Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

give me a fact. It does not you the doors way. Our lawyer, I guys'll let people roll in and we'll start in a few minutes. Or maybe like, seven or five. So if you want to grab this off a drink of something, I mean, but I want you know, if anyone if be attending, you thought we need to make coast. I think we're on the way. So we'll keep an eye on. Um, I'm happy that this action, but around on our long But I tried to go that idea. Paul drive. Yeah. Hi, everyone. Welcome to excess. To be as a committee have been doing progress. Testy training, which can be applied to be pretty much all of it. Um, around all the school was better is particular to Cardiff. In terms of the s case that we do. This is the last action, um, for now. But then my hope is do some ski teaching fashions online to make sure you do join those. So I'm gonna be doing rheumatology today, which I know a lot of people do struggle with that. Hopefully I can best in myths about it and make it up slightly easier because with rheumatology, especially with a lot of like specialties like these, you don't need to know one of the ends and out because you'll soon be out like management. It's quite similar. It might be quite difficulty on that, for you don't really need to know it. And it's quite specialist. However, every Metalious, as like a specialty is great. If you want to like that back, I fell. It's so just quickly going on to what we'll be covering. So this is one in a particular order. Just you guys don't start guessing questions. So if we get started now, right, so we've got our fast. SBA, which is a blender, is a 76 year old woman who is retired In the past six months, she's noticed stiffness and her fingers towards the end of the day, especially when lifting. She also notices having of taking one now, and she is a retired type of who does not smoke and drink alcohol on occasions with your B M I 31. So what is the most likely diagnosis is I'm gonna stop the pole that because we've got some good participation already, and a lot of you have gone for the crack time, so it's just option a so osteoarthritis. So I'll go through why that is the case. So I'll see you for a fast Teo anything to do with the bones and often write it progressively information or pain in that osteoarthritis is typically known as aware and tire of the joint on. Like many of the other things we will be talking about, it is not an inflammatory condition in the sense by you prob your own body cells attacking it. So where in time means as you got older, those of the joints I thought it gonna be getting, like fashion and things and overused, and therefore they will start walking a lot of the joints that you notice that stop it like so not stop by thing, but they will start having pain in them. On. Stiffness would be like your hip joint, which has a lot of weight threat, or like your knees, which have another lot, um, a lot of weight throughout, like the joint here and your gum underneath your thumb. That's another one affected because it's used a lot, especially if you're doing a lot of manual work that is what osteoarthritis this. There's a lot of risk factors for it. So as you can imagine it be like as you get older, because, like I said, it's five years, maybe city, because you're putting more strain through that joint occupations on Torme and females, Anyone who has had any histories off hormones like fractures, anything at young age. Also more likely to get off your ass. Drive after I can select a down the line because you're ruining that. So no center of your lining so clinical presentation and how you distinguish it from, say, like something like rheumatoid arthritis. These conditions where you have wearing her they're more worth when you over use the joint for the pain is typically worse at the end of the day, and it improves with the rest. You don't usually have some stomach upset because that this is stomach upset is caused by those inflammatory cells. Produce and find a kinds that joint instability of mentioned already, and I've mentioned all of the joints better. I mean, as I sit here, so in terms of a lot of these conditions, you'll need to be aware somewhat in for your rescue specifically how they present. So in terms of the radiological changes here, you need to run The pneumonic lost Is that wanted to buy you basket? Ali. What the what the I'll styles for the or something if you want to put it in the shop. Yeah, Good, Good. So we've got lots of joint space. Osteo if isis that trust so everything that you would expect to go with this condition. So you've got lots of joint space. You got osteophytes formation on osteophytes. Basically these out sparing so the growth like it's not the normal growth. You have this extra growth of bone where it should be. You got some chondral sclerosis. This is where is Harding? Well, naturally the front of your lining what you see, like it becomes more Hypoattenuating. So on also, the last s in subchondral cyst. So you've got loose, fluid filled black areas just below the joint space for the acronym it was lost on. Remember that it is a clinical diagnosis, which means that you do not need an X ray. So if someone presents was older presents the typical exercise induced pain, then osteoarthritis can be diagnosed because the symptoms do not correlate to the radiological findings to see, So you might find the one with, like, really, really bad Um X ray, but you might not have any symptoms at all. So in terms of the treatments, the treatments for osteoarthritis I'm sorry she's tract from the other previous slide. Okay, so anyway, so because it is pain related condition. So the main thing you want to consider is like paracetamol on and sets. But remember that topical and that can only be used for where it might affect your wrist or your knees. Therefore, any, um, when you're using and sets, you would need to use oral anti us for any other kind of pain in other joints. So the first time management for hip socks risk is top of the lens set for everything else. It's oral and said, and you can also consider using things like topical cups, a PSA, which is a chilly cream, and also remember to cover them away of PPI. Um, if you use against us, so next question. Then I let you guys read us. Okay, I'm gonna It's not sure your pole down. So this is why I was just having you. So it's just testing with an honest that I've told you so I'm gonna end up hold, write that. So we've got a spect between feeding and he on. It's just what I was telling you that, um, the answer is majority of the people have gone with which is prostate more and topical ibuprofen. So remember that it's neat, so you can use topical. I have a broken toe. That's first line, right? If it was something like the hip, you'd want to be using oral ibuprofen. So that's what it's talking about here on, then cycle I, like, have already said you can use the other things on. Also, remember that physiotherapy and muscle strengthening exercise are very important to support the joint and should be offered to all patients. Um, because they have to strengthen the joint. And you shouldn't have patients riding on medications like a time anyway, So hand signs are very important. Eso