joints when walking short distances and walks with
assistance of crutches for longer distances.
15.4 Reflexes: no reflexes
Vital signs
16.1 Blood Pressure: 143/90 mmHg
16.2 Pulse (bilateral) all seven: 93 beats / minute
16.3 Respiratory rate: 16 / minute
16.4 Temperature: 38 °C
120
17. Laboratory test
17.1 Serum uric acid: 0. 52mmol/ L
FOLLOW UP DAY 1
Main complaint: I feel worse today especially last night, my toe swelled up more
and my urine is still burning, and very little is being passed out.
Have you drank any liquids? No, except for Joko tea.
Pain: tearing increased
Radiation: none
Sensation: tearing is worse
Modalities: < motion, cold draft, evening, lying on painful side
> heat, rest, bandage, holding toe
Concomitant symptoms: burning, smelly and a little bit of urine
Have you noticed a change in any of the following?
Energy: I feel weaker today.
Sleep: terribly restless, I kept trying to find a comfortable position to sleep in but
couldn't
Fever: my fever is gone down
Perspiration: none
Bodyaches: my joints feel stiffer
Back: my lower back on the left is more painful today
Urination: burning, smelly and in drops
Headache: none
Appetite: I can't eat I feel nauseous.
Thirst: I'm thirsty but don't drink water.
Cravings/ aversions: none
Bowel movements: normal, once a day
Mental symptoms: even though the pain is worse, I can handle it
but if in a few days I'm not better I'll be forced to take a Brufen
or Cortisone injection.
Systems review: No change.
121
PHYSICAL EXAMINATION
Index joint
Color- dark red
Temperature - warm foot, joint hot
Texture- smooth, skin pulled tight
Inflammation- complete loss of joint contours
Tenderness - tender with wince and withdrawal
Numbness - loss of light touch sensation
normal pain sensation
Mobility of joint: pain on least movement of toe
Inability to flex and extend toe
Inability to stand and walk on affected foot without crutches
Musculoskeletal
Joints: decreased and limited range of motion of all joints with increased pain in
certain joints
Back: lumbar sacral pain on left side increased with renal tenderness,
No enlargement of left kidney.
Vital signs: BP: 140/90 mm/ Hg
Pulse: 89 beats / min
RR: 16 / min
T°: 36.8 °C
FOLLOW UP DAY 3
Main complaint: There was no change in my joint yesterday, except that my
throat got so dry I had to drink water at least four glasses. I had
a very restless sleep. This morning, I passed a lot of urine which
was yellow, sandy, burning and of a bad smell. My bladder felt
relieved. About an hour later I noticed the joint pain and
swelling came down. I could walk without holding my back
although the pain was still a bit there.
pain- bearable and reduced
radiation- none
122
sensation- reduced
modalities - < motion (I can limp walk, the pain is bearable)
heat
holding toe
cold (I can't tolerate the cold)
bandage (I apply heat but I stopped bandaging
because I don't need to)
rest (I don't need to rest my foot as long as
before)
I can lie on the painful side for a while and
when it's uncomfortable I turn again
Have you noticed a change in any of the following?
Energy: much better than yesterday
Sleep: restless
Fever: none
Perspiration: none
Bodyaches: my joints feel much more flexible than yesterday.
Backache: very slight pain,
Urination: yellow, a lot of urine, sandy, smelly. I passed urine about three times
today. Every time Igo my joints feel better
Headache: none
Appetite: increased, I started eating soup and fruits but not meat. I don't feel
nauseous.
Thirst: yes, 4 - 5 glasses of water
Cravings/ aversions: I crave water; I'm thirsty even after I drink water.
Bowel movements: stools were passed a bit easier today.
Mental symptoms: I almost gave up hope on your medication, until this morning.
My joints aren't so stiff, and my back not so sore. I haven't
noticed a change in my mental state.
Systems review: no change
123
PHYSICAL EXAMINATION
Index joint
Color- light red
Temperature- cool foot, warm joint
Texture- smooth
Inflammation- swelling, with some loss of joint contours
Tenderness- tender
Numbness- light touch and pain sensation normal
Perspiration- none
Mobility of joint: ability to flex and extend toe with wince
able to stand but not walk without crutches
Musculoskeletal
Joints: range of motion of all joints increased, pain decreased
Back: no pain in lumbar sacral area, no renal tenderness,
Vital signs: Blood Pressure: 140 / 85 mmHg
Pulse rate: 90 beats /min
Respiratory rate: 16 / min
Temperature: 37 r
FOLLOW UP DAY 6
Main complaint: I feel fine today, swelling and pain is gone and I can walk
normally. My urine was yellow on Day 4 and clear on Day 5.
The more I passed urine the better my joints felt
Have you noticed a change in any of the following?
Energy: I feel normal
Sleep: I woke up once last night to urinate; normally it's twice or thrice
Fever: none
Perspiration: none
Bodyaches: my joints are movable like normal
Urination: light yellow, with no smell. I noticed I wasn't dribbling as much today.
Headache: none
Appetite: normal
124
Thirst: I'm not thirsty anymore, but drinking water is helping so I try to drink 4
glasses a day.
Cravings\ aversions: none
Bowel movements: normal
Mental symptoms: I feel normal mentally. I'm pleased that my kidney pain is gone
and feel as if my whole bladder is empty. I couldn't pass all my
urine out before but yesterday I did.
PHYSICAL EXAMINATION
Index joint
Pain- no pain
Color- pink
Temperature- warm foot, cool joint
Texture- normal
Inflammation- none
Tenderness- none
Numbness- none
Perspiration- none
Mobility of joint: able to flex and extend toe and walk with no pain.
Musculoskeletal
Joints: range of motion of all joints normal, no pain
Back: no pain in lumbar sacral area, no renal tenderness
Vital signs: Blood Pressure: 140/90 mm/Hg
Pulse rate: 85 beats /minute
Respiratory Rate: 16 / minute
Temperature: 37 r
Serum uric acid: 0.41 mmol/L
FOLLOW UP DAY 15
Main complaint: no complaints my gout is gone
Systems review:
Headache: I did not get a headache over these past two weeks.
Ear: the ringing in my ears is softer than before but still there all the time.
125
Eyes: no change
Neck: my muscles feel tense
Respiratory: I noticed that I'm coughing up more mucus. It's yellow and thick.
Heart: I got a pain in my chest last night, but it went away after I drank water.
Gastrointestinal tract: normal
Male: I noticed my dribbling of urine stopped when I was taking the medication
but it started again two days ago.
Mental: normal
PHYSICAL EXAMINATION
Pain- no pain
Color- pink
Temperature- warm
Texture- normal
Tenderness- none
Inflammation- none
Numbness- none
Perspiration- none
Mobility- normal, flexion and extension of toe without pain. Ability to walk
normally.
Neck: limited range of motion with pain on certain movements and local muscle
tenderness
Thorax and lungs: decreased fremitus on both upper lobes of lungs, no wheeze
present
Cardiovascular:
Heart sounds and radiation: normal and no abnormal radiation
Jugular venous pressure: 3.5 cm at an angle of 45 ° th- Apex beat: localized at the point of ..) left intercostals and midclavicular line
Vital signs: Blood Pressure: 140/ 90 mmHg
Pulse Rate: 85 beats / minute
Respiratory Rate: 15 / minute
Temperature: 36. 7 °C
126
SUBJECTS QUESTIONNAIRE
Day 0 1 2 3 4 5 6
1. What would you rate your pain intensity as?
0 = minimum 10 = maximum
8 10 10 5 4 2 0
2. Level of swelling of joints?
0 = minimum 10 = maximum
8 10 10 5 4 1 0
3. Is there discoloration of the joint?
0 = minimum 10 = maximum
7 10 10 5 4 2 1
4. Is your sleep affected?
0 = minimum 10 = maximum
7 10 10 5 3 0 1
5. Level of activity?
0 = minimum 10 = maximum
6 10 10 6 3 2 0
6. Rate your improvement as a %
0= 100% improvement
10= 0% improvement
10 10 10 7 5 2 1
RESEARCHERS QUESTIONNAIRE
Day 0 1 3 6 15
a) Joint improvement?
0= total resolution
1= improvement of > 50%
2= improvement of< 50%
3= no change
4= worsening of symptoms or involvement
of previously uninvolved joints
4 4 2 0 0
b) Severity of swelling?
0= no swelling
1= swelling with some loss of joint contours
2= complete loss of joint contours
3= fluid
1 2 1 0 0
c) Degree of tenderness
0= no tenderness
1= tender
2= tender and wince
3= tender + wince+ withdraw
2 3 1 0 0
127
Case A
Sum of symptoms (sort:deg) This analysis contains 339 remedies and 8 symptoms. Intensity is considered
EXTREMITIES - PAIN - Toes - first - joints - gouty
URINE - BURNING (includes Hot)
EXTREMITIES - COLDNESS - Foot
1
1
1
24
156
195 A
GENERALS - NIGHT 1 176 4
URINE - ODOR - ammoniacal 4 47
BACK- PAIN - urination - during - scanty 3 1
FEVER - ALTERNATING with - chills 1 89 ;
STOMACH - NAUSEA 1 272
1 2 3 4 benz-ac. calc. phos. lyc.
5 sil.
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 ,22 merc. asaf. lach. bell. ant-t. dig. puls. am-m. ehel. kreos. rhod. iod. nit-ac. ferr. dulc. petr. aur.
12/14 10/21 10/20 10/18 10/18 9/22 9/19 9/19 9/18 9/16 9/16 9/16 9/13 9/12 9/12 9/12 8/22 8/19 8/18 8/17 8/17 8/1.5
1. 2 1 1 3 2 1 - - - - 2 -: 2. 2 1 1 2 1 3 2 2 3 2 2 2 1 2 1 1 - 3 2 1 1 t
3. 1 3 3 3 3 3 1 3 3 3 3 3 1 2 3 3 3 3 3 3 3.
4. 1 3 3 2 3 3 2 3 2 . - 2 3 2 1 1 1 3 3 3 3 2 v2
5. 1 2 2 1 1 2 3 2 1 1 e 1 1 1 1 1 1 3 2 2 2 2 2'
6. 1 - - - - - A
,
7. 3 2 2 2 3 1 3 2 2 1 3 1 2 1 `2 - - - .-
8. 1 2 2 2 3 2 1 2 3 3 3 3 2 2 1 2 2 2 2 3
,ft
I
LANCET LABORATORIES
WES WM IMI•rlAmvadancetzosal
PUJI . SKEWS
P.
A
Test > S -URIC ACID
Result Units Xeference 0.52 mso1/1 0.14 - 0.51
Teats • AUTO ORDER, S-UA
*** BIOCHEMISTRY *** PAGE : 1
Authorised by DR P COLE Por consultation by referring doctors phone : (011) 358-0808
•
: •
,111111111411111111111■ XIIIII 11111111011111011.
GU: YNNWOOD LABORATORY Clynnwood Hospital cnr Woburn Ave & Harrison Str. Benoni Tel:(011) 843-1960 Fax: (011) 421-9659
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• LANCET CL YNNWOOD LABORATORY Glynnwood Hospital cnr Woburn Ave & Harrison Str. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659
• LABORATORIES
• WES SIM Mtpc/Avonatoncat.cora/
PRN . MOMS
1
.---.--.---
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•
Tests : AUTO ORDER, S-UA
*** BICWHEM/STRY *** PACE : 1
Test > S -URIC ACID
Result Units Reference 0.41 mmo1/1 0.14 - 0.51
Authorised by DR P COLE For consultation by referring doctors phone (011) 358-0808
•
11611111.110111= PAM.. ralledigall
APPENDIX G
Patient B
Age: 60
Race: Indian
Sex: female
Occupation: housewife
Past medical history: diabetes mellitus
Past surgical history: hysterectomy
Family history: diabetes mellitus
Vaccination: all done
Allergies: none
Present medication: medication for hypertension and diabetes
Alcohol: none
Diet: small meals throughout the day, mostly salads and meat curry (red or white
meat) for supper. I cut down on all sugars and have fructose in it's place.
History of gout
When did it start? Two years ago
How did it start? Suddenly one night I felt feverish and I couldn't move my foot
because it was so incredibly painful. We went to the clinic
because I was so worried. They gave me Colchicine or Brufen I
can't remember.
Cause: My doctor said it's because I'm diabetic, I'm prone to get it and that I
should watch my diet. He was going to give me daily medication for my
gout to prevent attacks but I feel I'm taking too much tablets and feel I
should try something natural first.
Number of joints affected: Today it is only my toe, but once I felt it in my knee's
and the other time my shoulder.
Number of attacks during the year: this is my third attack, I had an attack in
January 2002.
Main complaint
When did it start? Two days ago. I walked through town quite a long distance in
uncomfortable shoes. When I came home I took off my shoes
130
because my feet were burning a lot. My left toe felt as i fI
twisted or sprained it and it was too painful to touch. I argued
with my husband that I was fine but my left toe was incredibly
painful and swollen. The right foot was normal. I realised then
that it was a gout attack and hoped it would go away by the next
day, but it didn't.
Locatiori: toe
Side: left
Type of pain: sore with a slight throb
Radiation of pain: none
Sensation: as if someone hammered my toe
Modalities: < touch. I can't touch it. I can't handle it if someone comes near it.
< movement. I limp and walk on one foot.
> heat packs
Concomitant symptoms: none
Have you noticed a change in any of the following?
Energy: I feel exhausted, my body feels tired as i f I had ran a marathon
Fever: I'm feeling hot and feverish, especially my head
Sleep: Very restless, the night that it happened I kept dreaming I was walking and
walking and walking and couldn't stop. I can't sleep at night, I toss and
turn but the pain keeps me awake. Sometimes I turn and find a comfortable
position and then it pains again and I have to find a new spot.
Body perspiration: I don't perspire, or smell.
Bodyaches: my body feels sore and tired. My leg muscles are sore from all the
walking. My muscles are getting weak.
Urination: no change. I urinate a lot of urine very often during the day and I must
wake up at night to go.
Headache: I feel a dullness and can't concentrate today. I'm in a daze.
Appetite: normal. No loss or gain of appetite.
Thirst: I am permanently thirsty normally; I drink water the whole day, about 8
glasses even more sometimes.
Cravings/ aversions: sugar, ever since I cut down sugar I crave it.
131
Bowel movements: normal, Igo 3 times a day. I am able to hold it in. I get
diarrhea when I eat sweet stuff.
Mental symptoms: Mentally, I'm healthy, I believe in natural healing like home
remedies, reflexology, herbs and homoeopathy. I'm
independent, confident and friendly. I'm tired of taking
medicines, so i f I can I avoid it.
Nose: sinusitis
Ear: no pain
Throat: dry, I'm always thirsty.
Eyes: I wear glasses, and find it difficult to see clearly. It feels as if sand is in my
eyes.
Neck: no pain
Respiratory: occasionalflu 's
Heart: shortness of breath
Nervous system: I'm loosing feeling in the tips of my fingers, and I get pins and
needles in my hands and feet often.
Female: I often get the itches and sometimes thrush.
PHYSICAL EXAMINATION
General survey
1.1 Height: 163 cm
1.2 Weight: 86 kg (I am losing a lot of weight over the past few years without
dieting or exercising.)
1.3 General state: normal
1.4 Dress: normal
1.5 Grooming: well
1.6 Personal hygiene: clean
1.7 Breath and body odors: none
1.8 Facial expression and manner: sickly
Index joint
Observation: patient winced and complained on approaching to touch joint.
Color- was red yesterday and the day before, now it's bluish purple
132
Temperature - hot joint, cold feet
Texture- smooth
Tenderness - tender with wince and withdrawal
Inflammation- swelling with fluid
Numbness - loss of light touch sensation and loss of pain sensation
Perspiration- no
Mobility of joint - patient complained of pain on approaching to examine
the joint, joint is immobile on account of the pain.
Patient walks on the unaffected limb and places
pressure on left heel. The left toe is untouched.
Surrounding areas affected- none
Skin
3.1 Abnormal lesions: normal, no diabetic ulcers or tophi
3.2 Color: normal, except brown discoloration on shins
3.3 Nails: normal, no presence of terry's nails
3.4 Conjunctiva: normal
Head
4.1 Scalp: normal
4.2 Hair: gray hair
4.3 Skull: normal
4.4 Face: normal
4.5 Headache: none, head hot from fever
Eyes
5.1 Visual acuity: normal with glasses
5.2 Visual fields: normal
5.3 Compare pupils: normal
5.4 Light reaction: normal
5.5 Retinoscopy: microaneurysms, hard exudates and cotton wool patches
Ears
6.1 Auricle: no tophi
6.2 Ear canal: normal
6.4 Eardrum: normal
133
6.5 Hearing: normal
6.6 Vertigo: none
Nose and sinuses: tenderness of maxillary sinus, no pain
Mouth and pharynx: normal, tongue looks dry
Neck: normal
Thorax and lungs: normal
Cardiovascular:
11.1 Heart sounds and radiation: normal with no radiation
11.2 Jugular venous pressure: 2.4cm at 45 ° angle
11.3 Apex beat: localized at the point of 5 th left intercostals and midclavicular
line
Abdomen
12.1 Abdominal masses: none
12.2 Bowel sounds: increased
12.3 Liver: normal
12.4 Spleen: normal
12.5 No bruits over carotid and femoral artery
Peripheral vascular system: presence of varicose veins, no diabetic ulcers.
Musculoskeletal system
14.1 Muscle: decreased muscle strength
14.2 Joints: normal
14.3 Back: stiffness in lumbar area
Nervous system
15.1 Cranial nerves: normal
15.2 Motor system, muscle tone, strength and bulk: normal
15.3 Gait and co-ordination: normal co-ordination. Patient walks on the
unaffected limb and places pressure on left heel when
stepping. The left toe is untouched.
15.4 Reflexes: normal
15.5 Loss of vibration sense
Vital signs
16.1 Blood Pressure: 140 / 90 mmHg
134
16.2 Pulse (bilateral) all seven: 65 / minute (diminished peripheral pulse)
16.3 Respiratory rate: 16 beats / minute
16.4 Temperature: 38.2 r
17. Serum uric acid: 0.4mmol/L
FOLLOW UP DAY 1
Main complaint: there has been a slight change. I'm still in pain. My joint is still
swollen and purple. I'm getting irritated because I can't do
anything with my toe like this.
Have you noticed a change in any of the following?
Energy: I feel a little less tired, but not normal.
Sleep: I wasn't so restless last night, I still tossed quite a bit though.
Fever: the fever has definitely gone down.
Perspiration: normal
Bodyache: my muscles feel a bit better.
Urination: frequent, no smell, yellow color
Headache: my head feels better today, it's not hot and my face doesn't look red
Appetite: normal, I eat my small meals through out the day.
Thirst: I don't feel as thirsty as yesterday
Cravings: none
Bowel movements: no change
Mental symptoms: I'm fine
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Pain- bruised, no change
Radiation- none
Color- blue
Temperature- hot joint, feet warm
Tenderness- tender + wince+ withdrawal
Inflammation- complete loss of joint contours
Texture- smooth
135
Modalities- < touch
< movement
< pressure
> heat packs
Numbness- can not feel pain sensation or light touch
Perspiration- none
Mobility- unbearable pain on moving joint and on touching affected area.
Unable to walk and put pressure on affected part
Vital signs
Blood pressure: 135/ 87 mmHg
Pulse rate: 64 beats/ min
Respiratory Rate: 18/ min
Temperature: 36.4°C
FOLLOW UP DAY 3
Main complaint: I'm beginning to feel OK I can touch my toe without
screaming, but the pain is still there. The color is getting a bit
normal.
