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

iv

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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page no.

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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page no.

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



4.2.3 Discussion 35




4.3 Patient C 37



4.3.3 Discussion 40




4.4 Patient D 42



4.4.3 Discussion 44

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page no.




4.5 Patient E 46



4.5.3 Discussion 49




4.6 Patient F 51



4.6.3 Discussion 53




4.7 Patient G 55



4.7.3 Discussion 58




4.8 Patient H 59



4.8.3 Discussion 61




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page no.

4.9 Patient I 63



4.9.3 Discussion 65




4.10 Patient J 67



4.10.3 Discussion 69




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

page no.

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

xi

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

xii

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

xiii

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

xiv

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

xv

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

xvi

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.

1

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

2

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

3

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

4

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).

5

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

6

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

7

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

8

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.


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).


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%


Sleep affected 0% 30% 60% 80% 80% 100% 100%


Overall

Improvement

0% 20% 30% 50% 70% 90% 90%


Day 0 1 3 6 15




4.2.6 Change in SUA on day 0 and Day 6

Day 0 6

SUA 0.4mmol/ L 0.38mmol/ L



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


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


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


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%


Sleep affected 30% 50% 60% 100% 80% 90% 100%


Overall

Improvement

0% 20% 30% 50% 70% 90% 90%


Day 0 1 3 6 15

a) Joint improvement 4 2 2 1




Day 0 6

SUA 0.32 mmol/ L 0.34 mmolJ L



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.


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).


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


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%


Sleep affected 30% 30% 30% 30% 60% 60% 70%


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





Day 0

SUA 0.53 mmol/ L 0.44 mmol/ L



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


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).


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


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%


Sleep affected 0% 80% 50% 70% 60% 50% 50%


Overall

Improvement

0% 30% 40% 40% 30% 40% 40%


Day 0 1 3 6 15





Day 0 6




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.


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).


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


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%


Sleep affected 20% 20% 40% 70% 100% 90% 100%


Overall

Improvement

0% 0% 30% 50% 50% 70% 80%


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


Day 0 6


ormal values: < 0.42 mmol/L in males


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


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).


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.


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%


Sleep affected 10% 0% 60% 70% 70% 50% 90%


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





Day 0 6




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.


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


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.


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%


Sleep affected 0% 70% 70% 70% 100% 100% 90%


Overall

Improvement

0% 20% 30% 30% 50% 60% 90%


Day 0 1 3 6 15





Day 0 6




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


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).


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


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%


Sleep affected 0% 70% 100% 90% 80% 40% 90%


Overall

Improvement

0% 90% 100% 100% 100% 30% 100%


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


Day 0 6

SUA 0.33mmol/ L 0.38 mmol/ L



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.


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)


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%


Sleep affected 0% 0% 70% 70% 80% 90% 90%


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





Day 0 6

SUA 0.56mmol/ L 0.42 mmol/ L

ormal values: < 0.42 mmol/L in males


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



> 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



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


12 Observers

joint

improvement


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

REFERENCES

Agrawal, Y.R. (1997) Homoeopathy in Rheumatism, Delhi: Vijay Publications,

pp. 130-131

Allen, T.F. (1994) Handbook of Materia Medica and Homoeopathic Therapeutics,

New Delhi: B. J. Publishers, pp 178, 307

Allen, H.C. (2001) Allens Keynotes, 9 th ed. New Delhi: B. Jain Publishers, pp. 42,

44, 59, 60, 61, 94, 95, 96, 111, 112, 183, 184, 273, 274, 275

Alloway, J. A., Moriaity, M. A., Hoogland, Y.T., and Nashel, D. J. (1993)

Comparison of Triamcinolone Acetonide with Indomethacin in the Treatment of

Acute Gouty Arthritis, Journal of Rheumatology, 20 (1): 111

Blackie, M. (1990) Classical Homoeopathy repertory edition, England:

Beaconsfield, pp 258, 260

Boericke, W. (1998) Homoeopathic Materia Medica and Repertory, New Delhi:

B. Jain Publishers pp 119, 133-134, 182, 398

Boyd, H. (1989) Introduction to Homoeopathic Medicine, 2 nd ed., England:

Beaconsfield Publishers pp. 135

Burnett, J.C. (1998) Gout and its Cure, New Delhi: B. Jain Publishers, pp3

Burt, W.H. (1995) Physiological Materia Medica, New Delhi: B.J. Publishers, pp.