remember that whatever you're in in an escape, so that's gonna be a bit of overlap. So this one of the conditions much good. Um, rheumatology is one of those things. I could come up in your rescue quite a loss. And whenever you're ready, ask you try to describe has just go back to your basics and you don't need to worry if you don't know what the condition is because I know some some people find it hard to differentiate between them as long as you're saying the basic stressing obviously what you can see So you can 32 hands Didn't see you have any things you could say that on. If you say well, I see swelling in this in this, even if you say the diagnosis wrong because you picked out the salient point you will not lose marks that for you conceive. In these cases, you can see information of the TIPSS Onda information and the pee I pee. So these are in keeping with the D. I. P. S are her bread and note habitants towed on. The others are, and I can't pronounce it to save my life. Uh, you get the idea? It says that on the thing. So if you say that even if you said so, don't be covering basically go like really quickly over God this spelling. So we're selling the pee I pee. So I think it's going to ruin with arthritis. If you say Well, I see this or if you say, for example, Oh, I see swelling from the D I. P. S. Why being the sharks? Like don't say that. Just say, I think finding the different to find your joint. I see selling of the proximal interphalangeal joints. Don't be. Haven't trying to name so specific names for them. Just say the simple terms of liking this is in keeping with that for osteoarthritis so that we go, um, on carbamazepine couple and to get even more effective than Pappy's in the way of the hand. And that's how you differentiate can with rheumatoid arthritis. No second question also, I don't know if you guys have found me to read up the questions, I just let me know in the chart. Yeah, I read the next question. I got lots of people saying, Good performer. If I read the question off, uh, you can get a stop it that on majority of you have got it right. Um, rheumatoid arthritis. So we'll be talking about that. You okay? Like I was saying, rheumatoid off the writers isn't environment trees. The arthritis Brian for inflammation. Here is an inflammatory autoimmune arthritis. Eso. What happens here is your body starts recognizing he was out of your joint to something that's not it's oh, so you got lots of macrophage. Is that everything coming along, destroying that joint on? It's actually bad because it's not one of those conditions, like like 10 to develop over time. It can elect to develop overnight and expect to a patient who had woken up the next day and just got selling all over his hands and feet and literally was in so much pain I'm got is typically what happens with this condition on It's a scribe us a symmetrical poly arthritis, meaning symmetrical meanings. Both of the hands are affected at the same time, and it's like a similar path in, um, and probably authorize just meaning it involves many joints. There is a genetic association such a great idea for NPR want t awful results of family like diabetes, like with the other autoimmune conditions that's much more common in women on middle aged. So what are some of the clinical feet trust you get this toe? Typically, it's metrical pain and stiffness, which is worse when you wake up in the morning And then, like with osteoarthritis, the pain tends to get better as your movements a joint. So when you're eliciting a history, make sure you ask them. So how long does it take for the pain to that bathroom? It's from somewhere around, more than and here it says more than two hours. But typically patients do tend to say more than 30 minutes. And that sort of the cutoff, um, on here we can see that we have a lot of associated symptoms, whether it toward arthritis. And that's what I was talking about with your general weight loss, your fatigue. Because, as you could imagine, you've got a lot of information happening. So this inflammation is driving, taking away all of the energy. So you got things like anemia? Yeah, again, Fatigue related to that. And you feel generally unwell because of the fight of friends and everything. But you still got so, um and, uh, the question as part of Jenny's work up. Sorry. Don't look at that spot of Jenny's work up. She sent for an X ray for her hand. You received a result of her extra which one of the following X ray findings would most favorite diagnosis of rheumatoid up toward arthritis possible causes? Is it some contrast? A court? Sclerosis is just our articular osteoporosis, loss of joint space, the chondral fist or osteophytes. Um and I'm hoping you buy system fever on that, but here you go, Her In fact, I'm going under pole that, um only because he's for that one. So just jacks, article, osteoporosis. We'll go over that in a second on So some of the radiological features we can see I like just drugstore Arctic last year. Process is an early form up front of rheumatoid arthritis. You got the typical loss of joint space on some weight. Teach was include, like subluxation and periarticular inversions. And you also find that the D. I P s are almost never affected in rheumatoid arthritis. So it typically affects, like your MCPs and your P I piece, as always, your rest. So it affects smaller joints. Because even in the diagnostic criteria that is picked up by like your rheumatologist gets more, the more joints there are, the more smaller joints that are involved. You more marks on the diagnostic sort of take sheet on in times of how it works. While is the reason you get older. This happening is you've got You need to be right. Something called a rheumatoid factor. The rheumatoid factor is an IgM antibody on that's recommended first line investigation as well. And what you need to basically understand from it is it's an antibody that makes that the attacks another antibody in the It's an antibody that attacks another antibody within your body, and that's where it causes a lot of this information. In patients who have rheumatoid factor negative, you can consider doing anti CCP is Mom, and that's a good That's good, because it's basically can be present much, much earlier around, even when patients don't have developed symptoms, haven't had developed symptoms. Other things that CRP any s are gonna be racist Well, but you need to remember that anyone, for example, say over the 40/45 years of age who presents with typical morning pain that's alleviated by exercise on morning pain and stiffness that's lasting more than 30 minutes. You should be suspecting Arthur, um, rheumatoid arthritis, and those patients lead over for a while to, uh, every metrology is to make that diagnosis because off all of the really bad things are associative that can happen with your hands on because of this whole like thing about sending them forward much, much idea, the sad rates of dropped and also the hand conditions that you see any return of arthritis there now much fast seen because that can be detrimental. As you imagine, patients use their hands a lot of the time. So you need to remember back the other thing you need to be aware of in terms of rheumatoid arthritis for