Have you noticed a change in any of the following?
Energy: I feel more energetic even though my toe still pains. I'm not as tired as I
usually am.
Sleep: I sleep normally but I need to change position when my toe gets numb.
Fever: none
Perspiration: none
Bodyaches: none
Urination: no change, frequent and profuse
Headache: none
Appetite: normal
Craving: sugar
Bowel movements: no change, three or four times a day.
Mental symptoms: I feel normal. I'm mentally stable. I'm confident and don't let
people try to change my point of view. I stand up for what I
136
believe in.
Systems review: I noticed that my muscles are feeling stronger.
PHYSICAL EXAMINATION
Index joint
Pain- it feels sore especially when I move it, and I can handle the pain better.
Radiation- none
Color- pale
Temperature- warm
Tenderness - tender with a wince
Inflammation- swelling with some loss of joint contours
Texture- smooth
Modalities - < touch-patient complains when touched but is able to bear the pain
< movement- is able to move the affected joint but complains of the
pain.
< pressure- is able to apply pressure on affected area for only a few
seconds and complains of the pain.
Numbness- loss of pain sensation and light touch sensation
Perspiration- none
Mobility- pain on touch and movement of affected joint and is able to flex and
extend the toe. Cannot walk or put pressure on affected part.
Vital signs
Blood pressure: 136/ 85 mmHg
Pulse: 65 beats / min
Respiratory rate: 16 /min
Temperature: 37 °C
FOLLOW UP DAY 6
Main complaint: I feel much better but not a 100%. The pain and swelling has
reduced but I don't feel like it's completely gone.
Have you noticed a change in any of the following?
Energy: I feel much more alive taking these tablets. I don't get tired as quickly.
Sleep: I slept well last night.
137
Fever: none
Perspiration: none
Bodyaches: one
Urination: normal. Frequent, profuse, no smell, yellow
Headache: none
Appetite: normal, I eat every few hours.
Craving: sugar
Bowel movements: same, three times daily.
Mental symptoms: normal
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Pain- slight pain on walking
Radiation- none
Color- pink
Temperature- warm
Tenderness- none
Inflammation- none
Texture- normal
Modalities- < motion- I get worse i f I walk too much around the house
Numbness- loss of pain sensation and light touch sensation
Perspiration- none
Mobility- is able to walk but not for long distances.
Flexion and extension of the toe is normal.
Vital signs
Blood pressure: 140/ 87 mmHg
Pulse: 65 beats / min
Respiratory rate: 16 / min
Temperature: 37 r
Serum uric acid: 0.38mmol/ L
138
FOLLOW UP DAY 15
Main complaint: even though my pain and swelling is gone, I still feel like I can't
move this joint as good as all the others.
Have you noticed a change in any of the following?
Energy: 60% energetic. Old age must be catching up. I get tired easily.
Sleep: my sleeping patterns are the way they used to be. I'm a light sleeper.
Fever: none
Perspiration: none
Bodyaches: none
Urination: normal, frequent, profuse, yellow, no smell
Headache: none
Appetite: normal, hungry every few hours, few meals daily
Craving: sugar
Bowel movements: normal, several times a day, soft stool, almost like diarrhea
Mental symptoms: normal
Systems review
Nose: my sinusitis is affecting me again
Ears: normal
Eyes: I can still feel sand in my eyes
Neck: no pain
Respiratory: I find it hard to breath with my nose congested.
Chest pain: none
Nervous system: loss of light touch and loss of pain sensation
Female: normal
PHYSICAL EXAMINATION
Index joint
Color- pink
Temperature- warm
Tenderness- none
Inflammation- none
Texture- normal
Modalities- none
139
Numbness- Loss of light touch sensation and pain sensation
Perspiration- none
Mobility-flexion and extension of toe is normal with no pain. Patient is able to
walk long distances as usual.
No relapses
Eyes: beginning stages of cataract developing
Nose: tenderness and pain of maxillary sinus
Vital signs
Blood pressure: 138/ 85 mm/Hg
Pulse: 64 beats / min
Respiratory rate: 16/ min
Temperature: 36.5 ° C
140
SUBJECTS QUESTIONNAIRE
Day 0 1 2 3 4 5 6
1.What would you rate your pain intensity as?
0 = minimum 10 = maximum
10 9 7 5 2 2 1
2. Level of swelling of joints?
0 = minimum 10 = maximum
10 8 7 5 1 1 0
3. Is there discoloration of the joint?
0 = minimum 10 = maximum
10 8 7 3 2 1 1
4. Is your sleep affected?
0 = minimum 10 = maximum
10 7 4 2 2 0 0
5. Level of activity?
0 = minimum 10 = maximum
10 7 5 3 1 0 0
6. Rate your improvement as a%
0= 100% improvement
10= 0% improvement
10 8 7 5 3 1 1
RESEARCHERS QUESTIONNAIRE
Day 0 1 3 6 15
a) Joint improvement?
0= total resolution
1= improvement of > 50%
2= improvement of< 50%
3= no change
4= worsening of symptoms or involvement
of previously uninvolved joints
4 3 2 1 1
b) Severity of swelling?
0= no swelling
1= swelling with some loss of joint contours
2= complete loss of joint contours
3= fluid
3 2 1 0 0
c) Degree of tenderness
0= no tenderness
1= tender
2= tender and wince
3= tender + wince+ withdraw
3 3 2 0 0
141
Case B
Sum of symptoms (sort:deg) This analysis contains 404 remedies and 8 symptoms. Intensity is considered
1. EXTREMITIES - PAIN - sprained, as if - Toes - First 1 7
2. SKIN - DISCOLORATION - bluish 4 74 3. GENERALS - PAIN - sore, bruised 3 251
4. EXTREMITIES - PAIN - Joints - gouty 1 190. ,
5. GENERALS - WALKING - agg. 1 1179
6. GENERALS - TOUCH - agg. 2 200t
7. HEAD - HEAT - coldness - Feet; with coldness of 2 34
8. SLEEP - POSITION - changed frequently 1 30 , •
1 arn.
2 ars.
3 4 5 6 7 8 9 10 11 12 bell. sulph. apis ph-ac. calc. carb-an. am-c. thuj. petr. rhus-t.
13 sil.
14 15 phos. aur. con.
16 17 18 19 nux-v. chin. cocc.
14/28 14/27 13/30 13/23 13/22 13/22 13/19 13/18 13/16 13/16 13/14 12/26 12/24 12/20 12/15 12/14 11/27 11/24 11/24
1. 2 - 1 - 2. 1 2 2 1 2 1 1 2 1 1 1 1 1 1 1 1 3 1 1 3. 3 2 2 1 1 2 1 1 2 1 1 3 3 2 2 1 1 3 3 4. 3 2 3 3 2 2 3 1 1 .; .,2 1 3 2 2 1 - 3 2 2 5. 2 2 3 3 1 2 3 2 1 1 2 3 2 3 1 3 3 3 3 6. 2 2 3 3 3 2 1 1 1 2 1 3 3 2 1 ) 3 3 3 7. 2 1 2 2 1 2 2 1 1 1 1 - ,/ 1 8. 3 - 1 1 1 -
,o
•
PAGE : I
Teets : AUTO ORDER, S-UA
*** BIOCUEMISTRY ***
Test > S -URIC ACID
Result Units Reference 0.40 mmol/1 0.12 - 0.37
Authorised by DR P COLE For consultation by referring doctors phone :,g011) 358-0808
•
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GLYNNWOOD LABORATORY Clynnwood Hospital car Woburn Ave & Harrison Str. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659
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Teats : AUTO ORDER, S-UA
*** BIOCHEMISTRY *** PACK : 1
Teat > S -URIC ACID
Result Units Reference 0.38 mmol/1 0.12 - 0.37
Authorised by DR P COLE For consultation by referring doctors phone :IOW 358-0808
LANCET LABORATORIES
WA Ms AftplAwwdlaw:WAxtral MA. =WS
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GLYNIVWOOD LABORATORY Glynnwood Hospital cnr Woburn Ave & Harrison Sty. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659
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APPENDIX H
Patient C
Age: 31 years
Race: White
Sex: male
Occupation: entrepreneur, I run my own clothing business.
Past medical history: childhood diseases- chickenpox and measles
bronchitis- during this winter
headaches- painstop helps
Past surgical history: none
Family history: father and grandfather had gout
Vaccination: all done
Allergies: none
Present medication: painstop for headaches
Alcohol: I only drink i fI go out and there is alcohol, I won't go out of my way to
buy alcohol. Igo out with friends and drink once in two months.
Diet: coffee and toast for breakfast
Pies or burgers, any take out foods for lunch
Meat (white or red) and veggies for supper whatever my mom cooks
History of gout
When did it start? My first attack was last year. I've had my third attack already
and don't like the way it feels. I'm hoping alternate therapy is
going to cure it.
How did it start: I knew I was going to get it. Then one morning after drinking at a
party the night before, I woke up with an excruciating pain. At the
hospital they tested fluid from my knee and said that I had gout.
Cause: I think family history more than alcohol, because my friends consume far
more alcohol than I do and they don't suffer from gout.
Number of joints affected: one
Number of attacks during the year: two
144
Main complaint
When did it start? I went to a braai last night and had a few chops and a couple of
drinks, about 3 or 4 beers. I get drunk easily compared to
others so I try to watch myself. I knew that I have a lot of work
to finish but it's hard to say no to your buddies when they ask
you to have a drink with them. I cursed myself this morning
when I woke up with a splitting headache and this painful toe. I
had to scream for my wife because it was too painful to move or
touch. She made me soak it in cold water because I could not bear
the touch of the ice pack. It helped a little.
Location: big toe
Side: right
Type of pain: tearing
Radiation of pain: none
Sensation: it feels stiff
Modalities: < any movement
tight bandaging because it stays still and the pressure helps ease
the pain.
cold application, soaking it in cold water
touching the toe
rest, when my toe is absolutely still
thinking about it
nothing really makes it better, it gets relieved for a while when I'm
dead still and as soon as I move it hurts again.
Concomitant symptoms: I have a pounding headache, it hurts when I
move my eyes or talk too fast. I feel like I have a hang
over even though I watched my alcohol intake.
Location: In the front of my head and the back (patient
points to occiput).
Radiation: none
Modalities: > pressing my temples with the palms of my
hands.
145
moving my neck even my eyes
alcohol,
not moving
Have you noticed a change in any of the following?
Energy: Yes, I've so much of energy to finish my work but I can't because of my
toe and so I'm venting out my anger on everybody that comes near me.
They just don't understand time is money and I can't afford to sit around
like this. I'm so irritated that I can't do anything it's making me restless.
The worst thing is that as soon as I move I'm reminded of my pain.
Sleep: I was so tired from the braai I slept like a baby for a few hours but woke up
in pain at about 5 0' clock this morning.
Fever: I feel hot but not feverish, I was sweating last night.
Body perspiration: I perspired a lot last night when I woke my clothes were damp.
This never happens.
Where do you perspire? Over my whole body, from my head down, I'm still
sweating see.
Bodyaches: my body feels stiff all the time, especially my low back
Urination: this morning I had an urge to go but nothing came out. So after I drank
water it was back to normal.
Appetite: I feel hungry but can't eat.
Thirst: /'m not thirsty, I normally drink 8 glasses of water daily.
Cravings/ aversions: none
Bowel movements: I didn't go to the loo today. I'm usually very regular every
morning.
Mental symptoms: normally I'm a nice person but today I've become angry and
irritable with everyone because of my foot. I have so much
work to do and it involves driving which I can't do with one leg.
Nose: fine
Ear: I think my ears are blocked with wax. I find it hard to hear sometimes
especially my right ear, because I use my cellphone a lot and I heard
radiation can affect it.
Eyes: I wear contact lenses, I can't see without them.
146
Neck: muscle tension from work.
Respiratory: I had a bad cough this winter it turned in bronchitis.
Chest: none
Nervous system: I get very anxious if things don't go according to plan, I give my
nerves a bit of a shock.
Male: fully functional
PHYSICAL EXAMINATION
General survey
1.1 Height: 164cm
1.2 Weight: 83 kg
1.3 General state: normal
1.4 Dress: normal
1.5 Grooming: well
1.6 Personal hygiene: clean
1.7 Breath and body odors: normal, patient does not smell of alcohol
1.8 Facial expression and manner: stiff, with little movement due to headache
Index joint
Observation: Patient is not wearing shoes on affected foot, is walking with
crutches to avoid the affected foot touching the floor. Foot is
tightly bandaged. Patient complained of pain on removing
bandages.
Color- red
Temperature- hot
Texture- smooth
Tenderness - tender+ wince+ withdraw
Inflammation- swelling with fluid
Numbness - no light touch and no pain sensation
Perspiration- none on joint or feet
Mobility of joint- patient complains of pain on slightest movement of the toe.
Too painful to flex, extend or move toe. Too painful to stand or
sit, needs assistance of crutches.
2.3 Surrounding areas affected- none
147
Skin
3.1 Abnormal lesions: none
3.2 Color: normal
3.3 Nails: normal
3.4 Conjunctiva: normal
Head
4.1 Scalp: dandruff
4.2 Hair: dry
4.3 Skull: normal
4.4 Face: normal
4.5 Headache: limited range of motion on account of intense pain,
muscle tension and tightness especially occiput and neck,
no vomiting, nausea, visual disturbances, sinus tenderness,
neurological symptoms.
Eyes
5.1 Visual acuity: normal with contact lenses
5.2 Visual fields: normal
5.3 Compare pupils: normal
5.4 Light reaction: normal
5.5 Retinoscopy: normal
Ears
6.1 Auricle: normal, no tophi
6.2 Ear canal: normal, no cerumen, redness or swelling
6.4 Eardrum: intact and normal
6.5 Auditory acuity — normal
6.6 Air and bone conduction- normal
6.7 Vertigo: dizzy when moving head, > keeping still
Nose and sinuses: normal
Mouth and pharynx: normal
Thorax and lungs
9.1 Movement of chest wall: normal
9.2 Percussion note: dull
148
9.3 Breath sounds: prolonged expiration
9.4 Vocal resonance: normal
9.5 Added sounds: coarse crepitations
Cardiovascular
10.1 Heart sounds and radiation: normal with no radiation
10.2 Jugular venous pressure: 2.5cm at 45 ° angle
10.3 Apex beat: localized at the point of 5 th left intercostals and midclavicular
line
Abdomen
11.1 Abdominal masses: none
11.2 Bowel sounds: normal
11.3 Liver: normal
11.4 Spleen: normal
11.5 Aorta: normal
Peripheral vascular system: normal
Musculoskeletal system
13.1 Muscle: normal
13.2 Joints: normal
13.3 Neck: stiff and tender
13.4 Back: muscle stiffness, tenderness and pain at the lumbosacral area < slight
movement, > keeping still, no renal tenderness or enlargement of
kidneys.
Nervous system
14.1 Cranial nerves: normal
14.2 Motor system, muscle tone, strength and bulk: normal
14.3 Gait and co-ordination: gait affected by gout pain, not nervous disorders
or influence of alcohol. Walks with the help of
crutches.
14.4 Reflexes: normal
Vital signs
15.1 Blood Pressure: 150/ 90 mmHg
15.2 Pulse (bilateral) all seven: 90 / minute
149
15.3 Respiratory rate: 16 beats / minute
15.4 Temperature: 38 r
16. Serum uric acid: 0.32mmol/L
FOLLOW UP DAY 1
Main complaint: the pain subsided but it's still swollen
Have you noticed a change in any of the following?
Energy: I feel more calm, not as anxious and irritated as yesterday.
Sleep: I had a better sleep last night. I stopped worrying about work. I slept with
my foot out of the blanket so that the blanket didn't touch me.
Fever: I don't feel feverish today.
Perspiration: I didn't perspire yesterday.
Bodyaches: none
Urination: even though I drink so much water my urine comes out yellow. I feel
much better after urinating.
Headache: my headache got worse when I first took the medication, it was awful
but went away after half an hour.
Appetite: my appetite came back after I had a bowel movement.
Craving: none
Bowel movements: I had a very good bowel movement last night, after a long
time.
Mental symptoms: I'm calmer. Not so worried I realized that worrying was not
helping.
Systems review: no real change except neck tension is reduced but not gone.
PHYSICAL EXAMINATION
Index joint
Pain- reduced I can touch my toe, but can't move or stand on it.
Radiation- none
Sensation- stiff
Color- red
Temperature - hot but cooler than day I
Tenderness - tender and wince and withdrawal
150
Inflammation- fluid reduced but joint contours not visible.
Texture - smooth
Modalities - < any movement. It pains when I move it, but I can bear .the pain.
< touch, I can touch it without squealing.
> rest, cold water and bandaging
Concomitant symptoms: the headache is gone
Numbness - loss of pain sensation and light touch
Perspiration- none over the joint
Mobility: inability to flex or extend toe. Cannot stand or walk on affected foot.
Headache: normal range of motion
muscle tension and tightness reduced in occiput and neck,
no vomiting, nausea, visual disturbances, sinus tenderness,
neurological symptoms or vertigo
Vital signs
Blood pressure: 145/ 90mm/ Hg
Pulse: 90 beats/ min
Respiratory rate: 16 beats / min
Temperature: 37° C
FOLLOW UP DAY 3
Main complaint: my toe hasn't healed a lot although I am feeling better.
Have you noticed a change in any of the following?
Energy: I feel calm, I feel I can deal with this problem.
Sleep: I haven't noticed a problem. I slept restfully.
Fever: none
Perspiration: none
Bodyaches: none
Urination: the color is normal; light yellow. No smell or burning
Headache: it's gone, I haven't experienced another one since.
Appetite: normal, I get hungry and eat breakfast lunch and supper.
Craving: none
Thirst: my thirst is gone but I still drink eight glasses of water.
151
Bowel movements: Igo twice a day now, and it feels great.
Mental symptoms: not so restless, I managed to get someone to help with some of
the work.
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Pain- the pain is less but not gone
Radiation- none
Sensation- more flexible
Color- light red
Temperature- warm
Tenderness- tender
Inflammation- swelling with complete loss of joint contours
Texture- smooth
Modalities - < movement, I can flex and extend my toe but I still feel a little pain
> rest and bandage
Numbness - pain sensation and light touch are normal
Perspiration- none
Mobility: ability to flex and extend toe, can stand on foot but complains of pain
and inability to walk on foot.
Headache: Normal range of motion
No muscle tension and tightness in occiput and neck,
No vomiting, nausea, visual disturbances, sinus tenderness,
neurological symptoms or vertigo
Vital signs
Blood pressure: 140/ 85 mmHg
Pulse: 90 beats / minute
Respiratory rate: 15 / minute
Temperature: 37°C
152
FOLLOW UP DAY 6
Main complaint: I can walk on my foot now, although it still pains a bit. The
swelling has gone down.
Have you noticed a change in any of the following?
Energy: I feel normal, I'm back at work. I can drive normally. I'm not angry or
irritable, I feel more controlled and focused.
Sleep: normal
Fever: none
Perspiration: none
Bodyaches: I have a backache from sitting too much.
Urination: normal
Headache: none
Appetite: normal
Craving: none
Thirst: no, thirst, but I like to drink water anyway.