115,216, 223, 224, 227, 257,785, 797,

Caspi, D., Lubart, E., Graff, E., Habot, B., Yaron, M. (2000) The effect of mini-

dose asprin on renal function and uric acid handling in elderly patients, Arthritis

Rheumatology 43 (1): 103-108

Chappell, P. (1994) Emotional Healing with Homoeopathy. Shaftesbury: Element

Books, pp. 220-227

98

Chou, P., Lin, K. C., Lin, H.Y. (2000) Community based epidemiological study

on hyperuricemia and gout in Kin- Hu, Kinmen, Journal of Rheumatology, 27 (4):

1045-1050

Clarke, J.H. (1997) A Dictionary of Practical Materia Medica, vol. 1, New Delhi:

B.J. Publishers, pp 274

Cohen, M.G., Emmerson, B. T. (1998) Gout, Rheumatology, Mosby, 8 (14): 1-8

Davies, M. (1994) Metabolic Disorders. In Lorimer, D.L. (ed) Neale's Common

Foot Disorders: diagnosis and management 4 th ed. Singapore: Churchill

Livingstone, pp. 357-359

Davis, J. C. (1999) A Practical Approach to Gout, Postgraduate Medicine, 106

(4): 115-123

Eizayaga, F.X. (1991) Treatise on Homoeopathic Medicine. 1 st ed. Buenos Aires:

Ediciones Marecel, pp 37, 49,53

Emmerson, B.T. (1996) The Management of Gout, New England Journal of

Medicine, 334 (7): 445-451

Fam, A.G. (1998) Gout in the Elderly, Drugs and Aging, 13 (3): 229-243

Fam, A.G. (2002) Treating Acute Gouty Arthritis with Selective COX 2

Inhibitors, British Medical Journal, 325: 980-981

Farrington, E. A. (1995) Clinical Materia Medica, New Delhi: B. Jain Publishers,

pp. 369, 453

Flieger, K. (1998) Getting to know Gout, Diabetic Gourmet Magazine, pp. 56-59

99

Gibson, D. (1987) Studies of Homoeopathic Remedies, Great Britain: University

Press Oxford, pp. 51, 54, 101, 102, 148, 149, 150, 309

Glynn, J. (1999) Gout, Curtin Department of Podiatry Encyclopedia, pp 304- 306

Goodman and Gilman, (1996) Treatment of Gouty Arthritis, Chapter 27, pp. 647-

655

Gunavante S.M. (1998) The Amazing Power of Homoeopathy, 1st edition. New

Delhi: B. Jain Publishers, pp.xv, xvii, xviii, xxi, xxii

Hahnemann, S. (1998) Organon of Medicine, 6 th edition. New Delhi: B. Jain

Publishers, pp. 19, 92,111, 188, 221, 298

Hahnemann, S. (1996) Materia Medica Pura, vol. 1, New Delhi: B. Jain

Publishers, pp. 106, 107

Hahnemann, S. (1996) Materia Medica Pura, vol. 2, New Delhi: B. Jain

Publishers, pp. 263, 265, 402, 408, 420

Harris, R.D., Siegel, L. B., Alloway, J.A. (1999) Gout and Hyperuricemia,

American Family Physician, 59 (4): 925-932

Haslett, C., Chilvers, E.R., Hunter, J.A.A., Boon, N.A. (1999) Davidsons

Principles and Practice of Medicine, 18 th ed. London: Churchill Livingstone, pp.