your exam Question this and I say, Oh, a person is going into G A. So what's something that they need? Um, and um oh, I was talking about subluxation here. You need to make sure that you're doing lateral on a p x rays of your neck because what can happen is you got like, your first rib and your second red sort of sits like this in that on it can move so you can imagine that new sport are move at all. It can cause compression of the final court, and that's more problematic and things like where they're gonna be like moving around and pushing you about, so you need to do track for that before you're doing. Um, before you put them into ta basically write you. So next question, Johnny is referred to the rheumatology with intermittent pain and swelling of the metacarpal. And I'm sleepy drugs. For the past six months, X ray shows just extra articular osteo process and soft tissues Valley. We we tried our factor is positive of dying goes like nervous of rheumatoid arthritis have made. So what is the initial management that's most likely to be started? Most guys you're gonna under told that, um on majority of you guys have gone for the right answer and explain to you the actual punishment what's gonna happen. So basically, you something you need to understand is that, like I said, really should arthritis that someone presents to you say, for example, in primary cast acting, it's a clinical diagnosis on the diagnosis can only be made by a rheumatologist. So then you send them along. But while they are waiting to be seen, you can give them a short course of steroids like reduce all of our information down. But then he definition my list mint, and that is typically done by a disease modifying antirheumatic drugs. So demons and there's a couple of them. So, like methotrexate's sulfasalazine level, um, left alone. Um, I'd on hydroxychloriquine on the last one on. That is like the It's the least strongest anti rheumatic drug, so it can use for, like, mild cases in terms of initiating therapy, you typically start first with methotrexate. Eight. Encephalitis are methotrexate, 8% of the one of those that dryness methotrexate, positive anti TNF drugs and forthright is but the tracks eight plus protects him. Ask. You always haven't met the tracks on that on In terms of anti TNF drugs, you need to remember things like tires up infliximab. Add a loom, um, ab and things like that because they can cause reactivation of TB has their immunosuppressive. So anything that immunity prices, you can cause reactivation of dormant things like happy TV, etcetera on detect them up as well. You need to be aware of the side effects which include, like nightmares, Onda. What you need to do with the returned arthritis patient is doing regular checkups on that, so you've got them to fill out something called August 28. Score on that text. How well they're doing and how well their disease of control. So it looks like crp like number joints. That's bone on that particular day. Phatra. Um, just to make sure that that repeat is what it should be on any acute flare is you can consider giving them a short course of steroids. So, Jane, uh, sorry. Jenny has been on methotrexate for four months. That complications. She was recently started on amlodipine for hypertension and trimethoprim for an uncomplicated UTI by her GP today, she professed a three p with a sore throat and feels unwell. Blood results show. Um, so I didn't really give you guys rangers, but she's got a low h b on, but she's got I don't even know the Rangers myself. She's got a no, I hate to be basically. And someone November, that's rice on Begin. Put it on your, uh, 4th 11. They're all low. Perfect. Thank you. They're all low. So what is the most likely cause of her symptoms with that gives you time to think so. She just had a UTI, and then she's got everything that slow So what's going on here? Give it a go. And if you don't know what's going on, Okay. Okay. Me to stop that right there. Um, so the answer is what majority of you guys have gone for it? It was good that you guys were considering any of your chronic disease that it's trimethoprim interaction. And I'll explain to you why. So we have that methotrexate can cause more on a suppression and with time. If you are like safer number trimethoprim with this, you can get very severe minus the pressure, and it can lead to neutropenic sepsis. And it is really, really difficult if this happens in patients because you need to bend my understanding like, um, hospital, just like taking a hospital bad. But also like in terms of bad house, you have to consider keeping them in a separate room and not doing them infection. So it can be quite difficult to just make sure in patients with taking methotrexate or any other sort of drugs like the thought you're looking out for track some eye interactive than minus depression. Because they both acted like folate In terms of the mechanism of action. These are some of the drugs that we use. Just remember the main things for each and then the rest You can add on later. You remember with methotrexate that to my to suppress of drug, remember that you needed to be six months office. Well, both my other son Father's. You need to be very careful before I'm getting pregnant because it's quite tragic. Jonah Cardiogenic with a felon know mild performed uropathy you something you need to consider something, Alice In a little go sperm you on hydroxychloriquine and causes retinopathy. See me to track patients are like to an eye examination before you stopped them. Some of the hand signs and Richard arthritis. So cancel the name. One is on the right hand side, right? I mean, the one that I'm pointing to hear. So I've got sworn now s one. That condition is fish live. Yeah, eso all of you guys and said Listen, it beautiful ears is right. It's a flexed pee. I pee with a hyper excited t i d. Whereas you can see the little neck of this arm's one here before for neck with hyper extended pee. I pee with flex GIP like fracture is when your fingers like this goes in words on. This is why what we try. Avoid them. That's more of a basic sanitation friend. Already some extra articular manifestations. Got to remember. It's a systemic disease that's an old timey and disease. You can get something called Coplin syndrome, but you got pulmonary fibrosis. Um, slash pulmonary nodule is associate it by a cold, where his name a Coney assist. You get bronchiolitis obliterans information before airways character conjunctivitis. Sicker is the most common ocular manifestations. Another name for that. It's just that dry eyes. I need me a chronic to see you. So it's good that you guys, because you can imagine, like whole of Europe, um, boys. Inflammatory response was taking up the nutrients Carpal tunnel syndrome, especially by laughter. Carpal tunnel syndrome. You should be thinking of things like rheumatoid arthritis on um, criminally on Felty syndrome is a tried or rheumatoid arthritis to neutropenia. No spinal Wrigley. Next question, then. Sorry, guys, I'm trying to hurry. This house, sitting tender in an hour of it is it's not happening for five year old lady presents with six month history of pain in the joints of the right hand on examination. She has tenderness in the