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Um um So I'm Doctor Samuel Hassan. I work as a GP in um in um West London. Um And also I'm a, a program director for the GP training scheme. So um doctors in the UK who want to become trainers GP. So um it's really, really brilliant to be able to be here and, and to share this um platform really to, to help you learn, you're in a really exciting journey as medical students. It's a fantastic career and it's a really privileged career. So um no matter what you do in your career, wherever, whichever specialty you go into, um just enjoy, enjoy the learning, it's lifelong learning. Um and people are fascinating and diseases fascinating. So, um right, so I'm going to um just remind me which year, which year are you in or are you all in different years? Can somebody I mute and just say I'm in 15 last year, 62. OK, great. Okay. All in different years. So you're from daddy to 60. Fine. Yeah. So I can just angle it at, you know, if it's, if you're fit all 50 years, um then it's gonna be, I can be a bit more sort of, I can send, you know, focusing on more sort of that. But if it's broad, then I'll keep it broad. Okay. So, um this is a presentation that was actually prepared by two of our medical students in the practice. So, um uh so this is really a good presentation. Okay. So the common conditions of joint pains. All right. So we're going to go through those. All right. So, um what are they? So what is arthritis? Arthritis means as you know, itis means inflammation, arth means joints. So, inflammation of the joints. So, rheumatoid arthritis, you know about um actually, I should have asked you first, what other type of arthritis can you tell me about? Does anybody know or you should know really septic arthritis, rheumatoid arthritis. Brilliant. Anything else? Okay. Um We'll go through other stuff. That's brilliant. Thank you for your contribution. Um So rheumatoid arthritis causes joint information and pain. Okay. Um The disease is commonly, I'll just put that sort of opening. Can you see this better? Let me just was it because the writing is quite small. Uh Now we could only see an email open deep. Maybe I should have done that then. Uh power point, painful joint. Okay. I'll go back then. Can you see that back to the painful joints? Yes. Somebody tell me. No. All right. Okay. Uh What can you see? Sorry. Uh Again your email page. Okay. Doctor is showing your email pulled up. Yeah. Stop share ing I'm just gonna read the share then. Okay. Shouldn't spring. Uh which is arthritis. Can you see that now? Yes. Yeah. Fine. Sorry about that. Ok. So I won't change anything here. So, rheumatoid arthritis, um is it causes joint inflammation and pain? The disease commonly affects the hands, knees or ankles and usually the same joint on both sides of the body. Okay. That's really important. Usually the same joint on both sides of the body, such as both hands or both knees. Okay. Um, does anybody know what else? Rheumatoid arthritis does um, progressive destruction of the joint? Absolutely. So this is really, this is key. What you've just said there, it is, um, it can cause destruction of the, of the joints. All right. And it can, it is quite a disabling disease if you don't manage it well. Okay. So if a patient has rheumatoid arthritis quite progressive and you leave it untreated, it will lead to joint destruction and disability. Okay. And what we're trying to do is avoid long term damage and disability. Okay. So please remember rheumatoid arthritis usually affects the same joints on both sides of bodies such as both hands or both knees. So it's almost like a symmetrical. Okay, obviously, you know, you can, there are no, you know, people are all very different, but usually usually it's symmetrical. If you've got arthritis in one hand, look for it in the other hand. Okay. Rheumatoid arthritis. Look at, look at the knees, look at the ankles. Um, I'm sorry, you probably can't see this but normal, very clearly normal joint looks like that. Nice. Uh, there's a cushion pad there between the two bones, the cartilage and if you can see there's real thinning here. So that's so the other kind of diseases, osteoarthritis. So, does anybody know what osteoarthritis is? It's inflammation of both the joints and the bones? Yeah. So osteoarthritis again, is inflammation. What's the difference between osteo and rheumatoid? Just in general terms, um, rheumatoid is autoimmune but osteoarthritis is not only in Yeah. So osteoarthritis is a, um, it's very common, very, very common and um is what we call the wear and tear disease of old age. So your joints basically because of your, of just old age and frailty, the, the joints become a little bit worn out. Okay. So it's a natural progressive disease. Some people have it more than others and it runs in, it can have a genetic disposition. So this is not, this is a wear and tear. So, if you remember, osteoarthritis is a wear and tear, um, a form of uh, bone damage disease, whatever you want to call it. Whereas rheumatoid arthritis is an actively self destructing, you know, the autoimmune, autoimmune means that the body attacks itself, healthy cells. Okay. So, if you see the difference, what's the difference between here and so normal joint and rheumatoid arthritis can you see the difference, if any, let's speak up soon, it, soon the envelopment of the trends. Yeah. Sorry, I didn't hear that. Say that again. The absolute self and the envelopment of the joint, it's going beyond the yes, uh, friction area. Yeah. So, there you go. Okay. So, so if you see that sort of, you know, it's a nice sort of