Bowel movements: normal
Mental symptoms: calm and controlled
Systems review: no change
PHYSICAL EXAMINATION
Index joint:
Pain- slight pain on driving
Radiation- no
Sensation- no
Color- pink
Temperature- cool
Tenderness- none
Inflammation- none
Texture- rough
Modalities- none
Numbness- normal pain and light touch sensation
Perspiration - none
Mobility- slight pain on walking and driving
153
Vital signs
Blood pressure: 140/ 90 mmHg
Pulse: 84 beats / minute
Respiratory rate: 16 / minute
Temperature: 36.7 r
Serum uric acid: 0.34mmol/ L
FOLLOW UP DAY 15
Main complaint: my toe is back to normal.
Have you noticed a change in any of the following?
Energy: hyperactive, I'm catching up with all the work I missed out on.
Sleep: I couldn't sleep, I keep dreaming about work
Fever: none
Perspiration: none
Bodyaches: the tension from my neck is in my back now
Urination: normal
Headache: none
Appetite: my appetite is lost during the day because I don't have time to eat.
Craving: none
Thirst: 8 glasses of water daily
Bowel movements: normal, once in the morning
Mental symptoms: I'm stressed from work, but I'm coping better than before. I'm
able to accomplish more.
Systems review
Nose: my sinusitis hasn't flared up or given me a problem this season.
Neck: my neck and shoulder are still tense.
Respiratory: normal
Chest pain: none
Nervous system: nervous but in control
Male: no problem
154
PHYSICAL EXAMINATION
Index joint
Pain- none
Radiation- none
Sensation- none
Color- pink
Temperature- cool to warm
Tenderness- none
Inflammation- none
Texture- normal
Modalities- none
Numbness- none
Perspiration- none
Mobility: normal, ability to walk, stand, flex and extend toe without pain.
Vital signs
Blood pressure: 143/ 90mm/ Hg
Pulse: 90 beats / minute
Respiratory rate: 16 / minute
Temperature: 37 r
155
SUBJECTS QUESTIONNAIRE
Day 0 1 2 3 4 5 6
1. What would you rate your pain intensity as?
0 = minimum 10 = maximum
10 8 7 5 5 3 1
2. Level of swelling of joints?
0 = minimum 10 = maximum
10 8 7 5 5 4 1
3. Is there discoloration of the joint?
0 = minimum 10 = maximum
10 8 6 4 2 1 0
4. Is your sleep affected?
0 = minimum 10 = maximum
7 5 4 0 2 1 0
5. Level of activity?
0 = minimum 10 = maximum
10 10 7 5 5 2 1
6. Rate your improvement as a%
0= 100% improvement
10= 0% improvement
10 8 7 5 3 1 1
RESEARCHERS QUESTIONNAIRE
Day 0 1 3 6 15
a) Joint improvement?
0= total resolution
1= improvement of > 50%
2= improvement of< 50%
3= no change
4= worsening of symptoms or involvement
of previously uninvolved joints
4 2 2 1 0
b) Severity of swelling?
0= no swelling
1= swelling with some loss of joint contours
2= complete loss of joint contours
3= fluid
3 2 2 0 0
c) Degree of tenderness
0= no tenderness
1= tender
2= tender and wince
3= tender + wince+ withdraw
3 3 1 0 0
156
Case C
Sum of symptoms (sort:deg) This analysis contains 416 remedies and 8 symptoms. Intensity is considered
1. EXTREMITIES - PAIN - tearing - Joints 4 126
2. GENERALS - TOUCH - agg. _.... _ 4 200
3. PERSPIRATION - PROFUSE _ . 1 224
4. HEAD - PAIN - motion - eyes, of 3 49
5. MIND - ANXIETY - business; about 1 30
6. EXTREMITIES - PAIN - pressure - amel. 3 6
7. GENERALS - MOTION - agg. 4 291.
8. EXTREMITIES - PAIN - Toes - First - Joints - gouty 4 2,6 ,
1 2 bry. sulph.
3 sil.
4 ars.
5 arn.
6 7 8 9 10 11 chin. plat. caust. calc. nux-v. lyc.
12 led.
13 14 15 16 17 18 19 20 sep. rhus-t. zinc. spig. nat-m. phos. puts. chg.
24/56 21/46 20/49 20/37 20/32 19/44 19/23 18/31 18/24 17/46 17/43 17/41 17/38 17/34 17/33 17/32 17/30 17/30 17/30 17/29,
1. 2 3 2 2 1 2 2 3 2 2 3 2 2 3 3 1 1 2 3 1
2. 3 3 3 2 2 3 1 1 1 3 3 2 3 3 2 3 2 2 2 2
3. 3 2 3 3 3 2 3 2 3 1 3 2 1 1 3 2 2 1
4. 3 1 2 1 2 1 2 1 2 2 1 1,
5. 1 1 1 1 1 3 - 1 1 - 1 1 1 1
6. 1 - 2 1 *- - - - A -
7. 3 3 3 2 2 3 1 1 1 3 1 3 2 1 2 yi 2 2 1 3
8. 2 1 2 1 2 1 2 1 3 3 - 1 - 1
s .
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• LANCET GLYNNWOOD LABORATORY Clynnwood Hospital cnr Woburn Ave 6 Harrison Str. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659
LABORATORIES
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PVC $2010SS
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Tests : AUTO ORDER, S-UA
*** BIOCHEMISTRY *** ,A1
Test > S -URIC ACID
Result Unita 0.32 mmol/1
Reference 0.14 - 0.51
Authorised by DR P COLE For consultation by referring doctors phone' (011) 358-0808
•
•
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YAW001) LABORATORY Clynnwood Hospital cnr Woburn Ave & Harrison Ser. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659
LANCET LABORATORIES
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Result Units Reference 0.34 mmol/1 0.14 - 0.51
•
Test > S -URIC ACID
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*** BIOCHEMISTRY •** PACE :
Authorised by DR P COLE For consultation by referring doctors phone 1 (011) 358-0808
•
C.
.s
APPENDIX I
Patient D
General survey
Age: 66
Race: Indian
Sex: male
Occupation: part time salesmen in shoe store
Past medical history: Car accident1991 - back problems ever since
cataract removed from my eye 1980
Arthritis since after forty
Past surgical history: none
Family history: my mother and father passed away in a car accident when I was
sixteen years old, I don't know if they had any disease.
Vaccination: yes, I did most of them in school.
Allergies: none
Present medication: arthrexin and deep heat whenever I feel pain, I can't afford
to go to a doctor.
Alcohol: brandy and ice when I get home and a nightcap to sleep.
Diet: Breakfast- porridge- wheatbix
Lunch- takeaways mostly the meat specials
Dinner- meat (white or red) or fish with rice
History of gout
When did it start? 20 years ago.
How did it start? I can't remember
Cause: too much alcohol and red meat
Number of joints affected: shoulders, fingers, toes, knees
Number of attacks during the year: I don't know
Renal stones/ tophi: tophi on finger joint
Main complaint
When did it start? I was restless last night. My feet got cold from the draft, I think
the window was open so the cold got to my foot. In the middle of
the night I couldn't sleep on my feet, it was pulling and got
159
tight like a cramp. I woke up because I couldn't open my toes
properly. Everytime I tried it felt like it was tearing. The joint in
my big toe is very painful.
Location: toes, (index joint- 1st Metatarsophalangeal joint)
Side: right
Type of pain: burning, tearing
Radiation of pain . none
Sensation: can't stretch toes open, it pains
Modalities: < cold draft
thinking about it
stretching
I rubbed my foot in the blanket to warm them.
I'm restless, I can't sit still but even i f I move it doesn't make the
pain better.
Concomitant symptoms: none
Have you noticed a change in any of the following?
Energy: I get weaker everyday; my body can't hold me up.
Sleep: I couldn't sleep; I keep turning to be comfortable.
Fever: no
Body perspiration: I don't sweat
Bodyaches: my whole body is weak, I can't walk without a crutch and I can't lift
heavy parcels. All my joints are sore and stiff:
Urination: sometimes I wet the bed when I sleep. It started last year.
Headache: no
Appetite: I don't feel like eating
Thirst: not today, I drink water when I feel thirsty. One glass a day.
Cravings/ aversions: I like salty and spicy food. I must add more salt on my food
without tasting it and any spice to flavor my food.
Bowel movements: I go three times a week normally.
Mental symptoms: I get lonely at home and feel better at work around people.
Nose: my nose is always blocked and I can't smell. When I blow it nothing comes
out.
160
Ear: I'm getting deaf
Eyes: can't see clearly.
Neck: my neck and back are very stiff especially when I stand after I'm sitting. It
feels as if I fell or hurt it.
Respiratory: I had a very bad cough, but it's gone now.
Chest: I get pain mostly when I'm coughing. I get a sharp pain in my heart
sometimes at night.
Nervous system: I noticed my hands shaking sometimes when I hold my tea cup
Male: I had a prostate check 15 years ago, it was fine. I'm impotent.
PHYSICAL EXAMINATION
1. General survey
1.1 Height: 173cm
1.2 Weight: 57kg
1.3 General state: weak, weary, fragile
1.4 Dress: normal
1.5 Grooming: normal
1.6 Personal hygiene: unhygienic, clothing has odor of not being washed
1.7 Breath and body odors: bad breathe and body odor
1.8 Facial expression and manner: sad
Index joint
Observation: joints in toes are contracted
Color- red
Temperature- warm
Texture- smooth
Tenderness - tender with wince
Inflammation- with complete loss of joint contours
Numbness - loss of light touch and normal pain sensation
Perspiration - none
Mobility of joint- inability to straighten first three toes. No flexion or extension.
Can't walk or stand on foot.
Surrounding areas affected- toes are contracted
161
Skin
3.1 Abnormal lesions: Tophi on joint of middle finger,
3.2 Color: normal
3.3 Nails: fragile and brittle
3.4 Conjunctiva: normal
Head
4.1 Scalp: oily
4.2 Hair: bald
4.3 Skull: normal
4.4 Face: old, wrinkled,
Eyes
5.1 Visual acuity: poor
5.2 Visual fields: poor
5.3 Compare pupils: normal
5.4 Light reaction: normal
5.5 Retinoscopy: normal
Ears
6.1 Auricle: normal
6.2 Ear canal: normal
6.3 Eardrum: normal
6.4 Hearing: hearing loss, examiner needs to repeat or shout when speaking
Nose and sinuses: loss of sense of smell,
Mouth and pharynx: rotten teeth, tongue and mouth full of thick saliva
Thorax and lungs
9.1 Movement of chest wall: reduced
9.2 Percussion note: resonant
9.3 Breath sounds: vesicular
9.4 Vocal resonance: normal
9.5 Added sounds: none
Cardiovascular
10.1 Heart sounds and radiation: normal with no radiation
10.2 Jugular venous pressure: 2.9cm at 45 ° angle
162
10.3 Apex beat: localized at the point of 5 th left intercostals and midclavicular
line
Abdomen
11.1 Abdominal masses: none
11.2 Bowel sounds: normal
11.3 Liver: normal
11.4 Spleen: normal
11.5 Aorta: normal
Peripheral vascular system: poor circulation, cold feet.
Musculoskeletal system
13.1 Muscles: atrophy of skeletal muscle, weak muscles with decrease in power
13.2 Joints: decreased range of motion, joints in body are all weak and fragile.
13.3 Back: paravertebral muscles are tight and feel tender
13.4 Neck: decreased range of motion, stiff muscles
Nervous system
14.1 Cranial nerves: slow to react
14.2 Motor system, muscle tone, strength and bulk: decreased with muscle
atrophy
14.3 Gait and co -ordination: experiencing difficulty walking with crutches due to
gout pain. Dependant on crutches due to arthritis and
old age. Poor co-ordination.
14.4 Reflexes: slight to no reaction
Vital signs
15.1 Blood Pressure: 130/80mmHg
15.2 Pulse (bilateral) all seven: 67 beats /minute
15.3 Respiratory rate: 17 /minute
15.4 Temperature: 36 cc
Serum uric acid: 0.53mmol/L
163
FOLLOW UP DAY 1
Main complaint
My toes can stretch today. Nothing else changed.
Have you noticed a change in any of the following?
Energy: no change
Sleep: I wasn't so restless last night but I didn't sleep well
Fever: no
Perspiration: none
Bodyaches: my joints are not paining as much but I'm still sore everywhere
Urination: I wet the bed last night
Headache: none
Appetite: normal. I eat 3 meals a day.
Craving: none
Thirst: no
Bowel movements: I didn't have one yesterday
Mental symptoms: normal
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Observation: first three toes are less contracted than Day 0. Patient is able to
stretch toes fully but experiences pain on stretching.
Pain- less than day 0
Radiation- none
Sensation- less tight then day 0
Color- red, no change
Temperature - warm, no change
Tenderness - tender with a wince
Inflammation- complete loss of joint contours
Texture- no change
Modalities - < cold and stretching
Numbness - normal pain sensation, loss of light touch sensation
Perspiration- none
164
Mobility- the joints of the first three digits are still contracted and are able to
stretch with pain. Patient is able to voluntarily bend toes with pain
but is not able to extend them. Metatarsophalangeal joint cannot be
flexed or extended.
Vital signs
Blood pressure: 130/ 80 mm/ Hg
Pulse: 65 beats / minute
Respiratory rate: 17 / minute
Temperature: 37 r
FOLLOW UP DAY 3
Main complaint: My toes are normal today but the swelling of my joint is still
there.
Have you noticed a change in any of the following?
Energy: no change, I didn't get a chance to rest my foot. I feel tired.
Sleep: I didn't sleep well last night, because I didn't take my nightcap.
Fever: no
Perspiration: none
Bodyaches: my joints feel less painful and my muscles are not sore.
Urination: I didn't wet myself yesterday in the bed I woke to use the bathroom
Headache: none
Appetite: normal
Craving: salt
Thirst: no thirst
Bowel movements: I went this morning after three days
Mental symptoms: I feel good, I needed time off from work to rest.
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Observation: l' three toes function normally, they are not contracted
Pain- much less
Radiation- none
165
Sensation- normal
Color- maroon
Temperature - hot
Tenderness - tender with a wince
Inflammation- complete loss of joint contours
Texture- smooth
Modalities- > hot
Numbness - pain sensation- normal
loss of light touch
Perspiration- none
Mobility of joint: metatarsophalangeal joint cannot be flexed and extended.
Inability to stand or walk on foot and wear closed shoes.
Musculoskeletal system
Joints- improvement in range of motion with less pain on motion.
Vital signs
Blood pressure: 130 / 80 mm /Hg
Pulse: 65 beats / minute
Respiratory rate: 17 / minute
Temperature: 37 r
FOLLOW UP DAY 6
Main complaint: My toe feels like all the rest of my joints know. Its much better
but not cured.
Have you noticed a change in any of the following?
Energy: no change
Sleep: I slept better last night, even though I didn't take my nightcap.
Fever: no
Perspiration: none
Bodyaches: my muscles and joints feel less stiff, my elbow joint couldn't bend
fully before and today it can.
Urination: fine, no problem
Headache: no
166
Appetite: increased. I bought Ensure yesterday, to make me strong.
Craving: chillies
Thirst: no thirst
Bowel movements: I had a bowel movement last night.
Mental symptoms: I feel good.
Systems review
Ears: no change, I still find it difficult to hear
Eyes: no change
Neck: a bit better but still stiff
Respiratory: none
Chest pain: none
PHYSICAL EXAMINATION
Index joint
Pain- no pain unless patient over works affected joint
Radiation- none
Sensation- normal
Color- pale
Temperature- cool
Tenderness - no tenderness
Inflammation- no swelling
Texture- rough
Modalities- none
Numbness- pain sensation and light touch is normal
Perspiration- none
Mobility flexion and extension of joint is normal when compared to other joints.
Ability to walk and stand with crutches (crutches are used normally
due to arthritis not only because of gout.)
Musculoskeletal system
Joints- improvement in range of motion with less pain on motion
Tophi still present, with no change
Vital signs
Blood pressure: 130/ 80mm/ Hg
167
Pulse: 65 beats / minute
Respiratory rate: 17 / minute
Temperature: 36 c'C'
Serum uric acid: 0.44mmol/L
FOLLOW UP DAY 15
Main complaint: My gout is gone, but after I stopped taking the medication my
joints got stiff again.
Have you noticed a change in any of the following?
Energy: I feel more energetic in the morning since I have been taking Ensure.
Sleep: I slept well, because I've been taking my nightcap.
Fever: none
Perspiration: none
Bodyaches: my muscles are weak and joints are stiff.
Urination: I haven't had a problem so far.
Headache: no pain
Appetite: normal
Craving: salt
Thirst: not thirsty
Bowel movements: I took laxatives two days ago because I was feeling
uncomfortable.
Mental symptoms: I'm back at work and doing fine
Systems review
Ears: I still don't hear well.
Eyes: no change
Neck: no pain in my neck, but my lower back is sore.
Respiratory: my cough is gone. I sometimes cough in the morning.
Chest: no pain
Male: no change
PHYSICAL EXAMINATION
Index joint
Pain- no pain
168
Radiation- none
Sensation- normal
Color- white
Temperature- cool
Tenderness- none
Inflammation- none
Texture-rough
Modalities- none
Numbness- none
Perspiration- none
Mobility- normal, patient is able to stand and walk on affected joint with
crutches.
Relapses: none
Musculoskeletal system
Joint: stiff, limited range of motion, with pain on moving
Tophi: no change,
Back: lumbarsacral pain, stiffness and tenderness
Muscles: no change
Neck: limited range of motion with no pain
Vision: no change
Auditory acuity: no change
Vital signs
Blood pressure: 130/80 mm/ Hg
Pulse: 65 beats / minute
Respiratory rate: 17 /minute
Temperature: 37°C
169
SUBJECTS QUESTIONNAIRE
Day 0 1 2 3 4 5 6
1. What would you rate your pain intensity as?
0 = minimum 10 = maximum
7 7 6 5 3 2 2
2. Level of swelling of joints?
0 = minimum 10 = maximum
7 7 7 7 5 3 2
3. Is there discoloration of the joint?
0 = minimum 10 = maximum
7 7 7 7 5 2 2
4. Is your sleep affected?
0 = minimum 10 = maximum
7 7 7 7 4 4 3
5. Level of activity?
0 = minimum 10 = maximum
10 10 10 9 5 3 2
6. Rate your improvement as a %
0= 100% improvement
10= 0% improvement
10 10 7 7 5 3 2
RESEARCHERS QUESTIONNAIRE
Day 0 1 3 6 15
a) Joint improvement?
0= total resolution
1= improvement of > 50%
2= improvement of< 50%
3= no change
4= worsening of symptoms or involvement
of previously uninvolved joints
4 3 3 1 0
b) Severity of swelling?
0= no swelling
1= swelling with some loss of joint contours
2= complete loss of joint contours
3= fluid
2 2 2 0 0
c) Degree of tenderness
0= no tenderness
1= tender
2= tender and wince
3= tender + wince+ withdraw
2 2 2 0 0
170
Case D
Sum of symptoms (sort:deg) This analysis contains 370 remedies and 8 symptoms. Intensity is considered
1. GENERALS - TENSION - Joints; of
2. EXTREMITIES - CONTRACTION of muscles and tendons - Joints
3. GENERALS - COLD - air - agg.
4
4
1
69
13
197
4. EXTREMITIES - PAIN - Joints - gouty 4 190 1
5. GENERALS - FOOD and DRINKS - salt - desire 3 1'02 I;
6. GENERALS - WEAKNESS - Joints, of 2 106"
7. GENERALS - WARM - amel. 1 l31
8. EXTREMITIES - ARTHRITIC nodosities 3 58 )
1 2 3 4 5 6 7 8 caust. nat-m. merc. colch. graph. nit-ac. sulph. caic.