right. D i p order an x ray of her hands and you were shown below those a shame. Good. I'm sorry. So what do you think is going on with her? Give it a go. I don't spend difficult trying to read extra are you? Guys could do anything where you see a passion one. I'm trying to teach her and do it that way. Okay, stop the pill. That majority of you have got the right. I'm so sorry. Attic. Arthritis. We'll go over the X ray train their vote stop in a second. Um so, yeah, we're sciatic arthritis activity presented me. What a present In patients who have got psoriasis. Some people say that there is, um, like, timeframe in which what happens. But generally, rheumatologist say that's not the case. And you should ask anyone. Whenever you're doing a history with off someone who comes in with joint pains, there are a few questions you should definitely be asking. That includes one of them is Have you had any rashes? And that includes rushes and childhood and rashes on. Don't forget to ask him about a rush in their skull because a lot of people forget about that and remember that psoriatic Remember, that's the rices time present in your hair. A swell. So ask about that is the heat hatred. Leiby, 27 involuntary arthritis that it belongs to something called Seronegative Spondyloarthropathy on these are set of conditions, which you don't have antibodies, but, um, like affect your spine. Two heads of Spondyloarthropathy be part and also patients with sorrow. I says you got them to complete something called the past screening tool. So then they will rate. They will talk about saying in there like, Have you ever had any pain in your joints? Have you ever home but like tired, etcetera, so that you can sort of rule in or rule out whether they might have arthritis? It isn't a nice condition, any converting from something like a mild pains and aches to basically destroying your joints, and we'll go into that in a sack. And some of the other risk factors include agent smoking you can call features is asymmetrical. Joint involvement is more suggestive. Story. Attic. Right? Then we retired, however, about 40% because it's metrical joint, so what it's trying to say here is that sarcastic arthritis has three types of presentation. Then one of the presentation that it can have some attitude is like a rheumatoid arthritis. My, it's a symmetrical disease, but in that case, how you differentiate it would be that rash and also the fact that it will have involvement of the D. I. P E joints. You can also have another episode of the disease, which was porky arthritis. My lesson on four joints are involved in the body, or you can have a condition, which is right, similar to, um, basically, I ask where your back. So it's more so. It's more in men in that in that case, where your back at feels culture, it is more effective. You get associating, they'll train just That's how you that's another way. You can help know that it's psoriatic arthritis on that includes pitting, so you'll see like a little dots as well as our Nikolai, so so your nails could be coming off the Remember whenever you get a picture of a hand to look at the nails, you can also get your articular disease leading to like full inflammation of your back to it so it can lead to talk to, like, test. Tactile Isis is really important because it's another important differential if sickle cell anemia. So my child on don't typically it a one year old we got to lie to Should you had showed a meeting, Go to sickle cell anemia on this is a low the differential for it. So and also any hatred of you 25 condition can give you an interior. Uveitis is love and other things like it kind of involve your tendons at the bottom of you. But you can get like, fresh up kind of plantar fasciitis and also Achilles tendonitis from things like that, because it can involve your tendon. So any hatred a B 27 so seronegative want a lot of the wrong with You can do that for you. So imaging in terms of psoriatic arthritis, you can see like you got bilateral disk is here on the yuppie joints are more affected than the I pee on some of the things that you might notice is like basically not in this picture particularly, but your joints been stopped using together and you get these erosions, and basically it will erode away slowly. Soda slowly. And this part will it a road away. So if I sort of draw on it, it will continue eroding. So all of the out of it a row to this bit starts setting in it. So then it will become something like a pencil and cup appearance. And you can see that here it's an involuntary conditions. You'll see like inflammation around here, Islam. They give you to cut soft tissue information. And you might also get inflammation of your whole digit. So just look out for like, a really fat, swollen fingers. While that will price point you toward the diagnosis off three attic arthritis of up. Yeah, CASS it pencil and you can't You can't see it here, but not that much. But if he starts it up, you should be able to get it. So the hand signs that we were talking about can you see? Like the article lysis here is coming off, um, and also fat phone in fingers, but just actual itis on. When I was talking about you can get really, really bad disease is basically if you imagine, if you go back to the X ray. All of your like digit can start getting like destroyed on the inside. Sorry that your district can start getting destroyed on the inside to the skin, then starts building in on itself and gives you something like they're so it's called telescoping of the finger because the skin is just folding folding, cause the bone inside literally doesn't exist on This is called arthritis mutilations, and it's something that's really like severe and off the sector of the disease. In times of the management, it's very similar to rheumatoid doctor. I just better get. It needs to be managed by everyone told wrists. And if you want to remember, you can give like. And that's for pain. If you consider giving them to me more than on TNF it. Tre Oh, next last, a 22 year old male presents you the CD, um, with painful left knee. Feeling tired of the rash was past medical history of food. Boyfriend three weeks ago is also sexually active, and basically, observations includes, so it doesn't read us on moved the pool on. So someone said someone who was like one year old typically have a child who's like one year old percent. Then you would suspect them toe have doctor lighters. Did you try patient here? Okay, I'm going to stop the whole now. Eso we've got quite a mix of things, so I says the sample science know before it just take it. Probably ask me what is the most likely to be observed from the sample on Option C has one on. Let me show you the answer. Sorry, guys. My school has become really crowded all of a sudden, and I can't seem to find the button to change it from you. There we go. Do you expect to see a star after it with height high? Wife will count when you take. When you do the analysis of the sign it instead of your fluid, you're basically gonna send it like MCL some things like that as well as cultures. Not immediately going to see like that's like the cultures and stuff. We're gonna take time to come back, and that's all. The answer is a star all started