1 Neurological and Musculoskeletal Pathophysiologic Processes Chronic illnesses predispose patients to a wide range of health complications that can cause pain in the toes, fever, chills, and swelling in the toe. The 58-year-old obese white shows signs of fever, chills, pain, and swelling in the right great toe. The right first metatarsophalangeal joint is very painful on adding any weight. The patient has a history of hypertension and Type II diabetes mellitus and is using hydrochlorothiazide 50 mg and metformin 500 mg to manage the disease. The simultaneous use of hydrochlorothiazide and metformin impacts the neurological and musculoskeletal pathophysiologic processes that would account for the patient presenting these symptoms. Neurological processes linked to pain in the toe are associated with damage to nerve cells in the area due to side effects of elevated uric acid levels in the blood. The use of hydrochlorothiazide 50 mg is associated with elevated serum uric acid levels in the body (Skoczyńska et al., 2020). As the acid increases, the rate of direct urate reabsorption in the proximal renal tubules grows, predisposing the patient to gout. Diuretics result in elevated urination, which leads to a decline in the amount of fluid in the patient’s body (Chekka et al., 2021). Reduced body fluid means that the remaining fluid is more concentrated and can form uric acid crystals in the joint tissue and the synovial fluid. The crystals are responsible for gout. The disease mainly affects toe joints, ankles, and knees, which explains the swollen toe joint and pain in the right first metatarsophalangeal joint (Rogers & Allen, 2021). Gout is also associated with chills and fever, explaining the manifestation of these signs by the patient. The musculoskeletal pathophysiologic processes that may lead to the symptoms reported by the patient include the development of MSU crystals in tissues around the joint and joint inflammation caused by a surge in acid in the body. The buildup of uric acid leads to the formation of sharp needlelike urate crystals that affect the joint and surrounding tissue, causing pain, inflammation, and swelling (Chekka et al., 2022). It should be noted that
2 because the patient is obsessing and exerts more weight on the feet, he is likely to suffer daily pain when he tries to move using the affected metatarsophalangeal. The patient is predisposed to racial or ethnic variables that may impact physiological functioning. White people are more likely to experience more adverse effects when they use diuretics than people of African descent or Asian (Chekka et al., 2021). The patient is of White race, which predisposes him to severe metabolic effects of hydrochlorothiazide. The changes in neurological and musculoskeletal pathophysiologic processes interact to impact the overall body health as gout affects nerves and muscles to cause pain in the toe. Severe gout may lead to fever and chills as more joints are affected and inflammation sets in. The fever would be due to the effects of gout in the joints around the toes (Mazumder & Singh, 2021). The resultant condition leads to a metabolic imbalance that affects the peripheral sensory neurons, increasing the risk of pain in the toe area (Skoczyńska et al., 2020). Moreover, the use of metformin 500 mg is also linked to fevers and chills as side effects. In conclusion, the accumulation of uric acid in the blood due to the use of hydrochlorothiazide 50 mg may have caused gout, which in turn leads to musculoskeletal pain. The fever, chills, pain, and swelling in the right great toe are a result of damaged neurological and musculoskeletal pathophysiologic processes, mainly due to high uric acid concentration in joints. The pain and fever are signs of damaged nerves and muscles in the metatarsophalangeal joint and limited movement of joints. The use of metformin 500 mg may also cause fever and chills. Therefore, symptoms presented by the patients could be a result of a combination of gout and side effects of metformin.
3 References Chekka, L.M.S., Chapman, A.B., Gums, J.G., Cooper-DeHoff, R.M., & Johnson, J.A. (2021). Race-specific comparisons of antihypertensive and metabolic effects of hydrochlorothiazide and chlorthalidone. The American Journal of Medicine, 134(7), 918-925. Chekka, L.M.S., Cooper‐DeHoff, R.M., Gums, J.G., Chapman, A.B., & Johnson, J.A. (2022). Pairwise comparison of hydrochlorothiazide and chlorthalidone responses among hypertensive patients. Clinical and Translational Science, 15(12), 2858-2867. Mazumder, A., & Singh, A. (2021). A review on metformin: Clinical significance and side effects. Research Journal of Pharmacy and Technology, 14(11), 6179-6186. Rogers, J., & Allen, J. (2021). Understanding the most commonly billed diagnoses in primary care: Generalized musculoskeletal pain. The Nurse Practitioner, 46(3), 38-45. Skoczyńska, M., Chowaniec, M., Szymczak, A., Langner-Hetmańczuk, A., Maciążek-Chyra, B., & Wiland, P. (2020). Pathophysiology of hyperuricemia and its clinical significance–a narrative review. Reumatologia/Rheumatology, 58(5), 312-323. Vazirpanah, N., Ottria, A., Van Der Linden, M., Wichers, C.G., Schuiveling, M., Van Lochem, E., ... & Broen, J.C. (2019). mTOR inhibition by metformin impacts monosodium urate crystal–induced inflammation and cell death in gout: a prelude to a new add-on therapy? Annals of the Rheumatic Diseases, 78(5), 663-671.