831-843

Howard, W. (1999) Gout, Australian Nursing Journal, 7 (4): 1

Hollingworth, P. (1988) Rheumatology, London: Heinemann Medicine Books,

pp. 145-147

100

Hubbard, E. W. (1997) A Brief Study Course in Homoeopathy, New Delhi: B.Jain

Publishers, pp. 13, 55, 56, 57

John, C. (1999) A Practical Approach to Gout, Postgraduate medicine, 106 (4): 5

Jones, R. E., Ball EV. (1999) Gout: Beyond the Stereotype, Hospital Practice,

Office ed. 34 (6): 95-102

Jouanny, J. (1996) Homeopathic Therapeutics Possibilities in Acute Pathology,

S.A. France: Boiron, pp. 55-56

Jouanny, J. (1994) Homeopathic Therapeutics Possibilities in Chronic Pathology,

S.A. France: Boiron, pp. 343, 344, 346, 358, 359, 360

Jouanny, J. (1984) The Essentials of Homoeopathic Materia Medica, S. A. France:

Boiron, pp 67, 69, 85, 105

Jouanny, J. (1984) The Essentials of Homoeopathic Therapeutics, S. A. France:

Boiron, pp 12-14

Kent, J.T., (1979) Lectures on Homoeopathic Philosophy, Califonia: North

Atlantic Books, p 34, 35, 102

Kent, J.T., (1957) What The Doctor Needs To Know In Order To Make A

Successful Prescription, Calcutta: P.K. Gosh, ppl, 2

Khaneja, H.S. (2001) Illustrated Guide to Homoeopathic Treatment, New Delhi:

B.Jain Publishers, pp. 335, 336

Lin, K.C., Lin, H.Y., Chou, P. (2000) The interaction between uric acid level and

other risk factors on the development of gout among asymptomatic hyperuricemic

men in a prospective study, Journal of Rheumatology, 27 (6): 1501-1505

101

Lockie, A., Geddes, N. (1995) The Complete Guide to Homoeopathy, 1 st ed.

London: Darling Kindersley, pp. 20

Lockie, A. (1990) The Family Guide to Homoeopathy, England: Hamish

Hamilton, pp 12-15

Moiloa, M.R.A. (2000) Manual of Clinical Homoeopathy, 1 st ed. Pretoria:

Production Printers, pp 135

Morrison, R. (1998) Desktop Companion to Physical Pathology, Califonia:

Hahnemann Clinic Publishing, pp 327, 328, 329

Morrison, R. (1993) Desktop Guide to Keynotes and Confirmatory Symptoms,

Califonia: Hahnemann Clinic Publishing, pp 58, 61, 64, 68

Nuki, G. (1996) Diseases of the connective tissues, Joints and Bones, In Edwards,

C. R.W., Bouchier, I.A.D., pp 881-888

Park, Y.B., Park, Y.S., Song, J., Lee, W.K., Suh, C.H., Lee, S.K., (2000) Clinical

Manifestations of Korean female gouty patients, Clinical Rheumatology, 19(2):

142-146

Perez- Ruiz, F., Calabozo, M., Pijoan J.I., Herrero-Beites, A.M. (2002) Effect of

Urate Lowering Therapy on the Velocity of Size Reduction of Tophi in Chronic

Gout, Arthritis and Rheumatism, 47(4): 356-360

Perez- Ruiz, F., Calabozo, M., Pijoan J.I., Herrero-Beites, A.M. (2002) Renal

Underexcretion of Uric Acid is Present in Patients with Apparent High Urinary

Uric Acid Output, Arthritis and Rheumatism, 47(6): 610-613

102

Pittman, J.R., Bross M.H. (1999) Diagnosis and Management of Gout, American

Family Physician, 59(7): 1799-1800

Puterman, D.J. (1994) The Treatment of Gout using Homoeopathy, Thesis, M.

Dip. Tech., Technikon Natal, Durban, pp. 49-50

Ray. M., (1994) The Principle of Homoeopathic Philosophy, London, Churchill

Livingstone, pp. 3, 93

Ritchie, D.M., Boyle J.A., McInnes, J.M., Jasani M.K., Dalakos T.G., Grieveson,

P and Buchanan, W.W. (1968) Clinical studies with an articular index for the

assessment of joint tenderness in patients with rheumatoid arthritis, Journal of

Rheumatology, 147: 393

Rose, B. (1999) Gout, Homoeopathy, vol. 49, no.3, p. 50, 51

Sankaran, R. (1995) The spirit of Homoeopathy, 2 nd ed. Bombay: Homoeopathic

Medical Publishers, p. 1

Schlesinger, N., Schumacher, H.R. (2001) Gout: can management be improved,

Current Opinion in Rheumatology, 13 (3): 240-244

Schlesinger, N., Schumacher, H.R. (2002) Update on Gout, Current Opinion in

Rheumatology, 47 (5): 563-565

Schroyens, F. (1997) Synthesis, London: Homoeopathic Book Publishers, pp

705,1564, 1575

Smith, 0., Quiney, J., Read, J. (1998) Salivary urate in gout, exercise, and diurnal