with high white cell count, especially with the fact that he had food poisoning three weeks ago. It's not gonna be like chlamydia or night in Syria. Um, for that reason, although we'll go into the other things again, reactive arthritis of a hitch really be 27 condition. It is a several accidents spondylar arthropathy a commonly presents with acute spot and joint, which, if your knee, it's associate it where infections that tries like a recent ST I or recent bout of diarrhea. So things you should be looking out for, like our see Johnny um, and salmonella salmon. Alice. Well, sorry, um, at the trial that you need to remember for it is can't CP or Crime a tea tree? Because you get Antara. UTI test, remember, is a hatred a B 27. It's a spondyloarthropathy. It's a reactive arthritis iga arthritis, and you got real retract. If that's why you can't sort of PT got pain and clearing peeing. One thing you do need to remember is that anyone present with a huge sold and joint acute mono swollen joint, you need to treat a septic arthritis until proven otherwise. So you need to give, like take crumples of the fluid test, except try and give the antibiotics until you got the results back. The management is typically used symptomatic relief with the allergies and and set. However, if you get like more professor, interview to Clinton's that I'm at the track for A and sulfasalazine in terms of sexually transmitted disease, you should be thinking of something like chlamydia. Because gonorrhea gives you like a crackle injection and gives you septic arthritis. I'm and the other thing that comes up right commonly as well is something called carotid Emma Field. I'll blender, right Chika, and these are like wax yellow brown papeles on the palms and soles. So if you see like someone who copy, can't climb a tree, I can't see can't peek on comma tree. I mean, they get these popular as you should be thinking of this condition. So Daniel, a 25 year old male, presents to keep you below a bath pain in his lumbar region. That's worse in the morning and last for 30 minutes before moving of action stretching. That's relieve the pain. It has a GP who refers for a chest X ray, which comes back normal. What is the next best investigation of them for this patient? Also excuse to grab her on the passion. It's very poorly written by me. I'm not too impressed. I if the number of people getting this correct. So I am proud. Just give it a try, even if you don't know. Yes, sir. And I could test want to the author up to use. Typically, do you mean, like, the rheumatoid factor is negative? And also, there is like, I'm not an autoimmune sort of element where there's something else going on like there is. There isn't a specific antibody that they can find a link to it on the spondyloarthropathy means not Typically, your back is the one that's affected on. I'm going to stop the hole right there. Uh, majority of you have got this corrects a referral for an MRI. So this condition was a story This crashing was referring to your ankle over in spondylitis on. This is a condition that everyone sort of knows us bamboo spine. Do you see it in the trash? Like you see ah X ray of the back and you're like, yes, you know, if there are a few other things that you should know about the conditions so it typically affects, um, young males who presented a low lower back pain, like patients who shouldn't really be having back pain. I like the company, the buttocks pain to That's your separate sacroiliitis. And this pain is typically worse in the morning of the second half of the night. It wakes them up, doesn't let him sleep. They, uh, also complained that basically, it takes around like 30 minutes for the pain to get better on, but only gets that when you're sort of exercising and moving about again with these, like inflammatory conditions, it can affect a lot of things, including your tendons, your joint spaces. Um, where your ligament to touch for you that you break that twice. You can get ossification of a lot of things. It has a gradual onset compared to say something like rheumatoid arthritis. So it's like it has a you you only some start suspecting it that's been present for more than three months. Investigations include blood like inflammatory markers. Have it should be 25 in testing on imaging of the X ray spine and say cream. However, if imaging is negative, that doesn't mean you really like the condition. Immediately. You can consider doing an MRI which will show like early disease changes on file Such a bone marrow edema as want bone already know in X ray off the enclosing spondylitis, you got a specific changes, like squaring the vestibule bodies that, like they become square subcontract sclerosis and erosions like you. Doing like osteoarthritis is closing, meaning like the joint where the joint joints for the death become hard. That's end dismal. Five. So this is you got bony growth from the areas by the ligaments but typically join other but like joined the better breast together get ostentation of the ligaments that sells the disk. The joints are like, basically, that's why you got that damn boost crime, because everything is basically becoming bone and the facet joint or even becoming a touch together. And you can also get cost over to bromine. Sick really are joined a huge on this wall. And it's quite unfortunately, he thinks, because if you can imagine if you got like a joint effusion and your trust here of your last number attached to your style and then you can get some trust pain, you could also get like restrictive lung disease. I'm closing spondylitis was also safety. It'd with things like a pickle. Fibrosis of your lungs are a lot of AIDS. Um, maybe node block Achilles tendonitis until you, the activists and things like that. It's also it gives you a lot of extra articular my manifestations as well. The management institute with your parent gets size of mobilization, and that's referred. That's what all of the patient, and remember that any time you have a basket pack, pain is never responsible. Paracetamol. It's only, and that's that can be used first line if that isn't working in considered a boot on TNF medications. And if that is the West, you can stop up immunosuppression and surgical correction of spinal deformity. Howard. That's no longer done nowadays because how good that people are catching the disease and managing it. Okay, it depends on a 55 year old female has been suffering from shoulder stiffness and weakness. Been getting out of a chair. However, yesterday, this pain progressively larger side of her head, along with their she noticed, haven't just hard when eating food and treat hot some blurring of vision for a few seconds. She times a any today because she is quite concerned and and generally is and how stressed with all her pain, what do you do for this patient? As people do attend anyone rather than going to GP and stuff like that, which is far enough in there in a lot of pain. And so I put discussion has been me. And it's if I don't want to have to get bored, like, throughout their talk. So just keep it being a okay, you more of you just give it a try the team out on nobody used for a spond know they do go into using, um, I see enough medications. Okay, I'm ending the pole here. So majority of you guys have gone with a correct answer on the other option laws you thought people have gone with. Um, the reason it's 60 is because of the eyes. But it's quite me in because I don't expect you to know whether it's 40 fixing me print me. That probably should know up. I'll go over in a second. So, gi see, a is, um, part of conditions where you got information off your blood vessels. So it's like it's a vasculitis. It infects the medium large off of vessels. Anything affect your temporal artery. The information that it causes is so much you savers. But if you think of currency, guess kept lesions. The peak onset is 70. 