Consult orthopaedic to pin point the problem

This query is on behalf of my father who is now 71-years-old. He has been suffering from body stiffness. He suffers from a swollen ankle sometimes and feels a sharp pain (chasaka) in his back and leg. He sometimes takes pain killer for the pain. He gets tired easily, perhaps due to old age. His uric acid is in normal range. He is taking blood pressure medicine too. If he has been suffering from gout, should he be referred to neurologist or an orthopaedic? Please suggest. — Anonymous

I do not think that your father is suffering from gout since you also mention that his uric acid level is normal. Usually, with gout or increased uric acid levels (hyperurecemia), one typically gets small joints inflammation-cum-swelling especially of the toes, ankle, and knee joints. There are incidences where people have increased uric acid levels but no symptoms, and others with lesser levels but with marked symptoms. It does run in the family, so a genetic or familial component is there. Basically, there is a deficiency of the enzyme ‘xanthine oxidase’ which breaks down uric acid that leads to its increased levels. Thus, it’s imperative to cut down on one’s purine diet of red meat, nuts and other high protein diet. Thus, in ancient times it used to be known as the rich man’s disease.

We must also understand that it is not only the joints that are affected but high uric acid levels also play a role in heart disease where the uric acid crystals gets imposed in the cholesterol deposits making them more difficult to break down during both pharmacotherapy and intervention therapy.

Yes, ankle swelling can be due to increased uric acid levels but that is normal in your father’s case. It could be due to the side effects of one of the medication which he is taking for hypertension too. Other causes of the leg swelling could be due to cardiac or renal reasons or simply dependent edema. Investigations like cardiac ECHO, abdominal ultrasound and renal blood parameters would have to be done to rule out these causes. The back and leg pain could very well be due to sciatica (compression of the sciatic nerve, the largest nerve in one’s body) or the lumbo-sacral syndrome where the spine bone prolapse or para spinal muscle spasm leading to the back pain.

The treatment consists of medications like anti-inflammatories, muscle relaxants, ointment combination applications, exercises to relax the muscles and physiotherapy. The last said is an important aspect in recent times but has to be done under expert hands where ultrasound, laser, electrical impulses/vibrations, heat wave, et cetera play a vital role.

Thus, your father ideally should be seen by an orthopaedic for his joint pains where X-rays and blood tests maybe required. The fatigue part could very well be a side effect of certain anti-hypertensive medication but also be due to varied causes from vitamin D deficiency, certain cardiac conditions and host of other factors like thyroid, pituitary, et cetera where a senior internal medicine or general practitioner should be first consulted who would try to pin point to the cause of his fatigue after accordingly ruling out different causative factors.

The doctors on THT Medical Board are

• Dr Sanduk RuitMedical Director, Tilganga Eye Hospital

• Dr Bhagwan Koirala Cardiac Surgeon,TUTH

• Prof Upendra Devkota Chief of Neurosurgery, National Institute of Neurological and Allied Sciences

• Dr Kundu Yangzom Chief of OBGYN Services, Patan Hospital

• Dr Kishore PandeyPediatrician, CIWEC

• Dr Sameer Aryal Dentist, Advanced Dental Care

• prof Dr Dwarika P Shrestha Head of Dermatology Department, Teaching Hospital and Consultant, Dermato-Venereologist,B&B Hospital

• Dr Ranjeet s Baral Consultant cardiologist, GP and Aeromedical Examiner at Ganga Lal, VAYODHA, Advanced Polyclinic and Norvic Hospital

• Dr Prativa Shrestha Das is a Consultant Dermatologist and Aesthetician at Vayodha Hosptial, Balkhu
• Dr Dilip Das is a Dentist at Vayodha Hospital, Balkhu
• Dr Bharat Rawat is Consultant Cardiologist and Head of Cardiology Department at Norvic International Hospital Katmandu, Tripureshwor
• Dr Uttam Kumar Sharma, is Associate Professor of Urology at TU Teaching Hospital and Urologist and Kidney Transplant Surgeon at Chirayu Hospital and Medical Institute, Basundhara, Kathmandu

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