variation, Lancet, 351 (9120): 1932

103

Spieght, P. A. (1979) A study course in Homoepathy, Bradford, England: Health

Science Press, pp. 3-8, 19, 20, 80

Steven, L. (1998) Hyperuricemia and Gout, Pharmacotherapeutics, 2 (2) Spring:

58-60

Steward, 0. J., Silman, A.J. (1990) Gout, British Journal of Rheumatology, 29:

485-488

Sturrock, R.D. (2000) Gout, British Medical Journal, 7228: 132-133

Tang, D., Xia, B. (1998) Influence of dietary habits and body weight an blood uric

acid in elderly, Hunan Yi Ke Da Xue Xue Bao, 23(5): 447-449

Tikly, M., Bellingan, A., Lincoln, D., Russell, A. (1998) Risk Factors For Gout: A

Hospital-Based Study In Urban Black South Africans, Rev Rhum (Eng Ed), 65(4):

225-231

Till, S., Snaith, M.T. (1998) Gout, Hyperuricemia and Crystal Arthritis, British

Journal of Podiatry, 53 (1): 3- 6

Tucker, F. (1999) Acute gouty arthritis: Diagnosis and treatment, Physician

Assistant, Sep: 12

Tyler, M.L. (1998) Homoeopathic Drug Pictures, New Delhi: B. Jain Publishers,

pp 152, 223, 305, 307, 308

Van Doornum, S., Ryan, P.F. (2000) Clinical Manifestations of Gout and their

Management, Medical Journal, 172 (10): 493-497

Van Wyk, E., (1998) The Remedy Finder, Pretoria: Natura, pp 4-7

104

Vermeulen, F. (1997) Concordant Materia Medica, 2 nd ed. Netherlands: Emryss

by Publishers, pp 285, 290, 294, 295, 326, 328, 370, 469, 596, 601, 602, 1018,

1019, 1021, 1390, 1391, 1393

Vithoulkas, G. (1998) The Science of Homoeopathy, Indian ed. New Delhi: B.

Jain Publishers, p. 153, 155, 217

Werlen, D. Gabay, C. and Vischer T.L. (1996) Corticosteroid therapy for the

treatment of acute attacks of crystal induced arthritis, Revue du rhumatisme: joint,

bone, spine diseases. English ed, 63(4), pp 248-254

Whitaker, J. (1995) Dr. Whitakers Guide to Natural Healing Rocklin, Califonia:

Prima Publishing, pp 252-255

Wood. J. (1999) Gout and its Management, The Pharmaceutical Journal, 262

(7048): 808- 811

105

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:

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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:

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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:

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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:

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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?


Is there discoloration of the joint?


Is your sleep affected?


Level of activity?


Rate your improvement as a %

0= 100% improvement

10= 0% improvement

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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


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

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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.

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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


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.)

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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.


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


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


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.


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


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


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


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


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.


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


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?


8 10 10 5 4 2 0

2. Level of swelling of joints?


8 10 10 5 4 1 0

3. Is there discoloration of the joint?


7 10 10 5 4 2 1

4. Is your sleep affected?


7 10 10 5 3 0 1

5. Level of activity?


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


Day 0 1 3 6 15

a) Joint improvement?

0= total resolution



3= no change



4 4 2 0 0

b) Severity of swelling?

0= no swelling



3= fluid

1 2 1 0 0

c) Degree of tenderness

0= no tenderness

1= tender

2= tender and wince


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

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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


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.


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


1.7 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


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


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



5.3 Compare pupils: 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


line

Abdomen


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.


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.