batman mask kind of thing. Um, whereas here it's sort of more enveloping at the top. Okay. Whereas osteoarthritis is a, is a loss of this space here and the bones start to rub against each other and it's quite painful and you can get swelling okay. But it's a, this is a sort of what we call a natural wear and tear. So as we all live longer, people are living into their nineties, eighties and nineties, this is, we see this a lot, okay. It can happen in younger people as well. Um, you know, in the fifties more common in mails and, uh, than males. But also, you know, athletes can get it because of the wear and tear. But it's, it's, you know, it depends on weight and lots of factors as you know, every disease is multifactorial. Okay. Any questions around that? No. Okay. I'll move on. Okay. So, rheumatoid arthritis, like one of you said, um, is a autoimmune disease. So why the fact that it means autoimmune? I've got this diagram up. What does, what does this convey to you, what is, you know, if it's an autoimmune disease, what does that mean? It's more to systemic? Yes. Absolutely. So, that's, um, so I can tell you're, you're just by the language you're using that you're, you're, you know, 50 year medical student. Is that right? Who said, who just said that? I'm, yeah, I'm in my final. Yeah. Yeah. Brilliant. You're, so, we're aware that once you do medicine you're actually learning a new language. So you're going to, when you, when you read um the symptoms and signs and the text books and speaking to patient's you and just listening to, listening into uh your seniors, you will see that the, the language that are using is quite um a different. So I can tell the difference between, you know, obviously a first year, third year and a 50 year and the final year medical student here we have in the UK six years. So final year means six years, six years students. So um so the language that you'll be using in your exams, you need to be very fluent in that. Um So it's a system disease, autoimmune means it can attack many organs around the body, many systems. So when you say many systems, it means a systemic, okay. So you've got that. Absolutely. That's beautifully said, systemic, it's a systemic disease. It affects, it's a multi system disease, okay. And it can affect, it causes fatigue, it can cause heart disease. I mean, a joint issue problem. Um you would not imagine that it could cause heart, heart disease, but it does the skin conditions, cartilage damage, um inflammation, um digestive problems, lung scarring, dry mouth and um I conditions okay. So it's a multi system. It's a systemic disease. Autoimmune systemic any questions. Okay. So, within autoimmune disease, like rheumatoid arthritis are, is rheumatoid arthritis. The immune system mistakes the body cells for foreign invaders and releases inflammatory chemicals that attack those cells. So the cells attacking the healthy tissue, okay, which leads to destruction of the joints of the, of the uh of the cells. All right. So, um it's, it's, it's a very, I mean, it can be a really serious disease if it's not diagnosed and managed. Okay. So a foreign invader. So it's, it's attacking itself for, you know, it's um it's uh basically um mistaking. It's a healthy normal cells, which is a disaster really if you think about it because cells, cells, all of these are really important for us. The inflamed Sino Veum gets thicker and makes the joint area feel painful and tender. Okay. So the inflamed sino Veum gets thicker and makes the joint area feel painful. So, pain means inflammation and it's tender tender when you touch it, when you're examining, the patient will flinch. Oh, it hurts. So the patient may say, uh it's really painful to walk on. But when you examine it and you touch it, it, it's inflamed it's red, it's hot. So that's what inflammation is red hot, it's tender to touch. Um moving the joint may be difficult. So, um movement is really important, you know, for all of us and just the fact that, you know, people cannot then move, it leads to other chronic diseases, then they can't exercise. Um then you, then they start to develop diabetes, you know, all sorts of things, heart disease. Um, you know, I've got patient who, um, you know, have gone from 55 kg to, you know, um 70 to 80 kg because the pain and the inflammation could not prevented them from doing their sort of daily walks and exercising and pain actually causes low mood. Um, so and anxiety. So then, you know, it's a sort of a vicious circle. So don't forget that you've got to look at the person as a whole, what's going on with them? Okay. Well, how is this affecting them? All right. It's not just a disease but how is it affecting them? Um, so, you know, also what does it, what job do they do? You know, how is it going to affect what they, what they, so how is it going to affect their work, their lifestyle? Um looking after family, you know, all sorts of things. So causes and symptoms and treatments. So it can affect the eyes, it can affect the mouth, skin, lungs, blood vessels, um um heart. So how do you treat it. So, what would you be looking out for in medical history? Anyone other autoimmune diseases, maybe? Mhm. Absolutely. Morning stiffness. Yeah. Stiffness is, is, um, is a symptom. Yeah, stiffness in joints. I mean, it does crossover with a rheumatoid and osteo, um, osteoarthritis is more, it's a different morning stiffness is usually more associated with osteo and then once you get moving then it's all relieves. But you can get stiffness. Yes. Absolutely. And you need to ask about morning stiffness to differentiate because actually they