79 year old on its typically affects people who have so she had, like shoulder pain and public girl pain. So people who typically help your mom it's described as a union astral headache with claudications like, um, like your jaw feels tired after eating. So that's the kind of questions you need to ask. The other thing you want to ask patients is like if they're up, they're hands through the hedge, and it's like trying to comb. So that's what people say, aren't you? Do it like Doc when I comb my hair like it feels really tender around the area. So that is something you need to address that with anyone that comes in with a headache, because these are the sort of conditions are very important, and you do not want to make some because it can go on to involve your eyes on cause like so basically it can cause something called a Veress, a spoon gas, which is a type of stroke on. That's where you had transient loss of your vision, but it can cause, like other things that blaring diplopia except Trump again. It's an inflammatory presentation. So you got the other things is so expensive for your weight loss, fatigue, the definitive management, a definitive diagnosis? Or is temporal artery biopsy, However, that's now been overtaken wire by ultrasound like not very definitive buying those this still in your Petri answer put biopsy. But most people don't go on to do that. Um, they tend to do ultrasound, and that should so like Heyler side, which is more thickening affect on you should be doing for because and you saw for this on, I'll show you why that's important in a second. And also remember that you don't need to wait for a biopsy before treating with, I said. If you suspect someone with PMR, then you need to be treated treating it because you can get quite quickly, develop a sight loss, and that's irreversible. And they said they can quote cost you a lot of money because people see you pretty much and and that's why it's important. Savior back in terms of the diagnostic criteria, you should be thinking about anyone who's over 50 with a new headache, which was temporal artery related. Like around this area with elevated ears are and you've got biopsy findings, then you can start thinking about it. You can manage them with steroids, and the type depends on whether this eye involvement. So if you've got, um, visual lost all together and then it's IV part. Whereas if you got pregnant in one and mild if it's mild visual Last said, it's like 60 mg. Where's no visual loss is body if you want to know the specifics but basically measure involvement IV me. Bar pride, no visual involvement. Prednisolone. Remember that, and they need to be urgently admitted. You could also consider giving them aspirin and, um, other things like bone protection. So don't forget about your PPI. Eyes were like a London eight as well as a calcium and vitamin D, because they're gonna be alright. High dose I'm on the other finger is that these patients should pretty much from proven 24 to 48 hours. If they're not, then you should be affecting something else because, like, it doesn't tend to be, um, take that long on. This is like a very detailed if you wanna know the exact ends on the outs. Well, what? My rheumatology consult Maybe, um, so PMR then it's a sister condition. So PMR is when you you should be thinking about in terms of older patients 22 80 in northern European who come in with, like, shoulder girdle. Oh, Onda, um, pelvic pain and how you sort of illness that that pain is they'll say, Oh, I have difficulty like any any conditions which electric proximal much stores or proximal areas on give you something like how your list that is You go. Okay, So, like, tell me about how it is getting up chair or coming out of the part. That's one. People tend to complain off like, Well, I can't seem to get out of the car. My car Brush my hair like really like it's ready. Just coats the hair. It's the pain and everything that causing um difficulty. The symptoms last for, like, more than two weeks, and again the management here should be with steroids. The investigations are sa sake, but you just sort of rule out other conditions, like a little arthritis CK like my inside tends etcetera. Because while PMR itself is like, um, a condition, you don't want to miss a swell. But other things are more important, like 25 years to mark my sight. Is some Cushing's. What makes I thought that can give you a muscle? Because so, man, if I like, if it is with long term oral steroids on typically you will eventually reduced. Bring them down on a reducing the dream, which can take quite a long while, uh, in terms of anyone. If you start on a steroid regimen, remember to tell them to Don't stop taking their medications suddenly this to refill for that because they shouldn't it can give you and it's only in crisis. But also that don't don't stop should remind you you need to remind them off their sector rules, so they should be doubling the dose of hydrocortisone on there. Six. On sick days, they should have a treatment card telling people that they are on steroids. So if they happen to faint that people can do that, maybe the monitor that it's only in crisis, they should have osteoporosis prevention. So, like I said, all righty with the other ones and people die protectionist. Mom. Okay, I thought I did have a question for gosh. So moving on to go to then, um out is I'll give you that once I find different training sensitivity. So moving onto gasthaus is a crystal arthropathy, which means that if you record time, you about crystals off something sort of like molecules chemicals that I depositing in your joints. So that's why the ARTHROPATHY comes from. So you've got, like, her joint problem on couches, Specifically course by chronically high level of uric acid. So there are many things I can increase your uric acid levels. It's very some that you can lessen the chart. Maybe I decided medications other things like, well, common things, that is Yeah. Call, um, perfect. Perfect. Yeah, right. Meet on fish. Red meat, alcohol being a beef high purine diet it Flatterer can all increase your chances of getting gout on what it does is all of these crystals and forming, like the most common example is in your toe. But it can also affect your knee and things like that. But always remember, Like I said before, you need to rule out septic arthritis before you do that. And while you're doing that, even then send them for like, a crystal announces as well. The typical joint effected is your toe. The first metatarsal joint a PSA classic one that we hear off. But, you