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



Index joint

Pain- bruised, no change

Radiation- none

Color- blue

Temperature- hot joint, feet warm

Tenderness- tender + wince+ withdrawal


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.


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.


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


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



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.


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



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




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.


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


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


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


Respiratory rate: 16/ min

Temperature: 36.5 ° C

140


Day 0 1 2 3 4 5 6



10 9 7 5 2 2 1



10 8 7 5 1 1 0



10 8 7 3 2 1 1



10 7 4 2 2 0 0



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


Day 0 1 3 6 15


0= total resolution



3= no change



4 3 2 1 1


0= no swelling



3= fluid

3 2 1 0 0


0= no tenderness

1= tender

2= tender and wince


3 3 2 0 0

141

Case B


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 -

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•

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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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


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


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


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.


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


General survey

1.1 Height: 164cm

1.2 Weight: 83 kg


1.4 Dress: normal

1.5 Grooming: well


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


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


3.2 Color: normal

3.3 Nails: 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




5.5 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




line

Abdomen



11.3 Liver: normal

11.4 Spleen: normal

11.5 Aorta: normal

Peripheral vascular system: normal


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



14.3 Gait and co-ordination: gait affected by gout pain, not nervous disorders

or influence of alcohol. Walks with the help of

crutches.


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


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.


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.


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.



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


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.


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.


Mental symptoms: calm and controlled



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




Temperature: 36.7 r

Serum uric acid: 0.34mmol/ L

FOLLOW UP DAY 15

Main complaint: my toe is back to normal.


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


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




Temperature: 37 r

155


Day 0 1 2 3 4 5 6



10 8 7 5 5 3 1



10 8 7 5 5 4 1



10 8 6 4 2 1 0



7 5 4 0 2 1 0



10 10 7 5 5 2 1


0= 100% improvement

10= 0% improvement

10 8 7 5 3 1 1


Day 0 1 3 6 15


0= total resolution



3= no change



4 2 2 1 0


0= no swelling



3= fluid

3 2 2 0 0


0= no tenderness

1= tender

2= tender and wince


3 3 1 0 0

156

Case C


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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*** 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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*** BIOCHEMISTRY •** PACE :

Authorised by DR P COLE For consultation by referring doctors phone 1 (011) 358-0808

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C.

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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


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.



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.


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


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




Ears

6.1 Auricle: 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


9.5 Added sounds: none

Cardiovascular



162


line

Abdomen



11.3 Liver: normal

11.4 Spleen: normal

11.5 Aorta: normal

Peripheral vascular system: poor circulation, cold feet.


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.


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




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



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



Temperature: 37 r

FOLLOW UP DAY 3

Main complaint: My toes are normal today but the swelling of my joint is still

there.


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.



Index joint

Observation: l' three toes function normally, they are not contracted

Pain- much less

Radiation- none

165

Sensation- normal

Color- maroon

Temperature - hot



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.


Joints- improvement in range of motion with less pain on motion.

Vital signs

Blood pressure: 130 / 80 mm /Hg



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.


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


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.)


Joints- improvement in range of motion with less pain on motion

Tophi still present, with no change

Vital signs


167



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.


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


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


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


Respiratory rate: 17 /minute

Temperature: 37°C

169


Day 0 1 2 3 4 5 6



7 7 6 5 3 2 2



7 7 7 7 5 3 2



7 7 7 7 5 2 2



7 7 7 7 4 4 3



10 10 10 9 5 3 2


0= 100% improvement

10= 0% improvement

10 10 7 7 5 3 2


Day 0 1 3 6 15


0= total resolution



3= no change



4 3 3 1 0


0= no swelling



3= fluid

2 2 2 0 0


0= no tenderness

1= tender

2= tender and wince


2 2 2 0 0

170

Case D


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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LANCET LABORATORIES

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LANCET LABORATORIES

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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


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



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.


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.


1. General survey

1.1 Height: 164cm

1.2 Weight: 91kg

1.3 General state: tired

1.4 Dress: normal




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


3.2 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





Ears

6.1 Auricle: pain on palpation of mastoid process left side.


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


9.2 Percussion note: dull


9.4 Vocal resonance: resonant


Cardiovascular




line

Abdomen



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.