9 sil.
10 11 12 sul-ac. anac. petr.
13 lyc.
14 bry.
15 16 17 18 19 sep. kali-c. rhus-t. puls. phos.
22/54 22/49 22/43 19/36 19/35 19/32 18/43 18/4118/30 18/20 16/2016/2015/4315/3815/38 15/35 15/34 15/33 15/32
1. 3 3 1 1 1 2 3 1 1 1 1 1 3 3 3 2 1 3 1
2. 2 2 2 2 2 2 2 1
3. 3 1 2 2 2 1 2 3 3 2 1 2 3 2 3 3 3 2 2
4. 3 2 3 3 2 1 3 3 2 . - 1 1 1 3 3 3 3 3 2 2
5. 2 4 1 2 1 2 1 ,1 1 . - 4
6. 2 2 3 1 1 2 3 3 2 1 1 2 3 2 3 S 3 2 2
7. 3 1 2 2- 2 1 2 1 2 2 1 2 1 2 2 3 3 1 2
8. 2 1 2 2 3 2 3 2 1 3 2 1 2 2
1
Test > 3-URIC ACID
Reference 0.14 - 0.51
Result Unita 0.53 mmol/1
GIYA71140019 LABORATORY Glynnwood Hospital car Woburn Ave 6 Harrison Str. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659
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Authorised by DR P COLE For consultation by referring doctors phone (011) 358-0808
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Testa : AUTO ORDER, S-UA
*** BIOCBEHISTRY ***
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GLYNNWOOD LABORATORY Glynnwood Hospital cnr Woburn Ave & Harrison Str. Benoni Tal:(011) 845-1960 Fax:(011) 421-9659
•••
•
- • •
Tests : AUTO ORDER, S-Uk
*** BIOCHEMISTRY ***
PAGE : 1
Test Result Units Reference
> S -URIC ACID
4.44 mmol/1 • 0.14 - 0.51
Authorised by DR P COLE Por consultation by referring doctors phone : (011) 358-0808
•
•
,aloessassonnassinarierso
APPENDIX J
Patient E
Age: 59 years
Sex: female
Race: Indian
Occupation: sells vegetables
Past medical history: low blood pressure
anemia
gout
Past surgical history: hysterectomy 1995
Family history: father- emphysema
mother- gout and arthritis
Vaccination: all done
Allergies: fish
Present medication: iron tablets, vitamin B12 and folic acid, brewers yeast tablets
daily
Alcohol: none
Diet: Breakfast- eggs and sausages (red or white) with coffee or tea
Lunch- meat (white or red) and potato's or rice, salads
Dinner- meat (white or red) and potato' or rice sometimes vegetables
History of gout
When did it start? 5 years ago
How did it start? My mom had it and I knew I would, I never bothered to watch
my diet. My foot swelled up and got terribly painful one night
when I was sleeping. The pain was awful. When I went to the
doctor he said it was gout. He gave me a voltaren injection and it
went away.
Cause: inherited condition from mom her kidney couldn't break down uric acid
properly
Number of joints affected: only the big toe
Number of attacks during the year: one
173
Main complaint
When did it start? I walk a lot to sell my products and don't have a car. Yesterday
I walked must be 5 km in the rain. When I came home and
finally got some rest, my feet felt heavy and sore, as i f I
sprained it. I soaked my feet in cold water but it did not help.
Then at night my pain got so bad in my right toe while I was
sleeping, I tossed and turned the whole night. I got a fever and
felt so sick.
Location: big toe
Side: right
Type of pain: bruised and stiff
Radiation of pain: my whole foot is paining (right foot)
Sensation: sprained
Modalities: > stretching the joint
moving slowly all the time, when I'm busy I don't think of the pain
when tired,
sitting, as soon as I sit the pain comes and when I stand to walk it
hurts
rest, the pain gets too bad
< lying down
at night
Concomitant symptoms: none
Have you noticed a change in any of the following?
Energy: I 'm tired and restless at the same time
Sleep: I couldn't sleep last night, I was very restless.
Fever: I feel feverish, I get cold and then hot
Body perspiration: yes, I perspire especially when I get hot with the fever. No
smell. I sweat over my whole body especially my chest.
Bodyaches: my whole body feels tired and sore, I feel sick like I have a cold. I
don't normally feel like this. I think it's because I walked in the rain
and the cold caught me.
Urination: no change, it usually comes out a little bit, it's dark and hot. There's
174
no smell, but it pains when I try to press it out.
Headache: I feel a bit dull in my head. I don't suffer with headaches normally.
Sometimes I get dizzy.
Appetite: I don't feel like eating even though I am hungry.
Thirst: my throat is dry and sore and I am very thirsty, but drinking water is not
making it better. I don't drink water everyday to avoid using public toilets.
Cravings/ aversions: none
Bowel movements: regular
Mental symptoms: I don't want to sit, I need to work, I'm very worried
if I don't get better who's going to pay the bills.
Nose: my nose is running, and I'm sneezing a lot.
Ear: the left ear started paining this morning
Throat: sore
Eyes: no problem
Neck: sometimes when I put the veggies on my head, my neck pains
Respiratory: my chest feels tight as if I'm getting a cough, it's dry.
Chest: my heart beats fast often and I get out of breathe quickly especially when I
walk too fast, then I get a sharp pain in my chest. It goes away if I stop
and rest.
Nervous system: my fingers shake sometimes when I don't eat.
Female: I passed menopause but didn't take any tablets for it, I feel dry and
uncomfortable inside.
PHYSICAL EXAMINATION
1. General survey
1.1 Height: 164cm
1.2 Weight: 91kg
1.3 General state: tired
1.4 Dress: normal
1.5 Grooming: normal
1.6 Personal hygiene: clean
1.7 Breath and body odors: none
1.8 Facial expression and manner: worried
175
Index joint
Color- dark red
Temperature- hot joint
Texture- smooth
Tenderness- tender with wince and withdrawal
Inflammation - swollen with complete loss of joint contours
Numbness- loss of light touch and pain sensation
Perspiration- no
Mobility of joint- patient winces on initial movement during flexion and
extension of affected joint. Pain is reduced on continuous
motion of joint. Patient is able to limp slowly on affected joint
but complains of pain on standing or sitting too long.
Surrounding areas affected - right heel, sole and toes of foot are sore
Skin
3.1 Abnormal lesions: none
3.2 Color: pallor of skin and palms of hands
3.3 Nails: pallor
3.4 Conjunctiva: pallor
Head
4.1 Scalp: normal
4.2 Hair: normal
4.3 Skull: normal
4.4 Face: pale
Eyes
5.1 Visual acuity: normal
5.2 Visual fields: normal
5.3 Compare pupils: normal
5.4 Light reaction: normal
5.5 Retinoscopy: normal
Ears
6.1 Auricle: pain on palpation of mastoid process left side.
6.2 Ear canal: normal
176
6.4 Eardrum: normal
6.5 Hearing: normal
Nose and sinuses: rhinitis, exudate is clear, thick and runny, not sticky
Mouth and pharynx: pharynx appears dark red, tonsils and adenoids are not
swollen, tongue appears dry.
Thorax and lungs
9.1 Movement of chest wall: normal
9.2 Percussion note: dull
9.3 Breath sounds: vesicular
9.4 Vocal resonance: resonant
9.5 Added sounds: none
Cardiovascular
10.1 Heart sounds and radiation: normal with no radiation
10.2 Jugular venous pressure: 2.7cm at 45 ° angle
10.3 Apex beat: localized at the point of 5 th left intercostals and midclavicular
line
Abdomen
11.1 Abdominal masses: none
11.2 Bowel sounds: normal
11.3 Liver: normal
11.4 Spleen: normal
11.5 Aorta: normal
Peripheral vascular system: pallor of feet, paresthesia in fingers, also in feet
when sitting for long periods of time.
Musculoskeletal system
13.1 Joints: range of motion is decreased, joints feels sore and stiff on initial
motion
13.2 Muscle: skeletal muscles are sore
13.3 Back: normal
13.4 Neck: limited range of motion, local muscle tenderness and pain on motion,
shoulders stiff
177
Nervous system
14.1 Cranial nerves: normal
14.2 Motor system, muscle tone, strength and bulk: normal
14.3 Gait and co-ordination: Patient is able to limp slowly on affected joint but
complains of pain on standing or sitting too long.
Co-ordination normal.
14.4 Reflexes: normal, except abdominal reflex absent
Vital signs
15.1 Blood Pressure: 100/ 60 mmHg
15.2 Pulse (bilateral) all seven: 106 beats /minute
15.3 Respiratory rate: 20 / minute
15.4 Temperature: 39 °C
Serum uric acid: 0.4 mmol/ L
FOLLOW UP DAY 1
Main complaint: It's still swollen and red but the pain is not so bad
Have you noticed a change in any of the following?
Energy: I slowed down a lot, I'm not so restless
Sleep: I had a very peaceful sleep yesterday for a whole 10 hours.
Fever: I felt the fever coming down after I took the medication for the second time.
I'm still a bit hot.
Perspiration: no
Bodyaches: my body feels lame but not as bad as yesterday
Urination: it's still very little and dark.
Headache: no pain
Appetite: once the fever came down, I got very hungry and had some chicken
soup.
Craving/ aversion: none
Thirst: I have been drinking a lot of coke, it gives me energy
Bowel movements: still regular twice a day.
Mental symptoms: I feel more relaxed not so restless like yesterday
178
Systems review
Ear: the pain is gone
Nose: dried up, I stopped sneezing and noticed my nose getting dry after I took the
pills.
Respiratory: no pain today
Throat: doesn't feel so dry
PHYSICAL EXAMINATION
Index joint
Pain- it's just sore not bruised like yesterday
Radiation- none, only the toe pains now
Sensation- sore
Color- dark red
Temperature- normal- warm joint
Tenderness- tender with a wince
Inflammation- swollen with complete loss of joint contours
Texture- smooth
Modalities- I still feel better when I'm walking or doing something
But I don't feel so restless when I'm sitting even
though I don't like to rest.
Numbness- loss of pain and light touch sensation
Perspiration- none
Mobility- pain on standing and resting or sitting
Movement eases the pain especially on walking
Initial flexion induces pain but continual motion of index joint relieves
the pain.
Ear: slight pain on palpation of left mastoid process
Throat: redness reduced
Nose: exudate dry and crusty
Musculoskeletal: range of motion improved with no pain
Vital signs
Blood pressure: 100/ 60 mm/Hg
Pulse: 98 beats / minute
179
Respiratory rate: 18 / minute
Temperature: 36.5 °C
FOLLOW UP DAY 3
Main complaint: There's not much change since yesterday
Have you noticed a change in any of the following?
Energy: normal
Sleep: restless, because I had to go back to work
Fever: none
Perspiration: no
Bodyaches: none
Urination: the same. Dark in color and very little comes out.
Headache: none
Appetite: normal
Craving: none
Thirst: no thirst
Bowel movements: constipated
Mental symptoms: Pm feeling restless because I have to sell more vegetables to
make enough money for today.
Systems review
Ear: no pain
Nose: normal
PHYSICAL EXAMINATION
Index joint
Pain- it 's a bit sore when I first bend it
Radiation- none
Sensation- none
Color- dark red
Temperature- hot
Tenderness - tender with a wince
Inflammation - swollen with complete loss of joint contours
Texture- smooth
180
Modalities- > moving around, I have to keep moving even though I know resting
will make it heal quicker but the pain goes if I'm moving
Numbness- loss of pain sensation and light touch
Perspiration-none
Mobility- pain experienced on initial movement, ability to flex and extend joint.
pain is not experienced during rest but patient is compelled to move,
slight pain is experienced when standing for too long, walking relieves
pain and overexertion causes pain to return.
Ear, nose and throat: normal
Vital signs
Blood pressure: 110/ 70 mm /Hg
Pulse: 96 beats / minute
Respiratory rate: 18 / minute
Temperature: 37 ° C
FOLLOW UP DAY 6
Main complaint: I was getting better, the last time I saw you but I had to go back
to work and it got worse on day 4 and 5. I expected it to be more
worse because I walked a lot but it isn't.
Have you noticed a change in any of the following?
Energy: I feel very, very tired after work, I work the whole day.
Sleep: I can't sleep at night
Fever: none
Perspiration: no
Bodyaches: I have aches but it's not as sore as before. I can carry boxes without
complaining.
Urination: I drank 2 glasses of water and I urinated more yesterday.
Headache: none
Appetite: normal, I eat three times a day to keep strong.
Craving: none
Thirst: I become thirsty when I walk a lot, but don't like to drink while working
because there is no toilets around.
181
Bowel movements: I'm still constipated
Mental symptoms: I feel normal. I'm not restless or calm, just normal.
Systems review: no change since Day 3.
PHYSICAL EXAMINATION
Index joint
Pain- bruised again
Radiation- both feet feel sore
Sensation- bruised
Color- dark red
Temperature- hot
Tenderness- tender with wince and withdrawal
Inflammation- swelling with complete loss of joint contours
Texture-smooth
Modalities- > movement
< rest
Numbness- loss of pain and light touch sensation.
Perspiration- none
Mobility- pain on initial flexion and extension has increased since Day 3,
continued motion relieves joint pain. Pain on rest has returned.
Walking relieves pain, but over exertion produces pain.
Musculoskeletal: no pain on motion
Vital signs
Blood pressure: 100/ 70 mm /Hg
Pulse: 93 beats / minute
Respiratory rate: 18 / minute
Temperature: 37 r
Serum uric acid: 0. 35 mmol/L
FOLLOW UP DAY 15
Main complaint: My toe came right on Day 10. It's normal now. I tried to rest
my foot over the weekend.
182
Have you noticed a change in any of the following?
Energy: normal
Sleep: I can't sleep at night, any noise wakes me
Fever: no
Perspiration: no
Bodyaches: my muscles are very sore from walking so much at work.
Urination: my urine is still dark and very little
Headache: none
Appetite: normal
Craving: none
Thirst: none
Bowel movements: constipated
Mental symptoms: I get tired some days from walking so much at work,
sometimes I get frustrated that I work so hard and get paid so
little.
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Pain- none
Radiation-none
Sensation-none
Color- normal
Temperature- warm
Tenderness- none
Inflammation- none
Texture-rough
Modalities-none
Numbness-no numbness
Perspiration- none
Mobility of joint: normal with no pain on resting, sitting or walking
Vital signs
Blood pressure: 105/ 70 mm /Hg
183
Pulse: 90 beats / minute
Respiratory rate: 16 / minute
Temperature: 37 ° C
184
SUBJECTS QUESTIONNAIRE
Day 0 1 2 3
1.What would you rate your pain intensity as?
0 = minimum 10 = maximum
10 7 6 5 7 7 6
2. Level of swelling of joints?
0 = minimum 10 = maximum
9 9 8 8 9 8 7
3. Is there discoloration of the joint?
0 = minimum 10 = maximum
9 9 8 8 8 8 7
4. Is your sleep affected?
0 = minimum 10 = maximum
10 2 5 3 4 5 5
5. Level of activity?
0 = minimum 10 = maximum
5 5 6 5 7 6 6
6. Rate your improvement as a%
0= 100% improvement
10= 0% improvement
10 7 6 6 7 6 6
RESEARCHERS QUESTIONNAIRE
Day 0 1 3 6 15
a) Joint improvement?
0= total resolution
1= improvement of > 50%
2= improvement of< 50%
3= no change
4= worsening of symptoms or involvement
of previously uninvolved joints
4 3 2 4 0
b) Severity of swelling?
0= no swelling
1= swelling with some loss of joint contours
2= complete loss of joint contours
3= fluid
2 2 2 2 0
c) Degree of tenderness
0= no tenderness
1= tender
2= tender and wince
3= tender + wince+ withdraw
3 2 2 3 0
185
-A
Case E
Sum of symptoms (sort:deg) This analysis contains 302 remedies and 8 symptoms. Intensity is considered
1. EXTREMITIES - PAIN - Joints - gouty 4 190
2. GENERALS - WEATHER - wet weather - agg. 3 147
3. EXTREMITIES - PAIN - sprained, as if - Joint 3 63
4. GENERALS - RESTLESSNESS 4 57 '
5. EXTREMITIES - STIFFNESS - Joints 4 75
6. EXTREMITIES - PAIN - motion - beginning to move • 1 26 . ;
7. GENERALS - STRETCHING - Affected parts - amel. 2 51 v
8. EXTREMITIES - PAIN - motion - continued motion amel. 3 f ,
1 2 3 4 5 6 rhus-t. puts. phos. bell. staph. agar.
7 lyc.
8 sil.
9 10 11 12 13 14 15 16 17 18 19 20 cham. sep. sulph. ars. caic. ran-b. ferr. rhod. petr. zinc. carb-v. kalr-c.
24/72 24/49 21/41 20/36 20/32 20/24 19/47 19/35 15/29 18/48 18/47 18/4418/39 18/25 17/30 17/30 17/28 17/28 17/20 16/28
1. 3 2 2 3 3 1 3 2 1 3 3 2 3 2 2 2 1 1 1 3
2. 3 3 1 1 1 1 2 2 1 2 2 3 3 2 2 3 1 2 2 1
3. 3 3 3 1 1 1 2 1 1 . 2 3 1 2 1 1 2 2 1 1
4. 3 1 2 2 1 2 1 2 ! .3 2 3 1 1 2 - 2 9
5. 3 2 2 2 2 2 3 3 - . 3,, 3 3 2 1 1 3 2 1 2=
6. 3 3 3 1 3 '2 - - 3 1t 1 1
7. 3 1 1 1_ 1 1 - 1 - - 1 .41 1 1 1 1 1
8. 3 2 1 3
,s
•
YAU510019 LABORATORY Glynnwood Hospital cnr Woburn Ave & Harrison Str. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659
LANCET LABORATORIES
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Tests : AUTO ORDER, S-UA
***BIOCHEMISTRY***
o PAGE : 1
Test
Result Unita
Reference > S-URIC ACID
0.40 mmo1/1
0.12 - 0.37 •
Authorised by DR P COLE Por consultation by referring doctors phone .:1(011) 358-0808
•
■ ,sonosca imam rem; men
• •
GLYNNWOOD LABORATORY Glynnwood Hospital cur Woburn Ave & Harrison Str. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659
LANCET LABORATORIES
WU 5Th Ittftp./Iwonalanarf.cesot
MN . SZCIOX
Test > S-URIC ACID
Result Units Reference 0,35 mmol/1 0.12 - 0.37
Tests : AUTO ORDER, S-UA
*** BIOCUENMSTRY *** FACE : 1
Authorised by DR P COLE For consultation by referring doctors phone : (011) 358-0808
•
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06 •
APPENDIX K
Patient F
Age: 42 years
Sex: male
Race: white
Occupation: manager of clothing store
Past medical history: Stomach ulcer
Irritable bowel syndrome
Depression
Gout
Past surgical history: appendectomy
Family history: not sure
Vaccination: all done
Allergies: tartazine
Present medication: Colchicum, Brufen, Arthrexin anything from chemist for gout
St john's wort for depression
Panado's for headaches
Cimetidine for stomach ulcer
Alcohol: 3-6 beers at night while watching television, and I love my daily hot
shots, Whisky as a night cap, Wine with supper. I don't keep count on
weekends, I can handle alcohol so I drink practically the whole day.
Diet: I live alone and don't cook at home so I eat takeaways.