know, things are common with carpal joint from base of the thumb also affected as well as the rest. Um, on just period. Sorry. Looks, um, investigation. We've really starts public arthritis. And you can do, like, joint X rays, which will show like a radio of structure joint. If you look at it here like this point joint destruction and punched out erosions start erosions would be like here we have lytic lesion, sclerotic boat border. So wherever you have, like, punched out lesions, say for something bad right here. Got punched out lesions. If you then imagine the green thing will be whether lesion, if it will be quite hard and solid, like you look much whiter. And that's what it was talking about. What if a sclerotic water on you have maintenance of the joint space and like in other conditions, like also arthritis, but you lose your joint space. Okay, So management of cute out pretty well and sides or culture. See, um, Colchicine, for example, if you're thinking of patients, but you need to see you, the patients were like heart failure on. You can also consider giving them starlets. Once that cute talk a sexual, you need to consider your memory therapy with something like other people, and I always remembered that basket of them are allopurinol. He needs to do more to cover them with cultures in. So that's like six months. I would like to six month course of a culture skin purse up allopurinol, and then you can, like, do other urinal on it. So another thing you need to remember is thought you can continue allopurinol if you were already on it and you gotta go to the talk. But if it's a new attack, then you wait until the attack of settled is generally what they say. And also don't forget to give them conservative management because they were gonna be on Morris. You can get like stones and your kidney as well, and you also like out is not like a nice condition itself. It's painful. It's not nice. It's limiting. So you want to give them advice about stopping some things they can do, like weight loss, hydration and diet restrictions and things like that. And also, another spy thing you need to know is like culture clean has caused diarrhea, and it's depending on the dose. So the more you take, the more is That's why, you know, provide to give them and stuff in the last place suit about is, um, formally known. I also notice chondrocalcinosis Do you guys know another condition where you might see the typical chondrocalcinosis on a condition? Yeah, I never like G I condition. Maybe if I say that to you, it's okay if you don't know that it's fine. So basically, uh, not well, since the other one, Maybe that could be putting keep a chromatosis. So I am. If you got hemochromatosis, you're more print off getting few days after. Yeah, so you get you see these topical like X ray changes. So what about is causing part of part of prostate crystals similar presentation to doubt, less severe. So, um, it can affect your knees shoulder. It's and rest. You want to rule out septic arthritis again, and Radford's again the famed and said the colchicine etcetera. Now How do you differentiate it? Because I know that's what people want to know. So gosh, remember that once we sent off, they'll give you lots of information sick out of all of the ends, negatively by your friends in with needle shape crystals and monosodium uric crystals. So the end of the sodium pseudogout controversy nose issue get peas, so it's Suda got positively buyer for engine with calcium Piros prostate crystals on. I know the RHOMBOID doesn't really fit with a P, but you can imagine the ours line. Isn't that so Wrong Grade shaped crystals? Um, so there we go. Okay, we're nearly getting to the other. So if you were with me So head on a 20 year old a few mil has come complaining of chest pain, which was relieved when she flipped her on his western lined up. She has any city she has any said, You've done not. Don't we shows tachycardia? Insulin shape ST. Elevation For out on a further history you're less about. She's been suffering with months if mild year, Um, Adireksarn aches and pains, and I forgot what the UW else did for a Nexium in a shin. You notice the butterfly rash across your cheek. Which antibody is more specific to this condition? Out of the listed below. I looked the pole. I think about which antibody would be it. More associated the best. Yeah. Trying that time from the charts on on the pole. You know, people have been revising. Well, some tests on some from the posterior one. It's just why we need to cover with colchicine. It's just something they say. Advice by the rheumatology department. Okay. Okay. I'm gonna end the whole, uh, and most of you have kind of the crackdowns. I don't do the normal one that you always get, which is antidouble stranded DNA. So you guys oppressed in thinking anti Semitic? So just to quickly go over the antibodies, anti centromere is limited. Catania's systemic sclerosis and s yellow is diffused. Could, um, diffuse system explosives and to call your wife and find the possible leopard? Um, anti mitochondrion is TV. See? Also, I'll briefly just touched upon cutaneous like I don't have a slide on it. But just to tell you, in types of systemic steroid test, do you have something called scleroderma and that covers systemic sclerosis? You got, like, a diffuse hot like you've got a limited. Um, I read, um, and I like the one that covers basically a systemic sclerosis as a service course. It was a really, really, really bad condition. So you can have limited or you cannot diffuse on my limited. You want to know something called a cross syndrome for involvement off, um, so containing meaning, like you've got to like skin attachments. That's you got skin involvement limited meaning it doesn't effect like you're entitled and turn our organs unlimited containing is there is a problem that I said was Crest. So you got like, acidosis. There's Raynaud's phenomenon esophageal dysmotility, have you? I forgot to, um, t o tragic TVs on started actually basically got tightening and hardening of the skin, and that can lead to make you prone for ulcerating and things like that. And diffuse is very similar to that in that you got all of the things with crest. But you also get like heart disease. You got like hypertension. You got high, potentially a pulmonary hypertension. You've got involvement of your kidneys, so you can go into like, a matter of renal crisis. But like really hypertensive renal crisis. So that's your diffuse on Limited, like the saddest crest syndrome. Think of that and it has very high, like Metallica and mobility. Associate it with that because, as you can imagine, people can't eat. They got ulcers all the time that it's painful that how about you seen a patient like on the other side of it, where she was in hospital all of the time, like on just touching NGF. You just want to take all these medications and she basically can't. She can't eat a tall and now, like because you got, like, powerful shut down of your vessels if it continues to have to put veins, and they will have to consider other banks. So if you got a chance to see PSA was system xclear excess like it is ready? Ready? Um, it's great, obviously not for the patient, but for yourself on SLE then