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



14.3 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


15.2 Pulse (bilateral) all seven: 106 beats /minute



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


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


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



179


Temperature: 36.5 °C

FOLLOW UP DAY 3

Main complaint: There's not much change since yesterday


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


Index joint

Pain- it 's a bit sore when I first bend it

Radiation- none

Sensation- none

Color- dark red

Temperature- hot


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



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.


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.


Index joint

Pain- bruised again

Radiation- both feet feel sore

Sensation- bruised

Color- dark red

Temperature- hot

Tenderness- tender with wince and withdrawal


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




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


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.



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


183



Temperature: 37 ° C

184


Day 0 1 2 3



10 7 6 5 7 7 6



9 9 8 8 9 8 7



9 9 8 8 8 8 7



10 2 5 3 4 5 5



5 5 6 5 7 6 6


0= 100% improvement

10= 0% improvement

10 7 6 6 7 6 6


Day 0 1 3 6 15


0= total resolution



3= no change



4 3 2 4 0


0= no swelling



3= fluid

2 2 2 2 0


0= no tenderness

1= tender

2= tender and wince


3 2 2 3 0

185

-A

Case E


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

WEB SIG hitplAwrodonarto220/

PIN . MOM

--------


***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

•

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• •

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


*** BIOCUENMSTRY *** FACE : 1

Authorised by DR P COLE For consultation by referring doctors phone : (011) 358-0808

•

‘15:11USSMIN pulsieralq

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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


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


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


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.


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



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.


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





191


Ears

6.1 Auricle: dirty, no lesions

6.2 Ear canal: full of wax

6.3 Eardrum: normal

6.4 Hearing: normal


Mouth and pharynx: bad breathe, rotten teeth, tongue dry

Thorax and lungs




9.4 Tactile fremitus: normal


Cardiovascular


10.2 Jugular venous pressure: 2.1cm at 45° angle


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


13.1 Muscle: normal

13.2 Joints: normal

13.3 Neck: normal

13.4 Back: normal

192

Nervous system



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


15.3 Respiratory rate: 17 /minute


16.Serum uric acid: 0.61mmol/L

FOLLOW UP DAY 1

Main complaint

The pain came back last night the medication did not help.


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



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


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



Temperature: 36.5° C

FOLLOW UP DAY 3

Main complaint: My pain and swelling reduced a lot..


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.



Index joint

Pain- reduced and bearable

Radiation- none

Sensation- none

Color- pale

Temperature- warm

Tenderness- tender


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



Temperature: 37 r

FOLLOW UP DAY 6

Main complaint: my gout is gone and I feel much better


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.)



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



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.


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.



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



Temperature: 37°C

198

SUBJECTS QUESTIONNAIRE Day 0 1 2 3 4 5 6



10 10 10 5 5 2 0

Level of swelling of joints?


10 10 10 5 5 2 0

Is there discoloration of the joint?


10 10 8 4 3 0 0



8 8 6 3 0 1 0



8 9 7 4 3 2 0


0= 100% improvement

10= 0% improvement

10 10 7 5 5 3 2


Day 0 1 3 6 15


0= total resolution



3= no change



4 3 1 0 0


0= no swelling



3= fluid

3 3 1 0 0

• c) Degree of tenderness

0= no tenderness

1= tender

2= tender and wince


3 3 1 0 0

199

Case F


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.

17/3717/27 13/20 12/16 11/21 10/23 9/23 9/15 9/15 9/10 9/9 8/19 8/12 8/11 8/8 7/7 6/12 6/10 6/10 6/8 6/7 •

1

2

3

3

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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

•

,uumesmsser maws ma:um

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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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- • •


*** 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


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


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.


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


1.4 Dress: 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


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


3.2 Color: normal

3.3 Nails: normal


Head

4.1 Scalp: rash on scalp

4.2 Hair: dry, thick

4.3 Skull: normal

4.4 Face: cuts on skin

Eyes






Ears

6.1 Auricle: normal


6.3 Eardrum: normal

6.4 Hearing: normal


Mouth and pharynx: white teeth, healthy gums

Thorax and lungs




205

9.4 Tactile fremitus: normal


Cardiovascular




line

Abdomen

11.1 Abdominal masses: normal


11.3 Liver: normal

11.4 Spleen: normal

11.5 Aorta: normal

Peripheral vascular system: cold hands and feet


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


14.2 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



15.4 Temperature: 37°C


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


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


Index joint

Pain- tearing pain in knee not as severe as Day 0

Sensation- feels as if beaten

Color- bright red

Temperature - cold



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




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.