Breakfast: coffee and a toasted sandwich or doughnut
Lunch: usually meat. I hate vegetables. I prefer toasted steak specials or
chicken livers.
Supper: Meat, livers, steak, kidney, sardines with rice, mash potato or pap.
Takeaways. I eat when I remember. Sometimes I can go the whole
day without eating. But I must have my beers. I don't like healthy
food, it's too bland and tasteless.
History of gout
When did it start? 5 years ago
How did it start? I used to drink a lot and got involved with the wrong crowd of
188
people. I woke up one morning with a painful fat red toe. The
doctor gave me medication for gout and said it will continue
unless I stop drinking. My first attack was painful but I get it so
often I'm used to the pain.
Cause: too much alcohol and red meat
Number of joints affected: mostly my big toe
Number of attacks during the year: 2 or 3, I'm not sure sometimes my joints get
sore and I ignore it.
Renal stones/ tophi: tophi on 1' metatarsophalangeal joint
Main complaint
When did it start? Two days ago
How did it start? I went to a nightclub and drank too much, woke up in the
morning groggy with an enormous amount of pain; my toe was
swollen. It was gout.
Location: big toe
Side: right
Type of pain: throbbing
Radiation of pain: none
Sensation: as if someone is tearing my skin from inside
Modalities: < moving it
touching
night
heat
rest
> putting ice packs on it or soaking it in ice water with ice
Have you noticed a change in any of the following?
Energy: low energy
Sleep: nothing new, I wake everyday groggy at 7am, I'm half asleep until 12pm.
Fever: yes, I got hot at times and then very cold last night
Body perspiration: no
Bodyaches: my body feels stiff like it needs exercise but I don't do any.
Urination: my urine is normal yellow and strong smelling, I urinate three times a
189
day
Headache: I often wake up with a hang over, but nothing a grandpa can't cure. I
had one two days ago with my gout attack , I don't have one now.
My head felt heavy and I couldn't lift it of the pillow the morning when
I had the attack. I felt better when I pressed it tight.
Ears: I often feel dizzy when I get up from sitting.
Nose: no problem
Throat: no change, I don't have a problem.
Appetite: I eat when I'm hungry, it varies sometimes I have three meals a day and
other days I can pass the whole day with toast in the morning.
Thirst: I'm thirsty for cold beer 's especially after work. Nothing refreshes like a
cold beer after work. I hate water I won't drink it.
Cravings/ aversions: beer, even after I have a beer I crave another
Bowel movements: I suffer with piles and have a bowel movement twice a week.
Mental symptoms: I like to be alone because people are cruel, very superficial
and judgmental. They gossip all the time. I wish my life was
different and drinking makes me forget.
Eyes: I hate the sun, it's too blinding in the morning, I sleep with the blanket over
my head to keep it away. Other than that my eyesight is fine.
Neck: it feels stiff
Respiratory: no problem
Chest: I get heartburn often after I eat bread, sour or spicy food
Nervous system: I get pins and needles sensation often, in my hands and feet.
Male: I have a very strong desire but my performance is weak.
PHYSICAL EXAMINATION
1. General survey
1.1 Height: I 7 Ocm
1.2 Weight: 98 kg with a beer belly
1.3 General state: chilly
1.4 Dress: untidy, dressed warmly with layers of clothing
1.5 Grooming: clothing has an odor of not being washed and of alcohol
1.6 Personal hygiene: unshaven and untidy
190
1.7 Breath and body odors: breathe is old and stale of alcohol
1.8 Facial expression and manner: listless, sad
Index joint
Color- pale
Temperature- joint hot to touch, feet cold
Texture- smooth
Tenderness - tender with wince and withdrawal
Inflammation- swelling with fluid
Numbness - loss of light touch and pain sensation, very sensitive
to touch winces and withdraws on touch
Perspiration - no
Mobility of joint- inability to flex and extend toe, too painful and stiff
Patient prefers not to wear socks because < heat and
< touch. Patient is wearing sandals with strap away from
affected joint avoiding touch. Limps avoiding pressure on
affected joint. No socks on affected foot.
Surrounding areas affected- none
Skin
3.1 Abnormal lesions: acne scars on face
3.2 Color: pale
3.3 Nails: brittle, dirty,
3.4 Conjunctiva: yellow
Head
4.1 Scalp: normal
4.2 Hair: thin, dry,
4.3 Skull: dry
4.4 Face: pale, looks older than his age
Eyes
5.1 Visual acuity: normal
5.2 Visual fields: normal
5.3 Compare pupils: normal
5.4 Light reaction: normal
191
5.5 Retinoscopy: normal
Ears
6.1 Auricle: dirty, no lesions
6.2 Ear canal: full of wax
6.3 Eardrum: normal
6.4 Hearing: normal
Nose and sinuses: normal
Mouth and pharynx: bad breathe, rotten teeth, tongue dry
Thorax and lungs
9.1 Movement of chest wall: normal
9.2 Percussion note: resonant
9.3 Breath sounds: vesicular
9.4 Tactile fremitus: normal
9.5 Added sounds: none
Cardiovascular
10.1 Heart sounds and radiation: normal with no radiation
10.2 Jugular venous pressure: 2.1cm at 45° angle
10.3 Apex beat: localized at the point of 5 th left intercostals and midclavicular
line
Abdomen
11.1 Abdomen: reduced bowel activity, pain in epigastrium
11.2 Liver: liver tenderness
11.3 Spleen: normal
11.4 Aorta: normal
Peripheral vascular system: poor circulation, lack of vital heat, body cold to
touch, pale skin
Musculoskeletal system
13.1 Muscle: normal
13.2 Joints: normal
13.3 Neck: normal
13.4 Back: normal
192
Nervous system
14.1 Cranial nerves: normal
14.2 Motor system, muscle tone, strength and bulk: normal
14.3 Gait and co-ordination: limps, avoiding pressure on affected joint.
Co-ordination normal
14.4 Reflexes: poor knee reflex and absent plantar response
Vital signs
15.1 Blood Pressure: 143/90mmHg
15.2 Pulse (bilateral) all seven: 75 beats / minute
15.3 Respiratory rate: 17 /minute
15.4 Temperature: 36 °C
16.Serum uric acid: 0.61mmol/L
FOLLOW UP DAY 1
Main complaint
The pain came back last night the medication did not help.
Have you noticed a change in any of the following?
Energy: my. energy level is good but I'm unable to do much work because the gout
is slowing me down
Sleep: I tried to sleep but couldn't until I took my nightcap.
Fever: I don't have a fever but I get cold easy
Perspiration: no
Bodyaches: sore and heavy worse than yesterday
Urination: no change
Headache: I woke up with a headache that left me after 10 minutes.
Appetite: no change
Craving: I didn't crave beer so much today but still drank it.
Thirst: no change
Bowel movements: my piles are burning a lot today.
Mental symptoms: my mind feels a bit clearer
Systems review: no change
PHYSICAL EXAMINATION
193
Index joint
Pain- throbbing worse than day 0.
Radiation- none
Sensation- as if something is tearing inside.
Color- pale
Temperature- hot
Tenderness- tender with wince and withdraw
Inflammation- swelling with fluid
Texture- smooth
Modalities- < motion, heat, night
> rest, ice packs
Numbness- loss of pain sensation and light touch
Perspiration- none
Mobility- inability to flex and extend toe. Stiff can't stand or walk without
limping.
Vital signs
Blood pressure: 140/ 90mmHg
Pulse: 70 beats / minute
Respiratory rate: 16 / min
Temperature: 36.5° C
FOLLOW UP DAY 3
Main complaint: My pain and swelling reduced a lot..
Have you noticed a change in any of the following?
Energy: I feel more energetic today.
Sleep: very well, after I had a nightcap
Fever: gone
Perspiration: none
Bodyaches: have disappeared
Urination: light yellow, bad smell
Headache: not today or yesterday
Appetite: I don't feel like eating
194
Craving: nothing
Thirst: I have become very thirsty and drank cool drinks the whole day.
Bowel movements: I had a bowel movement yesterday, my piles are not burning
today.
Mental symptoms: I'm fine, not depressed or happy. I take every day as it comes.
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Pain- reduced and bearable
Radiation- none
Sensation- none
Color- pale
Temperature- warm
Tenderness- tender
Inflammation- swelling with some loss of joint contours
Texture- normal
Modalities - > cold ice packs, I can bear movement whether I rest or not,
Numbness- no numbness
Perspiration- none
Mobility- ability to flex and extend joint has increased but is not totally resolved.
Joint is not stiff. Patient is able to stand but continues to limp.
Touch sensation is bearable, patient has shoes and socks on affected
part.
Vital signs
Blood pressure: 145 / 90 mmHg
Pulse: 70 beats / minute
Respiratory rate: 16 / minute
Temperature: 37 r
FOLLOW UP DAY 6
Main complaint: my gout is gone and I feel much better
Have you noticed a change in any of the following?
195
Energy: better than normal
Sleep: like a baby
Fever: none
Perspiration: underarms- bad smell
Bodyaches: none
Urination: light yellow, no smell
Headache: none
Appetite: I feel hungry today and haven't eaten yet
Craving: none
Thirst: I drank a litre of liquifruit juice
Bowel movements: I am constipated today
Mental symptoms: I know I need to stop drinking for my own good, I'm
trying to cut down but every time I do something happens and I
go back to drinking. I have no reason to live or be joyous.
(patient was advised to join alcoholic's anonymous or to seek
counseling.)
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Pain- none
Radiation- none
Sensation- none
Color- pink
Temperature- warm
Tenderness- no
Inflammation- no swelling
Texture- rough
Modalities- none
Numbness- none
Perspiration- none
Mobility- flexion, extension, sitting, standing and walking is normal with no pain
196
Vital signs
Blood pressure: 145/ 94 mm / Hg
Pulse: 69 beats / minute
Respiratory rate: 17 / minute
Temperature: 37 r
Serum uric acid: 0.50 mmol /L
FOLLOW UP DAY 15
Main complaint: I didn't get another attack, and everything is fine.
Have you noticed a change in any of the following?
Energy: I don't feel depressed or happy.
Sleep: I sleep soundless as long as I have my nightcap.
Fever: no
Perspiration: bad smell underarms
Bodyaches: none
Urination: light yellow, no smell
Headache: I had a headache on day 10, it stayed for the day.
Appetite: my appetite increased and I noticed I've been eating more food.
Craving: none
Thirst: I started drinking fruit juice at work
Bowel movements: I'm still constipated
Mental symptoms: I'm taking each day as it comes. I haven't had a chance to
contact a counselor.
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Pain- no pain
Radiation- none
Sensation- none
Color- normal pink
Temperature- warm
Tenderness- none
197
Inflammation- none
Texture- rough
Modalities- none
Numbness-none
Perspiration- none
Mobility- normal
Total resolution of joint with no relapses
Vital signs
Blood pressure: 140/ 95 mm / Hg
Pulse: 70 beats / minute
Respiratory rate: 16 / minute
Temperature: 37°C
198
SUBJECTS QUESTIONNAIRE Day 0 1 2 3 4 5 6
1.What would you rate your pain intensity as?
0 = minimum 10 = maximum
10 10 10 5 5 2 0
Level of swelling of joints?
0 = minimum 10 = maximum
10 10 10 5 5 2 0
Is there discoloration of the joint?
0 = minimum 10 = maximum
10 10 8 4 3 0 0
4. Is your sleep affected?
0 = minimum 10 = maximum
8 8 6 3 0 1 0
5. Level of activity?
0 = minimum 10 = maximum
8 9 7 4 3 2 0
6. Rate your improvement as a %
0= 100% improvement
10= 0% improvement
10 10 7 5 5 3 2
RESEARCHERS QUESTIONNAIRE
Day 0 1 3 6 15
a) Joint improvement?
0= total resolution
1= improvement of > 50%
2= improvement of< 50%
3= no change
4= worsening of symptoms or involvement
of previously uninvolved joints
4 3 1 0 0
b) Severity of swelling?
0= no swelling
1= swelling with some loss of joint contours
2= complete loss of joint contours
3= fluid
3 3 1 0 0
• c) Degree of tenderness
0= no tenderness
1= tender
2= tender and wince
3= tender + wince+ withdraw
3 3 1 0 0
199
Case F
Sum of symptoms (sort:deg) This analysis contains 250 remedies and 8 symptoms. Intensity is considered
EXTREMITIES - SWELLING - Joints - white• 4 4
EXTREMITIES - SWELLING - Toes - First _ . 4 18
EXTREMITIES - ARTHRITIC nodosities 3 58 t
EXTREMITIES - PAIN - Toes - First - Joints - gouty 26 3
GENERALS - FOOD and DRINKS - alcoholic drinks - desire 1 f I 3
EXTREMITIES - HEAT - Joints 1 6
GENERALS - COLD - amel. 1 106,
HEAD - HEAVINESS - morning 1 76'
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 ?I led. sulph. bry. sabin. caust. benz-ac. lyc. caic. sil. kali-s. plb. apis mang. arn. aster. chin. calc-p. cimic. nux-v. phos. med.
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LANCET LABORATORIES
ValSnEhMaMwwwitimmtAmmi MA1. 5201021
GLYNNWOOD LABORATORY Glynnwood Hospital cnr Woburn Ave & Harrison Str. Benoni Tel:(011) 845-1960 Fax:(01I) 421-9659
1•
PAGE : 1
Testa : AUTO ORDER, S-UA
*** BIOCHEHISTRT ***
0.14 - 0.51 Result Unita Reference
0.61 mmol/1 Teat
> S -URIC ACID
Authorised by DR P COLE For consultation by referring doctors phone ! 1 (011) 358-0808
•
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LANCET GL YNNWOOD LABORATORY Clynnwood Hospital enr Woburn Ave b Harrison Str. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659
LABORATORIES WES SIM htlyr/Awntlanastoore/
'VI .S201021
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- • •
Tests : AUTO ORDER, S-UA
*** BIOCEPHISTRY *** ,ft
PAGE : 1
Test
Result Units Reference > S-URIC ACID
0.50 mmol/1 0.14 - 0.51
Authorised by DR P COLE For consultation by referring doctors phone ,::(011) 358-0808
•
`020J161Aiisa traitsvama
131
APPENDIX L
Patient G
Age: 42
Sex: male
Race: Black
Occupation: Delivers furniture
Past medical history: sinusitis and backache
Past surgical history: none
Family history: High blood pressure- mother
Gout- father
Vaccination: not sure
Allergies: none
Present medication: I can't afford medicine
Alcohol: I drink every weekend, not in the week otherwise I'll get fired. Six pack
on Saturday and on Sunday
Diet: matebella for breakfast
Pap or white bread with vleis (kidney, liver, gravy) for lunch and supper
It's all red meat, I don't like white meat
History of gout
When did it start? In 1998
How did it start: It was the day after my brother's funeral, my knees got so painful
I couldn't walk. The doctors said I have gout and gave me some
pillies.
Cause: I don't know
Number of joints affected: ankle, toe, knee
Number of attacks during the year: one or two
Main complaint
When did it start? Two days ago
How did it start? My back was so painful day before yesterday I couldn't go to
work, so I slept the whole day. I was getting worse, my body got
hot the joints in my leg became painful. It started in my ankle
first I put gruff sout (rough salt) with hot water. It went down but
202
started in my toe yesterday. So I put some Mtlabelo on my toe it
didn't help. The gout came in my knee. Now it's burning my skin.
What is Mtlabelo? It's a African rub you take a new razor blade and make cuts on
the joint by the skin, so the blood comes out and then you put
Mtlabelo over it.
Location: ankle, toe and knee (index joint = knee)
Side: left
Type of pain: burning, stitching, cutting, tearing, shooting, pressing, pricking,
Radiation of pain: ankle to toe to knee
Sensation: as if somebody hit my legs
Modalities: < standing, walking. My legs feel tired after I walk, it's heavy and I
can't stand up when I'm sitting down
< pressure
> I don't know
Concomitant symptoms: my back is worse when I move or walk. It is paining too
much. I can't even touch it.
Alternating symptoms: none
Strange, rare and peculiar: none
Have you noticed a change in any of the following?
Energy: I 'm very tired
Sleep: I don't sleep well, I feel tired in the morning and sleepy now
Fever: yesterday, but it went after I took a panado
Body perspiration: I sweat a lot, everywhere, anytime.
Bodyaches: only my back is sore
Urination: not everything is coming out. My urine is hot and it burns down my
legs and penis. My urine is thick, do you know what I'm saying it's not
like water, it's thick. It's very, very, light, and some small stuff comes
out like sout (salt). It smells like sulphur. All the urine doesn't come out,
some stays inside.
Headache: not today
Ears: none
Eyes: none
203
Appetite: I don't want food
Thirst: I'm thirsty but don't drink because my urine is burning, it's too sore to go.
Cravings/ aversions: none
Bowel movements: it's ok, Igo everyday. I used to have pimples on my anus, it
went away after I put a rub.
Mental symptoms: I'm in too much pain, my back is so sore. I can't walk.
Neck: it 's stiff
Respiratory: I get flu's and coughing in winter
Chest: it gets tight in winter
Nervous system: none
Male: My penis burns inside when I urinate. I'm weak, I take bubenzi to get
strong. Sometimes I'm itching but there's no rash.
PHYSICAL EXAM INATION
General survey
1.1 Height: 179cm
1.2 Weight: 75kg
1.3 General state: normal
1.4 Dress: normal
1.5 Grooming: normal
1.6 Personal hygiene: normal
1.7 Breath and body odors: normal
1.8 Facial expression and manner: in pain
Main complaint
Color- red
Temperature- cold
Texture- smooth
Tenderness- tender with wince and withdraw
Inflammation- swelling with fluid
Numbness- no light touch and no pain sensation
Perspiration- none
Mobility of joint- patient complains of pain on rising from sitting
204
patient cannot walk or stand due to joint stiffness not
pain on pressure. Knee is unable to bend/ flex.
Patient complains of pain on extension.
Surrounding areas affected - ankle, sole. Patient complained of pain in heel when
standing and therefore required the use of crutches
Skin
3.1 Abnormal lesions: none
3.2 Color: normal
3.3 Nails: normal
3.4 Conjunctiva: normal
Head
4.1 Scalp: rash on scalp
4.2 Hair: dry, thick
4.3 Skull: normal
4.4 Face: cuts on skin
Eyes
5.1 Visual acuity: normal
5.2 Visual fields: normal
5.3 Compare pupils: normal
5.4 Light reaction: normal
5.5 Retinoscopy: normal
Ears
6.1 Auricle: normal
6.2 Ear canal: normal
6.3 Eardrum: normal
6.4 Hearing: normal
Nose and sinuses: normal
Mouth and pharynx: white teeth, healthy gums
Thorax and lungs
9.1 Movement of chest wall: normal
9.2 Percussion note: resonant
9.3 Breath sounds: vesicular
205
9.4 Tactile fremitus: normal
9.5 Added sounds: none
Cardiovascular
10.1 Heart sounds and radiation: normal with no radiation
10.2 Jugular venous pressure: 2.8cm at 45 ° angle
10.3 Apex beat: localized at the point of 5 th left intercostals and midclavicular
line
Abdomen
11.1 Abdominal masses: normal
11.2 Bowel sounds: normal
11.3 Liver: normal
11.4 Spleen: normal
11.5 Aorta: normal
Peripheral vascular system: cold hands and feet
Musculoskeletal system
13.1 Muscle: normal
13.2 Joints: normal
13.3 Neck: normal
13.4 Back: patient complained of pain only on the left lumbar region. Left kidney
tenderness and pain on percussion, no hypertrophy on palpation.