SLE is a condition which we all sort of think of when we think of a mile a rash. Another place where you might think of a mile or a rash is like acne rochet. So when you have, which that's also like white photo sensitive so you want to consider something like that. So with SLE, it's an auto immune disease that's a connective tissue disease, and that's why affects so many of your organs. But how you need to remember it? Onda um, it's associated with anti nuclear antibodies, so basically it starts a truck attacking the proteins within your nucleus. But anti nuclear antibodies are positive and a lot of things, and you need to take them in context of the patient's symptoms. So you look for things that are more specific. So you have things like antidouble stranded DNA and anti Smith, which are more specific for SLE. It can affect pretty much anything and always remember that most autoimmune conditions, like rheumatoid arthritis SLE etcetera, can also give you a Reynaud's phenomenon. They can affect your skin's your joints so you got those arthrology association with SLE. Infect your kidneys so you can get things you think of like Member Lesson from petit. You can also get like other never up you. Some things like that can affect your heart. Giving your hypertension it can affect your brain. It typically affects middle aged females who are African or after a car be in, and patients typically do present with, like, resistant hypertension in their twenties. And how is it, like sort of a meal that presented story they had, like his mother was affected by the same thing. It can also be drug induced. So, like my ass in Isaiah on this hatred a association. So any time you see a mile are rushed butterfly rash, which is very sensitive to think of SLE. So these are some of things already touched upon, but just to go with some of the other things that it might cause, like concludes, psychosis, seizures, depression, you can give you like a little bee directed caloris rash. Another place you might see that is there's two places you see on the libido. Erectile tickle area rash in rheumatology Number one is SLE because a cell is associated with Antiphospholipid syndrome so that antiphospholipid syndrome. You see the levity brilliant of a directive, flowers and the other place of pan probably arthritis meadow PSA. So those are the two things I remember and Hematologic Lee. It can give you like anemia again because it's not autoimmune disease, a pattern, but you can also get like a plastic anemia and things fixed up there where you want to treat the condition. How are you going to diagnose it can do like a thief. Easy. A saws honest on TV A. You can consider doing imaging the joints and everything I thought this fall you got It's beyond what we need to know. Yeah, that's it on in tandem am sorry intestine management Can we expect over that back education about lifestyle changes? Sun avoidance use of sun cream acute. You comanaged, um, with started hydroxychloriquine and said that factory So some patients are quite monitors you, so they're just happy with and suds hydroxychloriquine other patients like you have some kidney. Does he use the past treatment for that is typically microphone and mycophenolate on. Do you want to try stopping the other therapy to, like hydrochloride hydroxychloriquine it alone because of the fact that it is a lot of drugs. They're already at risk of other conditions because of the SLE. So you don't really low them with drugs which would give them other side effects with that. Well, thank thank you so much stuff. Everything. Try to keep it to try. If you got other questions. Or like you want to ask about any recurrent conditions quickly. If you're free piece Drew filled if you but for me I will pay up on the slide, See if there's any other like rheumatological conditions. Please. Ross Mycophenolate is typically used. I have renal disease. Associative of study. I'm sorry. What was the thing about? If you put your questions on the Q and A, I can read them to music. It appears girl s so, um limited. Cutaneous sclerosis is cracked syndrome on diffuses crest. Plus everything else like your internal organ involvement. So the difference between the scleroderma and the stomach sclerosis? Um, scleroderma. So it's the stomach sclerosis. As I'm Elaine. That you have involvement off your other things is also like you have your esophagus. And if I am in the limited disease for a scleroderma, so you have systemic sclerosis. That's one time spirit about or you can have just scared over on its number. It's just a high hardening and tightening of your skin. That's it coming from? Uh, yeah, I can go with this side of it. You don't really need to know the investigation for SLE Just need to know that you need to do like FB feel like you need to. You contract blood. Something to do. Um, it depends how the patients present really like that's how you're gonna diagnosed. I'm so safety presented with kidney problems, you're gonna do a renal biopsy, and that's the only way to finish the way you're gonna like those. The other things you can do is I can fbc using these copies that you do with information. Check the antibodies, um, track that complement levels as well. We are. It's quite confusing. I mean, people do so basically, people are like, don't fixate on the scleroderma thing. The only reason I was saying that is because people do tend to use them interchangeably. But the correct way of saying it is Scolaro derma is you can divide it into systemic sclerosis. Or it could just be like just the skin. That's the stomach Sclerosis conduct be five divided into diffuse are also stomach. Um, yeah. So I'm trying to remember now from the top of my head on. That's how you divide it further. So then you have limited Catania's are are systemic. Contain IUs unlimited. Cutaneous is where you get like the Crest syndrome on systemic is where you get crust plus, like your liver involvement, your heart involvement, long syndrome into the kidney involvement. Yeah, it's Claritin. Actually, it's kind of scleroderma is tightening of your fingers rescue Larry Derma means tiny looking skin. I can add it to the slide if you guys want, but it seems like it's such a minor boy. I was just saying it for like from a rheumatologist enthusiastic point of view that people tend to just sort of mix them up. Eso with power polyarteritis know dose is another condition, which is associated with a rash for the the video reticularis and I'm Pan is a medium sized vasculitis. It would give you all of the conditions that you got that with the oscal itis like the typical nonblanching rush on like fevers, weight loss center. Actually, a loss of being you, but to the main thing you need to know about Pan is that it's associated with happy. I does affect the lung off affects the I have kidneys, long heart again. If you look at the Boston, I think a lot of their recordings were just it sort of size a thick audiology. Give this girl threw. Haven't been. There are two recordings for everything. I don't know why it's the 50 stairs. The lungs, unfortunately. Oh, yeah. Okay. I'm gonna end the screen recording that doesn't even have any other questions related to your quality as a whole. As opposed to just, um