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


208


Index joint

Pain- reduced

Sensation- burning

Color- red

Temperature- cold

Tenderness- tender


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




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.


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.



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



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


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


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.


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.


Back: no renal tenderness or pain

Vital signs

Blood pressure: 140/ 97mmHg



Temperature: 37 °C

212




8 8 7 7 5 3 0



9 8 7 6 5 2 0



8 8 7 7 6 2 0



9 10 4 3 3 5 1



9 9 7 6 5 2 0


0= 100% improvement

10= 0% improvement

10 9 7 6 5 3 0


Day 0 1. 3 6 15


0= total resolution



3= no change



4 3 2 0 0


0= no swelling



3= fluid

3 2 2 0 0


0= no tenderness

1= tender

2= tender and wince


3 3 1 0 0

213

Case G


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

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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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Authorised by DR P COLE For consultation by referring doctors phone': (011) 358-0808

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Test > S -URIC ACID


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


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


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


1. General survey

1.1 Height: 1.65m

1.2 Weight: 80 kg

1.3 General state: weak

1.4 Dress: 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


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


5.5 Retinoscopy: Arteriole silver wiring with arteriovenous nipping.

Ears

6.1 Auricle: 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.



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


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


15.2 Pulse (bilateral): 110 beats / minute (diminished femoral pulse)


15.4 Temperature: 38.3 °C


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.


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



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


Texture- smooth


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



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


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



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


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)



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.


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


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



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


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.


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


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


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




Temperature: 37 r

228

SUBJECTS QUESTIONNAIRE Day 0 1 2 3 4 5



10 9 8 8 6 3 0



10 9 8 7 6 3 0



9 7 5 5 4 0 0



10 3 3 3 0 0 1



10 9 5 5 5 2 0


0= 100% improvement

10= 0% improvement

10 8 7 7 5 4 1


Day 0 1 3 6 15


0= total resolution



3= no change



4 2 1 0 0


0= no swelling



3= fluid

3 2 1 0 0


0= no tenderness

1= tender

2= tender and wince


3 2 1 0 0

229

ease ri


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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• LANCET LABORATORIES

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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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GLYNNWOOD LABORATORY Clynnwood Hospital cnr Woburn Ave & Harrison Str. Benoni Tel:(011) 845-1960 Fax:(011) 421-9659 rvo



Test Result Units Reference > S -URIC ACID 0%40 mmo1/1 0.14 - 0.51


APPENDIX N

Patient I

Age: 32 years

Sex: male

Race: Indian

Occupation: shopkeeper

Past medical history: occasional cough mixtures or flu tablets


Family history: both are still alive and healthy


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.


Sensation: I feel a beating sensation in my toe, like a heartbeat.


touch

> pressure

cold application

rest

Concomitant symptoms: fever


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


Chest: no pain

Nervous system: fine

Male: normal


General survey

1.1 Height: 158 cm

1.2 Weight: 83 kg


1.4 Dress: neat

1.5 Grooming: well

1.6 Personal hygiene: very hygienic


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


Skin

3.1 Skin: very hot too touch

234

3.2 Color: bright red

3.3 Nails: 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


5.3 Compare pupils: pupils inline



Ears

6.1 Auricle: bright red and hot to touch


6.4 Eardrum: normal

6.5 Hearing: normal


Mouth and pharynx: normal

Thorax and lungs


9.2 Percussion note: normal

9.3 Breath sounds: normal



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



11.3 Liver: normal

11.4 Spleen: normal

11.5 Aorta: normal

Peripheral vascular system: skin is bright red and hot to touch


13.1 Muscle: normal

13. 2 Joints: normal

13.3 Neck: normal

13.4 Back: normal

Nervous system



14.3 Gait and co-ordination: hops on one leg with the assistance of a walking

stick. Co-ordination normal


Vital signs


15.2 Pulse (bilateral) all seven: 75 / minute full and bounding



Serum uric acid: 0.33 mmol/

FOLLOW UP DAY 1

Main complaint: my fever has come down, and I feel much better.