Nervous system
14.1 Cranial nerves: normal
14.2 Motor system, muscle tone, strength and bulk: muscles are strong and bulky
14.3 Gait and co-ordination: limps on right leg, drags left leg.
Co-ordination is normal
14.4 Reflexes: good
Vital signs
15.1 Blood Pressure: 140 /100 mmHg
15.2 Pulse (bilateral) all seven: 68 beats / minute
15.3 Respiratory rate: 20 / minute
15.4 Temperature: 37°C
Serum uric acid: 0.59 mmol /L
206
FOLLOW UP DAY 1
Main complaint: I tried to drink water, I could only drink 3 glasses. My urine
was very hot and it was terrible, it burn't more. It was more sore
I was passing more small things like sand. My knee is still
swollen
Have you noticed a change in any of the following?
Energy: tired
Sleep: very sleepy, I couldn't sleep at night
Fever: none
Perspiration: none
Bodyaches: my back is still very sore
Urination: burning and hot, worse than yesterday.
Headache: none
Appetite: none
Craving: none
Thirst: I'm still thirsty but I don't want to drink water. (The patient was advised to
drink 8 glasses of water in order to drain toxins from the kidneys and to
reduce the back pain and improve the joint symptoms.
Bowel movements: I went to the toilet once today.
Mental symptoms: I think something is wrong with me. I don't think you can
cure me.
Systems review: normal
PHYSICAL EXAMINATION
Index joint
Pain- tearing pain in knee not as severe as Day 0
Sensation- feels as if beaten
Color- bright red
Temperature - cold
Tenderness - tender with wince and withdrawal
Inflammation- swelling with some loss of joint contours
Texture - smooth
Modalities - < standing or moving
207
> rest
Numbness- loss of light touch, pain sensation normal
Perspiration- none
Mobility- cannot flex or extend knee joint
Unable to walk or stand. Pain in heel still persists
Back: no change in tenderness or pain
Vital signs
Blood pressure: 148/ 100 mmHg
Pulse: 70 beats / minute
Respiratory rate: 18 / minute
Temperature: normal
FOLLOW UP DAY 3
Main complaint: I drank 6 glasses of water yesterday and today 3 glasses so far.
My knee is sore today.
Have you noticed a change in any of the following?
Energy: a bit better. I have more energy to walk
Sleep: good sleep at night
Fever: none
Perspiration: none
Bodyaches: my back pain is a bit better, it's working for my back.
Urination: yesterday, it was burning a lot, but I felt much better afterwards, my
back pain went away. It was yellow and with small things like da sout
(salt). Today a lot comes out, it is not burning but da sout (salt) still
comes out.
Headache: none
Appetite: I'm very hungry, even after I eat
Craving: none
Thirst: no thirst
Bowel movements: once a day
Mental symptoms: I feel it's cleaning me inside my kidneys
Systems review: no change
208
PHYSICAL EXAMINATION
Index joint
Pain- reduced
Sensation- burning
Color- red
Temperature- cold
Tenderness- tender
Inflammation- swelling with complete loss of joint contours
Texture - smooth
Modalities - < standing, sitting, walking
> urinating
Numbness- none
Perspiration- none
Mobility- knee joint is able to flex and extend with pain, patient is still
unable to stand or walk
Musculoskeletal System
Back: no change in pain and tenderness
Vital signs
Blood pressure: 140/ 95 mm/Hg
Pulse: 66 beats / minute
Respiratory rate: 18 / minute
Temperature: 37° C
FOLLOW UP DAY 6
Main complaint: I could see yesterday my gout was getting better. At night it was
fine, I could stand and walk like normal, there was no pain.
Have you noticed a change in any of the following?
Energy: yes, I feel brand new. I have too much energy.
Sleep: good. I did not wake up at night.
Fever: none
Perspiration: none
Bodyaches: my back, it's still sore, but not so bad. It gets better everyday.
209
Urination: my urine not burning, but too much comes out, I had to go three times
yesterday. A little bit sand, the sand is white. The urine is light yellow.
Headache: none
Appetite: I'm not hungry today.
Craving: none
Thirst: I am very thirsty, yesterday and the other day I had about 2 liters of water,
I'm still thirsty.
Bowel movements: good, I'm not pushing so much when I go, it just comes out
nicely but my anus is itching, I scratch the pimples.
Mental symptoms: I feel good and clean inside, I feel brand new.
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Pain- no pain
Radiation- none
Sensation- none
Color- normal
Temperature- cool
Tenderness- none
Inflammation-none
Texture- normal
Modalities- none
Numbness-none
Perspiration-none
Mobility- normal, flexion and extension of knee.
Patient is able to walk, stand and sit normally with no pain.
Vital signs
Blood pressure: 140/ 95mg/Hg
Pulse: 70 beats / minute
Respiratory rate: 18 / minute
Temperature: 37° C
Serum uric acid: 0.40 mmol/L1
210
FOLLOW UP DAY 15
Main complaint: I'm fine, I can walk and there's no swelling
Have you noticed a change in any of the following?
Energy: no, I feel normal.
Sleep: not so good, I wake up sleepy
Fever: none
Perspiration: I'm sweating too much at work, it's too hot.
Bodyaches: my back pain is gone since Tuesday (day 10).
Urination: it's yellow again, but not burning and no sand.
Headache: none
Ears: no pain
Eyes: no pain
Appetite: I'm not hungry at work, but I must eat when I come home.
Craving: none
Thirst: yes, I am thirsty and I try to drink lots of water when I can.
Bowel movements: normal, once a day.
Mental symptoms: I'm number one
Systems review
Neck: it's sore today, because I carried heavy bags yesterday
Respiratory: no problem
Cardiovascular: my chest hurts when I come home from work, mostly when we
pick up the big furniture
Neurological: none
Male: It's the same, I've got no power.
PHYSICAL EXAMINATION
Index joint
Pain- no pain
Radiation- none
Sensation- none
Color- normal
Temperature- cool
211
Tenderness- none
Inflammation- none
Texture- normal
Modalities- none
Numbness- none
Perspiration-foot sweat, bad odor
Mobility- normal, ability to walk and stand with no problems.
Musculoskeletal system
Back: no renal tenderness or pain
Vital signs
Blood pressure: 140/ 97mmHg
Pulse: 68 beats / min
Respiratory rate: 18 / min
Temperature: 37 °C
212
SUBJECTS QUESTIONNAIRE Day 0 1 2 3 4 5 6
1. What would you rate your pain intensity as?
0 = minimum 10 = maximum
8 8 7 7 5 3 0
2. Level of swelling of joints?
0 = minimum 10 = maximum
9 8 7 6 5 2 0
3. Is there discoloration of the joint?
0 = minimum 10 = maximum
8 8 7 7 6 2 0
4. Is your sleep affected?
0 = minimum 10 = maximum
9 10 4 3 3 5 1
5. Level of activity?
0 = minimum 10 = maximum
9 9 7 6 5 2 0
6. Rate your improvement as a%
0= 100% improvement
10= 0% improvement
10 9 7 6 5 3 0
RESEARCHERS QUESTIONNAIRE
Day 0 1. 3 6 15
a) Joint improvement?
0= total resolution
1= improvement of > 50%
2= improvement of< 50%
3= no change
4= worsening of symptoms or involvement
of previously uninvolved joints
4 3 2 0 0
b) Severity of swelling?
0= no swelling
1= swelling with some loss of joint contours
2= complete loss of joint contours
3= fluid
3 2 2 0 0
c) Degree of tenderness
0= no tenderness
1= tender
2= tender and wince
3= tender + wince+ withdraw
3 3 1 0 0
213
Case G
Sum of symptoms (sort:deg) This analysis contains 315 remedies and 8 symptoms. Intensity is considered
1. EXTREMITIES - PAIN - Joints - gouty 1 190
2. URINE - THICK 4 71
3. EXTREMITIES - PAIN - tearing - Knee 4 112
4. URINE - SEDIMENT 2 125
5. EXTREMITIES - PAIN - Joints - wandering 4 35
6. KIDNEYS - PAIN - motion - agg. 2 13
7. EXTREMITIES - PAIN - Foot - Heel - standing 2 7".
8. BLADDER - URINATION - incomplete 2 37,
1 2 3 4 5 6 7 berb. camph. coich. phos. kali-bi. caust. lach.
8 iris
9 10 11 12 13 puls. sep. merc. nux-v. ars.
14 15 16 17 18 19 arn. rhus-t. hep. suiph. mang. bell. "-
21/31 14/20 13/27 13/24 13/23 13/21 12/26 12/16 11/3211/29 11/25 11/23 11/22 11/21 11/21 11/20 11/19 11/18 11/17
1. 1 - 3 2 1 3 - - 2 3 3 3 2 3 3 2 3 2 3
2. 1 1 2 - 1 1 - 3 2 3 2 2 1 2 1 1
3. 2 1 2 2 1 2 2 1 3 , 2 2 - 2 3 1 2 1 2
4. 2 2 2 2 2 1 2 3 f .3 3 1 2 1 1 2 2 1 v 5. 1 2 2 3 2 2 3 - 2 2
6. 2 2 1 .
- - 2 - -
7. 1 - - - - - a* 4 -
8. 2 1 2 3 - 1 - 3
LANCET LABORATORIES
WHI SSTIIMplAwiwirmesto3sci PLC 120108
GLYNNWOOD LABORATORY Glynnwood Hospital cnr Woburn Ave & Harrison Str. Benoni Tel:(01J) 845-1960 Fax: (011) 421-9659
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PACE : 1 *** BIOCHEMISTRY ***
Test > S -URIC ACID
Result Units Reference 3,0.59 mmo1/1 0.14 - 0.51
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Tests : AUTO ORDER, S-UA
Authorised by DR P COLE For consultation by referring doctors phone': (011) 358-0808
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LABORATORIES VITS SR6 telplAweadarboefxoso/
MN .32010S
Mabee eleaSeriel .
GLYNNWOOD LABORATORY 61ynnwood Hospital cur Woburn Ave & Harrison Str. Benoni Te1:(011) 845-1960 Fax:(011) 421-9659
-------
----------
Tests : AUTO ORDER, S-UA
*** BIOCUEMISTRT *** PAGE :
Test > S -URIC ACID
Result Units Reference 9.40 mmol/1 0.14 - 0.51
Authorised by DR P COLE , For consultation by referring doctors phone : (011) 358-0808
APPENDIX M
Patient H
Age: 65
Sex: male
Race: black
Occupation: retired
Past medical history: Shingles- 45 years old
Hypertension- stopped medication last week didn't go to
clinic to get more
Gout- Brufen
Stomach ulcers- Gaviscon
Past surgical history: none
Family history: can't remember
Vaccination: I was vaccinated as a child but not in the past 30 years
Allergies: none
Present medication: was taking coversyl and urirex K for high blood pressure
Alcohol: African beers (nkomobti)
Diet: Breakfast- matabelli porridge
Lunch and supper- red meat and vegetables. I tried to eat white meat but I
don't like it with pap and rice. My doctor said I mustn't eat spicy food and
salt, so I don't.
History of gout
When did it start? Early 30's, I used to drink a lot of beers and we only eat red
meat. One day I woke up sweating and had a pain in my foot. I
thought I was going to die. The doctor said I have gout. He gave
me some pills and told me to stop drinking alcohol and eating
red meat. I didn't listen. If I stopped drinking my friends would
have left me, I'll be bored every weekend.
Cause: beer and red meat
Number of joints affected: shoulders, knee, l st metatarsophalangeal joint
Number of attacks during the year: last time it attacked me is last of last year, I
take Brufen as soon as I feel a pain coming.
216
Main complaint
When did it start? yesterday
How did it start? I was sleeping in the afternoon and started feeling hot. I drank
water but it didn't help. I started sweating on my face. When my
daughter came home from work, I complained because my
shoulder was so sore. In the evening my toe was so bad I was
screaming. I didn't have any medication at home, I couldn't
sleep the whole night. Next morning my toe was burning. It was
dark red. and hot and so painful I couldn't touch it.
Location: 1 st metatarsophalangeal joint (index)
Side: left
Type of pain: burning and tearing
Radiation of pain: shoulder to metatarsophalangeal joint (index)
Sensation: it's so sore
Observation: patient on wheel chair, unable to stand or put any pressure on toe,
no shoes on affected foot
Modalities: < movement
touch
< pressure
evening
rest
< cold
Alternating symptoms: none
Have you noticed a change in any of the following?
Energy: weak and tired
Sleep: restless, I can't sleep with the pain.
Fever: it's not as bad as last night.
Body perspiration: I don't sweat at all, but it does smell in my groin and under
Arms, I was sweating on my face with the fever.
Bodyaches: my body always pains my joints and muscles are getting weaker.
Urination: this morning it was burning, dark and very little. Normally I urinate
many times and lots come out.
217
Head: I do get headaches but not today.
Nose: everything is smelling stronger, whatever I'm smelling makes me sick
Ear: I 'm losing my hearing
Eyes: I don't see as well as I used to, I can't read the small print on the
newspaper but I see the words. I don't wear glasses.
Appetite: since yesterday, no appetite. I want to eat but if I smell
food I want to vomit. I'm drinking milk and juice for
energy.
Thirst: no thirst, I don't drink water only milk and juice. 3-5 glasses a day.
Cravings/ aversions: crave sand, I like to eat sand
Bowel movements: I'm mostly constipated but this morning it came out easy and
loose.
Generals: I'm losing weight
Mental symptoms: I'm old my body is giving up and I can't remember a lot
of things. My memory is weak. I'm sad when I can't do things
for myself and need my daughter.
Neck and back: my neck and whole back pains
Respiratory: my chest feels tight. I get sharp pains when I breathe. This happens
for the past year.
Cardiovascular: my heart beats fast sometimes and I get short of breathe. This is
happening since 2001.
Nervous system: no problem
Male: normal
PHYSICAL EXAMINATION
1. General survey
1.1 Height: 1.65m
1.2 Weight: 80 kg
1.3 General state: weak
1.4 Dress: normal
1.5 Grooming: normal
1.6 Personal hygiene: clean
1.7 Breath and body odors: normal
218
1.8 Facial expression and manner: in a lot of pain
Index joint
Observation (no shoes on affected foot, patient in wheelchair due to acute gout
symptoms)
Color- dark red
Temperature - joint is hot but rest of foot is cold
Texture - smooth
Tenderness - tender with wince and withdraw
Inflammation- swollen with fluid
Numbness- normal light touch and normal pain sensation
Perspiration - none
Mobility of joint- patient winces on touching and moving joint. Pain on
touch and movement is unbearable
Skin
3.1 Abnormal lesions: naevi on neck
3.2 Color: normal
3.3 Nails: brittle, long
3.4 Conjunctiva: normal
Head
4.1 Scalp: normal
4.2 Hair: baldness and hair loss, gray hair
4.3 Skull: normal
4.4 Face: old and wrinkled
Eyes
5.1 Visual acuity: poor
5.2 Visual fields: poor
5.3 Compare pupils: in line
5.4 Light reaction: normal
5.5 Retinoscopy: Arteriole silver wiring with arteriovenous nipping.
Ears
6.1 Auricle: normal
6.2 Ear canal: normal
219
6.4 Eardrum: normal eardrum
6.5 Hearing: hearing is abnormally acute, patient can hear soft whispers clearly
and complains that everything sounds too loud.
Nose and sinuses: acute sense of smell
Mouth and pharynx: false teeth
Thorax and lungs
9.1 Movement of chest wall: barrel chest, decreased ability to move respiratory
muscles
9.2 Percussion note: dullness
9.3 Breath sounds: difficulty inspiring, with stitching cutting pain. No other
abnormalities.
9.4 Vocal resonance: normal
9.5 Added sounds: none
Cardiovascular
10.1 Heart sounds and radiation: tachycardia with no radiation or murmurs
10.2 Jugular venous pressure: 2cm at 45 degree angle
10.3 Apex beat: 5th intercostals space and midclavicular line
Abdomen
11.1 Abdominal masses: no pain on palpation
11.2 Bowel sounds: borborygmi and increased bowel sounds
11.3 Liver: not enlarged
11.4 Spleen: normal
11.5 Aorta: no abdominal aorta aneurysm noted, no renal artery bruit
Peripheral vascular system: legs, poor circulation in feet,
both feet are cold to touch
Musculoskeletal system
13.1 Muscle: atrophy of muscle, poor muscle tone and strength
13.2 Joints: limited range of motion
13.3 Neck: tenderness in neck region
13.4 Back: kyphosis, tenderness around paravertebral and lumbar area, no
kidney enlargement
220
Nervous system
14.1 Cranial nerves: reaction is slow, and weak
14.2 Gait and co-ordination: patient on wheel chair, unable to stand or put any
pressure on toe, hops on unaffected leg. Weak and
poor co- ordination
14.3 Reflexes: very poor reflexes
Vital signs
15.1 Blood Pressure: 160/ 100 mmHg
15.2 Pulse (bilateral): 110 beats / minute (diminished femoral pulse)
15.3 Respiratory rate: 20 / minute
15.4 Temperature: 38.3 °C
Serum uric acid: 0.47 mmol/L
FOLLOW UP DAY 1
Main complaint: I feel a little better, I can touch my toe but it still pains. I can't
move it and it's still swollen.
Have you noticed a change in any of the following?
Energy: more alive
Sleep: a good sleep last night
Fever: no fever
Perspiration: none
Bodyaches: still weak
Urination: more urine than usual, still dark but not burning.
Headache: none, a ringing noise doesn't want to go
Did you have this noise before? no
Appetite: I 'm hungry but i f I smell the food I feel sick. I had soup at night for
supper and cereal for breakfast. I can eat i f I block my nose.
Craving: none
Thirst: not thirsty but I must drink juice or milk
Bowel movements: I had a loose stool not diarrhea. My stomach feels clean
inside.
Mental symptoms: I don't feel so sad today.
221
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Pain- I can handle the pain but it's still there
Radiation- none
Sensation- it 's not so sore
Color- red
Temperature- joint hot and feet cold
Tenderness- tender and wince
Inflammation- swelling with complete loss of joint contours
Texture- smooth
Modalities: < movement
touch
< pressure
evening
cold
rest
Numbness- none
Perspiration- none
Mobility- patient winces on bending toe. No pain on extension, cannot stand or
walk on affected part
Vital signs
Blood pressure: 160/100mmHg (patient advised to go to clinic for
antihypertensive medication
Pulse: 100 beats / minute
Respiratory rate: 19 / minute
Temperature: 37 °C
FOLLOW UP DAY 3
Main complaint: My feet are looking better today. I can move my toe but I can't
walk on them. It's still a bit swollen and red.
222
Have you noticed a change in any of the following?
Energy: I feel more awake today
Sleep: I had a good sleep
Fever: none
Perspiration: none
Bodyaches: my back is still sore.
Urination: normal now, yellow and not burning
Headache: no headache
Ear: normal
Nose: I'm smelling properly also
Eyes: no change
Appetite: good, I ate meat and pap without feeling sick
Craving: none
Thirst: not thirsty
Bowel movements: very good, I used to be constipated but the tablets make me
feel very good. I went twice today.
Mental symptoms: I feel happy
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Observation: patient on crutches with sandals on feet.