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.



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





237

FOLLOW UP DAY 3

Main complaint: my gout is gone and hasn't come back so far.


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,



Index joint

Pain- no pain


Sensation- none

Color- pink

Temperature- warm

Tenderness- none

Inflammation- none

Texture- normal

Modalities- none

Numbness- no

Perspiration- none

238

Mobility- normal


Vital signs




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.


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.


Mental symptoms: I'm a bit afraid that the pain might come back, but otherwise

there's no complaint


239


Index joint

Pain- no pain


Sensation- none

Color- pink

Temperature- warm

Tenderness- none

Inflammation- none

Texture- normal

Modalities- none

Numbness- no

Perspiration- none

Mobility- normal


Vital signs



Respiratory rate: /7/ minute

Temperature: 37 °C


FOLLOW UP DAY 15

Main complaint: I haven't had another attack, and have been fine so far


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


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



Index joint

Pain- no pain


Sensation- none

Color- pink

Temperature- cool

Tenderness- none

Inflammation- none

Texture- normal

Modalities- none

Numbness- no

Perspiration- none

Mobility- normal


Vital signs



Respiratory rate: / 7/minute


241




10 1 0 0 0 8 0



10 1 0 0 0 7 0



10 0 0 0 0 6 0



10 3 0 1 2 6 1



10 2 0 0 0 3 0


0= 100% improvement

10= 0% improvement

10 1 0 0 0 7 0


Day 0 1 3 6 15

Joint improvement?

0= total resolution



3= no change



4 1 1 0 0

Severity of swelling?

0= no swelling



3= fluid

3 0 0 0 0

Degree of tenderness

0= no tenderness

1= tender

2= tender and wince


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


'

..

.

•

•

■ -

•

PACE : 1

Reference

0.14 - 0.51

•

.

• O. ION gm as am NOM auttleall •


*** 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


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


Sensation: the pain is in my bone

Modalities: < rainy weather

night

movement, my joint feels very weak when I stand or walk

rest

sitting


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


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



1.8 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.


Skin


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






Ears

6.1 Auricle: 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



10.3 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


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


14.2 Gait and co-ordination: slow to walk due to weakness of joint not pain.

14.3 Reflexes: poor

249

15. Vital signs


15.2 Pulse (bilateral) all seven: 60 beats / minute carotid pulse rapid and visible


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.


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.


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


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.


Vital signs




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.


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,


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


Index joint

Pain- less

Radiation- none

Sensation- nothing really

Color- light red

Temperature- warm

Tenderness- tender


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




Temperature: 36.5 r

FOLLOW UP DAY 6

Main complaint: my gout is gone, and my joint feels normal again


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.


Mental symptoms: I'm happy, content with life



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.


Vital signs




Temperature: 37°C


FOLLOW UP DAY 15

Main complaint: My toe is normal and fully functional


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.


Mental symptoms: very happy, I met an old friend over the weekend. It was good

to see her again.

Systems review: normal

254


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


Vital signs




Temperature: 37 r

255


Day 0 1 2 3 4 5 6



9 10 10 6 4 3 0



9 9 8 6 6 2 0



8 7 5 5 4 0 0



10 10 3 3 2 1 1


0 ---- minimum 10 = maximum

10 10 10 7 5 3 0


0= 100% improvement

10= 0% improvement

10 10 7 5 5 2 1


Day 0 1 3 6 15


0= total resolution



3-- no change



4 2 1 0 0


0= no swelling



3= fluid

3 2 1 0 0


0= no tenderness

1= tender

2= tender and wince


3 3 1 0 0

256

4

Case J


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


*** BIOCHEHISTRY ***

Test > S-URIC ACID

Result Unita Reference 0.56 mmol/1 0.14 - 0.51

‘allalaalna am MON possamse

le

4

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MI SITE littp.JAwnalonastaxita/ MI.20100

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_ _ . _ 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

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