Pain- slight
Radiation- none
Sensation- none
Color- pink
Temperature - warm joint and feet
Tenderness- tender
Inflammation- swelling with some loss of joint contours
Texture- rough
Modalities- none
Numbness- none
Perspiration- none
223
Mobility- patient able to flex and extend first digit with no pain,
pain on walking
Vital signs
Blood pressure: 160/ 90 mmHg (patient began hypertension medication on Day 1)
Pulse: 90 beats / minute
Respiratory rate: 20 / minute
Temperature: 37 r
FOLLOW UP DAY 6
Main complaint
I woke in the morning, walked to the kitchen, my daughter she got a shock
because I was walking normally with out my crutches. I didn't realize that
my gout is gone.
Have you noticed a change in any of the following?
Energy: normal, I don't feel tired
Sleep: I had a lot of dreams but I can't remember them.
Fever: none
Perspiration: my arms smell bad
Bodyaches: my back is still stiff
Urination: more comes out, it's not burning and it's still yellow
Head: my hair still falls out
Ears: normal
Eyes: normal
Nose: normal
Appetite: I can eat normally, I don't feel sick anymore
Craving: meat
Thirst: I drink lots of milk for my bones to get strong, about a liter a day
Bowel movements: my stomach is working everyday, my daughter is feeding me
good vegetables, but I want my meat
Mental symptoms: I feel good today because I can walk again. I'm not so tired
but I 'm still losing weight
Systems review: I feel tired when I walk too far
224
PHYSICAL EXAMINATION
Index joint
Observation: patient has shoes and socks on and is walking normally without the
use of crutches
Pain- no pain
Radiation- none
Sensation- none
Color- pink
Temperature- warm
Tenderness- none
Inflammation- none
Texture- normal
Modalities- none
Numbness- no
Perspiration-foot odor
Mobility- normal
Vital signs
Blood pressure: 150/80 mmHg
Pulse: 100 beats / minute
Respiratory rate: 20 / minute
Temperature: 37 r
Serum uric acid- 0.40mmol /L
FOLLOW UP DAY 15
Main complaint: my gout is gone, I can walk normal with no pain
Have you noticed a change in any of the following?
Energy: I'm tired again.
Sleep: I sleep fine.
Fever: no fever
Perspiration: I don't sweat.
Bodyaches: the same, my muscles and joints are weak
Urination: no smell, yellow, no problems
225
Headache: no headache but my hair is still falling
Appetite: normal
Craving: none
Thirst: not thirsty, still drinking milk and juice
Bowel movements: normal, I went once yesterday
Mental symptoms: I feel alright
Systems review
Respiratory: I feel a pain in my chest especially when I 'm coughing
Cardiovascular: I rest if I feel my heart beating too much, especially i f I walk far.
PHYSICAL EXAMINATION
Index joint
Pain- no pain
Radiation- none
Sensation- none
Color- pink
Temperature- warm
Tenderness- none
Inflammation- none
Texture- rough
Modalities- none
Numbness- none
Perspiration- bad foot odor
Mobility- ability to flex and extend toe, stand and walk without complaining of
pain.
Eyes
Visual acuity: poor
Visual fields: poor
Compare pupils: in line
Light reaction: normal
Retinoscopy: Arteriole silver wiring with arteriovenous nipping.
Ears
Auricle: normal
226
Ear canal: normal
Eardrum: normal eardrum
Hearing: normal
Nose and sinuses: normal
Thorax and lungs
Movement of chest wall: barrel chest, decreased ability to move respiratory
muscles
Percussion note: dullness
Breath sounds: difficulty inspiring, with stitching cutting pain. No other
abnormalities.
Vocal resonance: normal
Added sounds: none
Cardiovascular
Heart sounds and radiation: tachycardia with no radiation or murmurs
Jugular venous pressure: 2cm at 45 ° angle
Apex beat: 5th intercostals space and midclavicular line
Abdomen
Abdominal masses: no pain on palpation
Bowel sounds: normal
Liver: not enlarged
Spleen: normal
Aorta: no abnormalities
'Peripheral vascular system: normal
Musculoskeletal system
Muscle: atrophy of muscle, poor muscle tone and strength
Joints: limited range of motion
Neck: tenderness in neck region
Back: kyphosis, tenderness around paravertebral and lumbar area, no kidney
enlargement
Nervous system
Cranial nerves: reaction is slow, and weak
Gait and co -ordination: gait normal with no wheelchair. Weak and poor co-
227
ordination
Reflexes: poor reflexes
Vital signs
Blood pressure: 150/ 80 mmHg
Pulse: 88 beats / minute
Respiratory rate: 17 / minute
Temperature: 37 r
228
SUBJECTS QUESTIONNAIRE Day 0 1 2 3 4 5
1.What would you rate your pain intensity as?
0 = minimum 10 = maximum
10 9 8 8 6 3 0
2. Level of swelling of joints?
0 = minimum 10 = maximum
10 9 8 7 6 3 0
3. Is there discoloration of the joint?
0 = minimum 10 = maximum
9 7 5 5 4 0 0
4. Is your sleep affected?
0 = minimum 10 = maximum
10 3 3 3 0 0 1
5. Level of activity?
0 = minimum 10 = maximum
10 9 5 5 5 2 0
6. Rate your improvement as a%
0= 100% improvement
10= 0% improvement
10 8 7 7 5 4 1
RESEARCHERS QUESTIONNAIRE
Day 0 1 3 6 15
a) Joint improvement?
0= total resolution
1= improvement of > 50%
2= improvement of< 50%
3= no change
4= worsening of symptoms or involvement
of previously uninvolved joints
4 2 1 0 0
b) Severity of swelling?
0= no swelling
1= swelling with some loss of joint contours
2= complete loss of joint contours
3= fluid
3 2 1 0 0
c) Degree of tenderness
0= no tenderness
1= tender
2= tender and wince
3= tender + wince+ withdraw
3 2 1 0 0
229
ease ri
Sum of symptoms (sort:deg) This analysis contains 337 remedies and 8 symptoms. Intensity is considered
1. EXTREMITIES - PAIN - Joints - gouty . _. .
4 190
2. EXTREMITIES - SWELLING - Joints 2 68
3. STOMACH - NAUSEA - food - smell of 1 19
4. GENERALS - TOUCH - agg. 2 200
5. FACE - PERSPIRATION 1 153
6. EXTREMITIES - PAIN - Joints - wandering 4 38
7. GENERALS - FOOD and DRINKS - sand - desire 1 2 i..
8. MIND - SENSITIVE - pain, to 2 35
1 2 colch. ars.
3 4 5 6 7 8 9 10 11 12 13 aur. ferr-p. cocc. mang. kali-bi. ant-t. nat-s. rhod. sabin. kalm. bell.
14 15 hep. nux-v.
16 lyc.
17 puts.
18 19 20' arn. calc-p. aesc.
16/38 16/32 15/25 15/17 14/30 14/26 13/24 13/21 13/18 12/26 12/24 12/22 11/31 11/29 11/29 11/27 11/27 11/26 11/24 11/13
1. 3 2 1 1 2 2 1 1 2 2 3 2 3 2 3 3 2 3 3 1
2. 3 2 1 2 2 1 1 2 2 1 2 3 3 2 2 2
3. 3 2 2 - - -
4. 3 2 1 1 3 3 2 2 1 . 3 ! _
3 1 3 3 3 3 2 2 1 2
5. 1 2 1 1 2 2 1 2 ' - 3 1 3 3 3 2 2 ^t,
6. 2 2 3 1 2 2 3 ,2 1 2' 1 2 3 2 1 6
7. - - - 1 .
-
8. 1 2 2 1 1 - 1 2 4 2 1 2
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GLYNNWOOD LABORATORY Clynnwood Hospital cnr Woburn Ave & Harrison Str. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659
Teat > 5-URIC ACID
Result Unita Reference•
0.47 mmol/1 0.14 - 0.51
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Tests : AUTO ORDER, S-UA
*** BIOCHEMISTRY *** PAGE : 1
Authorised by DR P COLE Tor consultation by referring doctors phone : (011) 358-0808
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GLYNNWOOD LABORATORY Clynnwood Hospital cnr Woburn Ave & Harrison Str. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659 rvo
Tests : AUTO ORDER, S-UA
*** BIOCHEMISTRY *** PAGE : 1
Test Result Units Reference > S -URIC ACID 0%40 mmo1/1 0.14 - 0.51
Authorised by DR P COLE For consultation by referring doctors phone : (011) 358-0808
APPENDIX N
Patient I
Age: 32 years
Sex: male
Race: Indian
Occupation: shopkeeper
Past medical history: occasional cough mixtures or flu tablets
Past surgical history: none
Family history: both are still alive and healthy
Vaccination: all done
Allergies: sulphur dioxide
Present medication: none
Alcohol: social drinker, I drink a lot on weekends. Breezers, beers, tequila,
cocktails, wines, shooters. I love to try new drinks on the market and my
tolerance is good I don't get drunk quickly.
Diet: I am not health conscious, I can eat anything provided it's tasty. Coffee or
tea and toast in the morning. Meat (white or red) for lunch and supper. I
don't eat veggies as a side dish, but my mum continues to make it and I don't
eat salads.
History of gout
When did it start? My second attack was in the beginning of 2002.
How did it start? The first time was terribly painful, I woke up one Sunday night
after partying, with a terrible pain in my toe. I wanted the fastest
pain relief and settled for a voltaren injection. The next attack I
was given cataflam.
Cause: my drinking habit
Number of joints affected: one, big toe
Number of attacks during the year: one
Renal stones: no
Main complaint
How did it start? It all happened so suddenly I was fine yesterday. Last night I
started feeling hot. I was burning hot and couldn't sleep with a
232
blanket and then. I felt a sharp pain in my toe, I screamed. I
hopped to the kitchen and put ice on it. It only helped a bit, I'm in
so much pain now.
Location: tarsal and metatarsophalangeal joint (index)
Side: right
Type of pain: This must be the worst pain of my life, I can't bear it. It feels like
it's tearing inside.
Radiation of pain: none
Sensation: I feel a beating sensation in my toe, like a heartbeat.
Modalities: < movement
touch
> pressure
cold application
rest
Concomitant symptoms: fever
Have you noticed a change in any of the following?
Energy: depleted energy
Sleep: no sleep
Fever: sudden fever, I'm burning up, I can't take the heat. I was chilly before I
came, I don't feel well
Body perspiration: my head mostly and my body, I'm wet
Bodyaches: none
Urination: I don't know I didn't urinate this morning like usual. I don't have an
urge to go.
Appetite: I'm very hungry
Thirst: no thirst
Cravings/ aversions: salt and vinegar chips
Bowel movements: normal twice daily, It was normal this morning.
Mental symptoms: I'm in pain, and I feel sick, tired and restless.
Head: my head is burning up and the throbbing gets bigger and bigger as if its
going to burst
Nose: no pain
233
Ear: I feel a lot of pressure in my ear, it feels blocked
Eyes: I wear contacts, they don't agree with my eyes so sometimes my eyes get
red.
Neck: no pain
Respiratory: no problem
Chest: no pain
Nervous system: fine
Male: normal
PHYSICAL EXAM INATION
General survey
1.1 Height: 158 cm
1.2 Weight: 83 kg
1.3 General state: normal
1.4 Dress: neat
1.5 Grooming: well
1.6 Personal hygiene: very hygienic
1.7 Breath and body odors: none
1.8 Facial expression and manner: friendly
Index joint
(1 3t metatarsophalangeal joint)
Color- very bright red
Temperature- joint very hot to touch, but feet are cold
Texture- very smooth
Tenderness- tender with wince and withdraw patient winces on
approaching to touch
Inflammation- intense swelling with fluid
Numbness- no numbness
Perspiration- none over joint
Mobility of joint- immobile, slightest movement causes pain
Surrounding areas affected- none
Skin
3.1 Skin: very hot too touch
234
3.2 Color: bright red
3.3 Nails: normal
3.4 Conjunctiva: normal
Head
4.1 Scalp: normal, but hot too touch
4.2 Hair: normal
4.3 Skull: normal
4.4 Face: bright red
Eyes
5.1 Visual acuity: normal with contact lenses
5.2 Visual fields: normal
5.3 Compare pupils: pupils inline
5.4 Light reaction: normal
5.5 Retinoscopy: normal
Ears
6.1 Auricle: bright red and hot to touch
6.2 Ear canal: normal
6.4 Eardrum: normal
6.5 Hearing: normal
Nose and sinuses: normal
Mouth and pharynx: normal
Thorax and lungs
9.1 Movement of chest wall: normal
9.2 Percussion note: normal
9.3 Breath sounds: normal
9.4 Vocal resonance: normal
9.5 Added sounds: none
Cardiovascular
10.1 Heart sounds and radiation: no abnormalities
10.2 Jugular venous pressure: 2.8 cm at 45 ° angle
10.3 Apex beat: 5th left intercostals and midclavicular line
Abdomen
235
11.1 Abdominal masses: none
11.2 Bowel sounds: normal
11.3 Liver: normal
11.4 Spleen: normal
11.5 Aorta: normal
Peripheral vascular system: skin is bright red and hot to touch
Musculoskeletal system
13.1 Muscle: normal
13. 2 Joints: normal
13.3 Neck: normal
13.4 Back: normal
Nervous system
14.1 Cranial nerves: normal
14.2 Motor system, muscle tone, strength and bulk: normal
14.3 Gait and co-ordination: hops on one leg with the assistance of a walking
stick. Co-ordination normal
14.4 Reflexes: normal
Vital signs
15.1 Blood Pressure: 120 / 90 mmHg
15.2 Pulse (bilateral) all seven: 75 / minute full and bounding
15.3 Respiratory rate: 18 / minute
15.4 Temperature: 40 °C
Serum uric acid: 0.33 mmol/
FOLLOW UP DAY 1
Main complaint: my fever has come down, and I feel much better.
Have you noticed a change in any of the following?
Energy: my energy has normalized, I don't feel weak like yesterday
Sleep: I slept quite peaceful last night
Fever: I felt my fever coming down after taking the first dose and by the third it
was almost gone.
Perspiration: no perspiration
236
Bodyaches: none
Urination: back to normal, no pain, yellow color, it flows normal
Headache: I woke up with a headache, but it's gone now
Appetite: normal, I'm not hungry at the moment
Craving: none
Thirst: no thirst, but I normally drink water during the day even though I'm not
thirsty.
Bowel movements: normal, twice daily.
Mental symptoms: I feel much better compared to yesterday.
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Pain- no pain
Radiation- no radiation
Sensation- none
Color- pink
Temperature- warm
Tenderness- no tenderness
Inflammation- no inflammation
Texture- normal, dry and rough
Modalities- none
Numbness- none
Perspiration- none
Mobility- normal, patient is able to stand and walk on affected foot, as well as
flex and extend toe.
Surrounding areas affected: none
Vital signs
Blood pressure: 120/ 90 mmHg
Pulse: 68 beats / minute
Respiratory rate: 18 / minute
Temperature: 37.5 °C
237
FOLLOW UP DAY 3
Main complaint: my gout is gone and hasn't come back so far.
Have you noticed a change in any of the following?
Energy: I'm pretty normal, works been very busy, so I'm pretty exhausted when I
get home.
Sleep: I have been having normal good sleeps
Fever: no fever
Perspiration: I perspire a lot on hot days, but it doesn't come out of my skin, it
only gives off a smell.
Bodyaches: none
Urination: normal, yellow, no pain and about three times a day.
Headache: none
Appetite: normal, I get hungry at twelve o' clock my lunchtime and four o' clock
tea time and at suppertime.
Craving: peanuts, I feel like having peanuts today.
Thirst: no thirst, I drank 4 glasses of water yesterday and 2 glasses today.
Bowel movements: normal, twice a day, no constipation.
Mental symptoms: I feel fine, I get tired in the evening after work,
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Pain- no pain
Radiation- no radiation
Sensation- none
Color- pink
Temperature- warm
Tenderness- none
Inflammation- none
Texture- normal
Modalities- none
Numbness- no
Perspiration- none
238
Mobility- normal
Surrounding areas affected: none
Vital signs
Blood pressure: 120/ 90 mmHg
Pulse: 70 beats / minute
Respiratory rate: 17 / minute
Temperature: 37 °C
FOLLOW UP DAY 6
Main complaint: I had another attack last night, I felt a fever coming on and my
toe started throbbing but not as bad as when I first saw you. I
immediately took the medication you gave and I was fine in the
morning.
Have you noticed a change in any of the following?
Energy: I feel normal. Not sick that's a good thing.
Sleep: restless before the fever and normal after taking medication
Fever: I got really hot, and slept without the blankets
Perspiration: I felt hot last night, but didn't perspire
Bodyaches: none
Urination: it burnt a bit this morning.
Headache: none
Appetite: normal
Craving: no craving
Thirst: no thirst, I know the benefits of water in keeping me sober, so I drink a lot
of water especially before I go out to drink. No I haven't drank alcohol
since we began treatment.
Bowel movements: normal
Mental symptoms: I'm a bit afraid that the pain might come back, but otherwise
there's no complaint
Systems review: no change
239
PHYSICAL EXAMINATION
Index joint
Pain- no pain
Radiation- no radiation
Sensation- none
Color- pink
Temperature- warm
Tenderness- none
Inflammation- none
Texture- normal
Modalities- none
Numbness- no
Perspiration- none
Mobility- normal
Surrounding areas affected: none
Vital signs
Blood pressure: 120/ 90 mmHg
Pulse: 70 beats / minute
Respiratory rate: /7/ minute
Temperature: 37 °C
Serum uric acid: 0.38 mmol /L
FOLLOW UP DAY 15
Main complaint: I haven't had another attack, and have been fine so far
Have you noticed a change in any of the following?
Energy: we have been very busy with work and I've been drinking a lot of coffee
to stay alert
Sleep: I have been sleeping restlessly, my body is tired but my mind stays awake
Fever: no fever
Perspiration: none
Bodyaches: we have been carrying a lot of boxes so my back is feeling some
strain
240
Urination: normal
Headache: my head feels dull, from a lack of sleep
Appetite: normal
Craving: coffee
Thirst: no thirst
Bowel movements: normal
Mental symptoms: irritable at work, I feel like I do everything and there's no one
to help me, the staff are family members so I can't shout them
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Pain- no pain
Radiation- no radiation
Sensation- none
Color- pink
Temperature- cool
Tenderness- none
Inflammation- none
Texture- normal
Modalities- none
Numbness- no
Perspiration- none
Mobility- normal
Surrounding areas affected: none
Vital signs
Blood pressure: 120/ 90 mmHg
Pulse: 70 beats / minute
Respiratory rate: / 7/minute
Temperature: 36.8 °C
241
SUBJECTS QUESTIONNAIRE Day 0 1 2 3 4 5 6
1.What would you rate your pain intensity as?
0 = minimum 10 = maximum
10 1 0 0 0 8 0
2. Level of swelling of joints?
0 = minimum 10 = maximum
10 1 0 0 0 7 0
3. Is there discoloration of the joint?
0 = minimum 10 = maximum
10 0 0 0 0 6 0
4. Is your sleep affected?
0 = minimum 10 = maximum
10 3 0 1 2 6 1
5. Level of activity?
0 = minimum 10 = maximum
10 2 0 0 0 3 0
6. Rate your improvement as a%
0= 100% improvement
10= 0% improvement
10 1 0 0 0 7 0
RESEARCHERS QUESTIONNAIRE
Day 0 1 3 6 15
Joint improvement?
0= total resolution
1= improvement of > 50%
2= improvement of< 50%
3= no change
4= worsening of symptoms or involvement
of previously uninvolved joints
4 1 1 0 0
Severity of swelling?
0= no swelling
1= swelling with some loss of joint contours
2= complete loss of joint contours
3= fluid
3 0 0 0 0
Degree of tenderness
0= no tenderness
1= tender
2= tender and wince
3= tender + wince+ withdraw
3 0 0 0 0
242
SuM of symptoms (sort:deg) This analysis contains 174 remedies and 8 symptoms. Intensity is considered
1. GENERALS - PAIN - appear suddenly 4 67
2. EXTREMITIES - DISCOLORATION - Joints - redness 4 13
3. EXTREMITIES - HEAT - Joints 3 10
4. EXTREMITIES - SWELLING - Joints 1 68
5. FEVER - BURNING heat 4 73
6. EXTREMITIES - PAIN - pulsating 2 7-
7. MIND - SENSITIVE - pain, to 1 35
8. HEAD - PAIN - bursting - fever, with 2 3'.
1 bell.
2 3 4 5 6 7 8 puls. kali-bi. form. acon. ars. nux-v. apis
9 lyc.
10 11 12 13 14 15 16 17 18 19 20, rhus-t. nit-ac. tarent. merc. canth. dulc. med. sabin. eup-per. sil. stann.
21/4012/32 12/12 11/18 10/25 10/24 10/20 10/1910/15 9/22 9/17 9/17 9/14 9/13 9/13 9/13 9/13 9/9 9/9 f.
9/9-
1. 3 2 1 1 2 2 2 - 1 - 3 2 2 - 1 2 1 1 1
2. 1 3 1 2 - 1 - 3 - 2 1
3. 1 1 2 - - - - - - -
4. 3 1 1 2 2 2 2 2 - 1 2 - 1 1 1 1 1
5. 3 3 3 3 2 3 2 . , 2- 1 2 1 1 2 2 1 1 1 1,
6. 1 - .. - -
7. 2 4 2 2 1 1 - 1 1 -; - 1
8. 1 - - 4-
;.
LANCET LABORATORIES
WES W hltioftwonsionoot.coso/
Pith . SMOSS
CLYNNWOOD LABORA TORY Glynnwood Hospital cnr Woburn Ave & Harrison Str. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659
(
e Tests : AUTO ORDER, S-UA
***BIOCHEMISTRY*** •
Test Result Units > S -URIC ACID 0.33 mmo1/1
Authorised by DR P COLE For consultation by referring doctors phone : (011) 358-0808
'
..
.
•
•
■ -
•
PACE : 1
Reference
0.14 - 0.51
•
.
• O. ION gm as am NOM auttleall •
Teets : AUTO ORDER, S-UA
*** BIOCIIDUSTRT *** so
PAGE : 1
Test
Result Units Reference > S -URIC ACID
0.38 mmol/1 0.14 - 0.51
Authorised by DR P COLE ,1 For consultation by referring doctors phone : (011) 358-0808
LANCET LABORATORIES
WU Rib PrItir.//mwaloneeteese/ PIA .31010N
a WORM CO LABORATORY Clynnwood Hospital cnr Woburn Ave & Harrison Str. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659
1 rl
•••
•
‘1010MINgana MII34111 pealoicsio •
APPENDIX 0
Patient J
Age: 45
Sex: male
Race: white
Occupation: manager of the bakery
Past medical history: gout, renal stones, asthma, anemia
Past surgical history: none
Family history: gout- father
Vaccination: chickenpox, measles, hepatitis A, yellow fever
Allergies: tartarzine
Present medication: multivitamins, iron supplements, Genasma and venteeze
Alcohol: I enjoy drinking. I have one or two beers daily with lunch or supper. A
six pack of beers on a weekend including a few hot shots eg. Jack daniels,
brandy, scotch. I don't get drunk, I drink because it relaxes me,. it's nice
to come home, relax and have a drink.
Diet: I love food, I have very big helpings during meal times.
Breakfast: I eat 2 pork sausages, 3 eggs, 6 slices of bread, tea and biscuits,
Lunch: I order big meals or family meals of steak or spare ribs
Through out the day I munch on the cakes and pastries in the bakery
Supper: two or three helpings of whatever is on the table, usually red meat.
Generally I 'm put off by meat especially when I get gout like today I won't
eat red meat because it will make me feel worse. My doctors keep telling me
that I must reduce weight for my health, but I love to eat and drink.
History of gout
When did it start? I was very naughty as a youngster, I did all the things my mom
warned me about; like drinking, smoking, truanting school and
having girlfriends
How did it start: we drank every weekend, sometimes on school days, I hid alcohol
at home before my legal age, pretty soon alcohol was a part of my
life. I had my first gout attack in my thirties, it was a terrible
experience, but not terrible enough to stop drinking.
245
Cause: family history, alcohol and diet
Number of joints affected: mostly my big toe, occasionally my knee, fingers or
shoulders
Number of attacks during the year: usually one sometimes two in a year
Renal stones: my doctor suspects I have stones but I refuse to go for further tests
because I'm terrified of surgery.
Main complaint
When did it start? two days ago, I got caught in the rain and walked home from
the grocery store around the block. When I got home my joints
were cold and stiff and my feet were ice cold. I had a hot bath
and wrapped myself in blankets. I had a restless sleep and broke
out into a fever. I was shocked in the morning when I woke up
with gout because I didn't eat any red meat the day before or
drink more than my usual beer.
Location: knee
Side: left
Type of pain: stitching and burning
Radiation of pain: none
Sensation: the pain is in my bone
Modalities: < rainy weather
night
movement, my joint feels very weak when I stand or walk
rest
sitting
Have you noticed a change in any of the following?
Energy: I'm weak and tired with no energy. My body feels lame and lifeless I
don't want to do anything. On that rainy day I felt very tired walking up
the stairs to my apartment. It's on the second floor.
Sleep: I couldn't sleep last night
Fever: none
Body perspiration: I sweat a lot, it's embarrassing because I wet my armpits.
Musculoskeletal: I don't have any muscles, it's all covered in fat
246
Urination: no change or problems
Appetite: funny I'm not feeling hungry now
Thirst: I'm not thirsty now and I never get thirsty generally, I don't drink water
Cravings/ aversions: I don't like eating cabbage
GIT: I used to be constipated but since I take psyllium husks everyday, I have a
regular bowel movement.
Mental symptoms: I 'm feeling very weak and tired, my body is so lame, I don't
have the strength to pick myself up.
Head: I get headaches when I read for too long
Nose: I have a very weak immune system and get colds, and flu's every winter. I
felt a flu coming on after walking in the rain and took med lemon. I'm fine
now.
Ear: none
Eyes: I wear glasses, I have astigmatism
Neck: no pain
Respiratory: I get short of breathe easily especially walking upstairs, I was told to
loose weight. I have asthma which is under control.
Chest: when I have an asthma attack my chest gets tight, I get short of breathe
and my heart beats fast.
Nervous system: normal
Male: no problems
PHYSICAL EXAM INATION
1. General survey
1.1 Height: 159cm
1.2 Weight: 90 kg
1.3 General state: overweight, fidgets while talking, slow to answer
1.4 Dress: normal
1.5 Grooming: neat
1.6 Personal hygiene: clean
1.7 Breath and body odors: normal
1.8 Facial expression and manner: friendly
247
Index joint
Observation: the patient has shoes and socks on affected foot
Color- dark red or purple
Temperature - cold feet and joint
Texture- smooth
Tenderness - tender, wince and withdrawal
Inflammation - swelling with fluid
Numbness- loss of light touch and pain sensation
Perspiration - cold profuse perspiration, with bad smell
Mobility of joint - ability to flex and extend joint slightly with pain.
Patient is unable to walk due to weakness of
joint not because of pain. He is able to bear the pain.
Surrounding areas affected: none
Skin
3.1 Abnormal lesions: none
3.2 Color: pallor in the palms of hands and skin
3.3 Nails: middle finger koilonychia
3.4 Conjunctiva: pallor
Head
4.1 Scalp: perspiration
4.2 Hair: wet hair from perspiration
4.3 Skull: normal
4.4 Face: pale face, rings around eyes,
Eyes
5.1 Visual acuity: normal with glasses
5.2 Visual fields: normal
5.3 Compare pupils: normal
5.4 Light reaction: normal
5.5 Retinoscopy: normal
Ears
6.1 Auricle: normal
6.2 Ear canal: normal
248
6.3 Eardrum: normal
6.4 Hearing: normal
Nose and sinuses: tenderness of maxillary sinus
Mouth and pharynx: cracks at the side of the mouth, tonsils removed
Thorax and lungs
9.1 Movement of chest wall: diminished
9.2 Percussion note: normal
9.3 Breath sounds: vesicular, expiration prolonged
9.4 Vocal resonance: decreased
9.5 Added sounds: wheeze on expiration
9.6 Other: dyspnea on walking short distances
Cardiovascular
10.1 Heart sounds and radiation: normal with no radiation
10.2 Jugular venous pressure: 2.7cm at 45 ° angle
10.3 Apex beat: 5th left intercostals and midclavicular line
Abdomen
11.1 Abdominal masses: accumulation of fat, no masses
11.2 Bowel sounds: normal to decreased
11.3 Liver: normal
11.4 Spleen: normal
11.5 Aorta: normal
Peripheral vascular system: poor circulation, feet are ice cold
Musculoskeletal system
13.1 Muscle: lack strength, tone and bulk
13.2 Joints: weak
13.3 Neck: normal
13.4 Back: renal angle pain on right side
Nervous system
14.1 Cranial nerves: normal
14.2 Gait and co-ordination: slow to walk due to weakness of joint not pain.
14.3 Reflexes: poor
249
15. Vital signs
15.1 Blood Pressure: 150 / 100 mmHg
15.2 Pulse (bilateral) all seven: 60 beats / minute carotid pulse rapid and visible
15.3 Respiratory rate: 20 / minute
15.4 Temperature: 38 r
16.Serum uric acid: 0.56 mmol/ L
FOLLOW UP DAY 1
Main complaint
My joints feel a little stronger but not totally improved. The pain got worse at
night, I couldn't sleep. I've become very thirsty and drank three glasses of
water last night. My fever is gone down.
Have you noticed a change in any of the following?
Energy: I feel I have more energy compared to yesterday, but I'm not going to
work incase I make my toe worse.
Sleep: I couldn't fall off to sleep, I hardly had a wink of sleep.
Fever: none
Perspiration: I didn't perspire as much yesterday.
Bodyaches: my body feels tired. My bones feel a weak.
Urination: when I first start urinating it burns but the pain on urination gets less
the more I urinate.
Headache: no problem
Appetite: my appetite is still lost.
Craving: none
Thirst: I drank a lot of water yesterday, 3 glasses. I wasn't thirsty though.
Bowel movements: normal
Mental symptoms: it's very strange that even though my gout pain got worse, I
feel like I'm going to be fine. While urinating I was in a lot of
pain but I felt much better after I urinated
Systems review: my nose started running I think i'm getting the flu.
250
PHYSICAL EXAMINATION
Index joint
Pain- burning, worse than yesterday but bearable
Radiation- none
Sensation- as if my toe is on fire
Color- dark red
Temperature -foot warm but joint remains cold
Tenderness - tender with wince and withdraw
Inflammation- with complete loss of joint contours
Texture- smooth
Modalities - < any movement or work
> rest
Numbness - loss of pain and light touch sensation
Perspiration- perspiration reduced
Mobility- Wincing on flexion and extension of affected joint.
Pain on motion. Patient complained of the pain getting worse than
yesterday. Before it felt as if it would break i f it was moved too much. It
feels much stronger today except that the pain is much worse.
Surrounding areas affected: none
Vital signs
Blood pressure: 150/ 100 mmHg
Pulse: 60 beats / minute
Respiratory rate: 20 / minute
Temperature: 37°C
FOLLOW UP DAY 3
Main complaint: the improvement is a bit slow, my joint pains i f I walk too much,
but I can stand and limp a short distance. My joints feel stronger than normal, not
only my toe but all of them. I'm much calmer than usual.
Have you noticed a change in any of the following?
Energy: I feel calm, I can't explain it. It's different to my everyday reactions.
Sleep: no complaints
251
Fever: none
Perspiration: my perspiration is less.
Bodyaches: my back feels less stiff - than usual
Urination: I am urinating a lot more, the burning is less, I have been drinking
'water because I can't bear the burning pain on urination. I figured
water will help to flush out the pain.
Headache: none
Appetite: normal, I get hungry before lunch and supper
Craving: none
Thirst: no thirst,
Bowel movements: normal
Mental symptoms: I feel calm, it's not normal because I'm not use to it. An
incident happened where I would normally get worried but I
remained calm.
Systems review: my flu went away yesterday
PHYSICAL EXAMINATION
Index joint
Pain- less
Radiation- none
Sensation- nothing really
Color- light red
Temperature- warm
Tenderness- tender
Inflammation- swelling with some loss of joint contours
Texture- normal
Modalities- > rest
Numbness - no numbness
Perspiration - no perspiration, bad odor
Mobility- flexion and extension normal, patient can stand but winces on exerting
pressure during motion.
252
Vital signs
Blood pressure: 145/ 100 mmHg
Pulse: 60 beats / minute
Respiratory rate: 20 / minute
Temperature: 36.5 r
FOLLOW UP DAY 6
Main complaint: my gout is gone, and my joint feels normal again
Have you noticed a change in any of the following?
Energy: I'm still feeling calm
Sleep: no problem
Fever: no
Perspiration: I'm not perspiring as badly as I used to.
Bodyaches: I feel a bit stronger
Urination: my urine is light yellow and it stopped burning
Headache: no pain
Appetite: normal
Craving: none
Thirst: I drink tea and juice and a little water when I remember.
Bowel movements: normal
Mental symptoms: I'm happy, content with life
Systems review: no change
PHYSICAL EXAMINATION
Index joint
Pain- no pain
Radiation- none
Sensation- none
Color- pink
Temperature- warm
Tenderness- no
Inflammation-no
253
Texture- normal
Modalities- > rest
Numbness- no
Perspiration- bad foot odor
Mobility-ability to flex and extend joint without pain, ability to stand and walk.
Surrounding areas affected: none
Vital signs
Blood pressure: 145/ 100 mmHg
Pulse: 60 beats / minute
Respiratory rate: 20 / minute
Temperature: 37°C
Serum uric acid: 0.42 mmol/L
FOLLOW UP DAY 15
Main complaint: My toe is normal and fully functional
Have you noticed a change in any of the following?
Energy: back to normal, I get tired easy
Sleep: no problem
Fever: none
Perspiration: I started perspiring the way I used to, I find without the medication I
perspire alot.
Bodyaches: occasional body pains at the end of the day.
Urination: normal again, light yellow and burns sometimes
Headache: no headaches
Appetite: normal
Craving: none
Thirst: normal. Tea or juice during the day, beer at night.
Bowel movements: normal
Mental symptoms: very happy, I met an old friend over the weekend. It was good
to see her again.
Systems review: normal
254
PHYSICAL EXAMINATION
Index joint
Pain- no pain
Radiation- none
Sensation- none
Color- pale
Temperature- cold
Tenderness- none
Inflammation- none
Texture- normal
Modalities- > rest
Numbness- none
Perspiration-foot odor
Mobility- normal, 100% resolution of joint
Surrounding areas affected: none
Vital signs
Blood pressure: 145/ 100 mmHg
Pulse: 60 beats / minute
Respiratory rate: 20 / minute
Temperature: 37 r
255
SUBJECTS QUESTIONNAIRE
Day 0 1 2 3 4 5 6
1.What would you rate your pain intensity as?
0 = minimum 10 = maximum
9 10 10 6 4 3 0
2. Level of swelling of joints?
0 = minimum 10 = maximum
9 9 8 6 6 2 0
3. Is there discoloration of the joint?
0 = minimum 10 = maximum
8 7 5 5 4 0 0
4. Is your sleep affected?
0 = minimum 10 = maximum
10 10 3 3 2 1 1
5. Level of activity?
0 ---- minimum 10 = maximum
10 10 10 7 5 3 0
6. Rate your improvement as a %
0= 100% improvement
10= 0% improvement
10 10 7 5 5 2 1
RESEARCHERS QUESTIONNAIRE
Day 0 1 3 6 15
a) Joint improvement?
0= total resolution
1= improvement of > 50%
2= improvement of< 50%
3-- no change
4= worsening of symptoms or involvement
of previously uninvolved joints
4 2 1 0 0
b) Severity of swelling?
0= no swelling
1= swelling with some loss of joint contours
2= complete loss of joint contours
3= fluid
3 2 1 0 0
c) Degree of tenderness
0= no tenderness
1= tender
2= tender and wince
3= tender + wince+ withdraw
3 3 1 0 0
256
4
Case J
Sum of symptoms (sort:deg) This analysis contains 364 remedies and 8 symptoms. Intensity is considered
1. GENERALS - WEAKNESS - Joints, of 3 106
2. GENERALS - WEATHER - wet weather - agg. 3 147
3. GENERALS - FOOD and DRINKS - meat - agg. 2 46
4. KIDNEYS - STONES 1 58
5. EXTREMITIES - PAIN - Knee - gouty 3 ,9
6. EXTREMITIES - COLDNESS - Knee 4 50 ■ i
7. GENERALS - PAIN - Bones 1 1,67
8. PERSPIRATION - PROFUSE 1 224
1 2 3 caic. lach. petr.
4 sil.
5 6 7 8 9 10 sep. chin. sulph. puls. merc. ars.
11 12 13 14 15 16 17 18 19 carb-v. verat. colch. nux-v. graph. nit-ac. phos. caust. nat-m.
18/43 16/30 16/20 15/33 15/32 15/27 15/27 14/3214/31 14/30 14/27 14/26 14/24 14/21 14/17 13/27 13/27 13/17 12/21
1. 3 2 2 2 3 2 3 2 3 1 1 2 1 2 1 2 2 2 2
2. 3 2 1 2 2 1 2 3 2 3 2 2 2 1 2 2 1 1
3. 2 1 1 2 1 2 1 1 1 1 2 1 1 - 1 1
4. 3 1 2 2 2 1 2 - - 1 2 2 1 w
5. 3 2 1 - - - 2 1 .
6. 1 2 1 3 2 2 1 2 2 3 3 2 2 - 1 3 3 - 2
7. 2 1 1 2 2 2 2 3 3 1 1 1 1 1 1 f3 2 1 1
8. 3 2 1 3 3 3 2 2 3 3 3 3 2 2 1 2 2 2 3
• • •
PACE : 1
Teets : AUTO ORDER, S-UA
*** BIOCHEHISTRY ***
Test > S-URIC ACID
Result Unita Reference 0.56 mmol/1 0.14 - 0.51
‘allalaalna am MON possamse
le
4
LANCET LABORATORIES
MI SITE littp.JAwnalonastaxita/ MI.20100
—1==—
GLYNNWOOD LABORATORY Glynnwood Hospital cnr Woburn Ave & Harrison Str. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659
_ _ . _ 11.0
Authorised by DR P COLE For consultation by referring doctors phone :'1011) 358-0808
•
, . .
Test > S -URIC ACID
Result Units Reference 0.42 mmo1/1 0.14 - 0.51
p.
:4
GLYNNWOOD LABORATORY Clynnvood Hospital cnr Woburn Ave & Harrison Str. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659
r
LANCET LABORATORIES
Val WM hltiv./Avffealanast.carei
PIN . 92010111
• • •
,,afailsmaa 2:Seet flUtletee121$
Tests : AUTO ORDER, S-UA
*** BIOCHEMISTRY *** PAGE : 1
Authorised by DR P COLE Por consultation by referring doctors phone :,(011) 358-0808
•
•
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