could have osteo and osteo and rheumatoid arthritis. Okay. Excellent. Anything else in their medical history? The involvement of more than three joints, maybe because usually. Absolutely brilliant. Yeah. Okay. And what would you look for in the physical examination? Um So pain, swelling, redness, tenderness. Yeah. Sorry, pain is a uh symptoms. I wouldn't look for that in the examination, but look for tenderness and look for deformities like routinized deformities. Swan neck deformity said deformities. Yeah. Brilliant. Ok. And even before they sit down, um when they're coming, walking into the room. So what I, what, what I normally do is I always, you know, go into the waiting room and call the patient in, then I can um assess that they, how they walking, you know, you can, you can just, just by not even knowing their name. Obviously, you've got their name on your records. But you can just say, you know, Mr Smith, would you like to come in. Mrs Smith, would you like to come in and the way they get up off their chair or if they've got a walking stick, you know, if I've never met them, I don't know them. I've got so many clues, you know, of their sort of physical examination, even before I've asked them to, you know, roll up their trouser leg or roll up their sleeves to examine their joints. So look at, look at them, what aides are they using? Are they using a Zimmer frame, a walking frame? Where, what is it? You know, just visually make an assessment um and see whether, you know, they've got any sort of um to be grips, bandages, wrist, um, support things, anything like that that will give you clues. Okay. So even before you examine them, the way that they are walking and they're getting up and off the chair, um the way they walk into examination room is really important for you to see. Okay. So I do, I think that it's, you know, it's very important that you just watch them first before you. Absolutely, you know, say to them, right? Can you just sit down and, and undress, you know, and I will examine your joints, get them to, if you're, if they're already sitting in the examination room, then ask them, say that, you know, you're so and so and say, may I ask you just to walk from, um from the door to the to the window and that will give you so many clues. Okay. So, um, so that's a healthy joint. That's a rheumatoid arthritis joint. Okay. Vast difference, sir. Can you see that that's all red and hot and swollen. Um, look at this deformity, I mean, it's, yeah, very unhealthy joint, okay. Very painful, very painful. Um So what we have to, so what we, like we said before, we have to stop the inflammation or reduce it to the lowest possible level to put the, prevent the disease from progressing to put the disease in remission because if we don't, then it will progress for a lot of people. Okay. Um What we have to decide the treatment is relieve the symptoms. How would you relieve symptoms? So I could use an sides? Yeah. Do you use a depending on the severity, I could try to maybe use steroids. I have to. Yeah. Absolutely. And then I would go on to use the like anti rheumatoid medications like the demands Abilass. Yeah, brilliant. So, um for those more Judea and said nonsteroidal anti inflammatories. Um, so basically painkillers over the counter painkillers. So you try the painkillers that you don't need prescriptions for. Okay. I mean, obviously if it gets to this stage, it's going to be a bit more than over the counter painkillers. So, in early stages, but we always do start off with the lowest, um, you know, the analgesia ladder, you will all be um, if you don't know, analgesia ladder, look at, look it up, always start at the lowest, the least harmful. Um, but you also need to take a proper medical history because if they've got peptic ulcers, you know, do deedle ulcers, you can't give them nonsteroidal. So taking a medical, really good medical history is important drug history, allergies, etcetera, etcetera. Um So yeah, so there are on the analgesia ladders and um, paracetamol anti inflammatories. And then, you know, you could use steroids for the inflammation and then the dimard, which is a disease, modifying anti rheumatic drugs. Okay. That's when you, that's when you're getting into very specialist area. Okay. That's when they've gone to the rheumatologists specialists and they're being diagnosed and um started on that medication. So we want to prevent joint and organ damage. All right. And that really is through. Um, so a patient with rheumatoid arthritis will have, um, they will have to have not just a joints examine, they may have to have a chest X ray. They may need to have a CT chest. Um, you know, may need to see a dermatologist, a patient may present with skin problems or heart problems and then you end up diagnosing rheumatoid arthritis. All right. So sometimes rheumatoid arthritis is diagnosed completely, you know, randomly in the sense that you've got these random symptoms of chest and skin issues, chest or skin issues. But actually, you know, then the joint swelling and inflammation, pain comes along later. All right. So the blood tests and the, you know, will, will hopefully give you some clues. Okay. So, um, what we do want to do is prevent joint and organ damage, prevent joint damage to keep people as mobile as possible. Um, to keep them, you know, working and living the healthy lifestyles that, you know, we all should be um to prevent further other diseases from creeping in. Okay. So um um so yeah, reduced long term complications. So ending up, you know, ending up disabled, not being able to walk, not being able to go to work all sorts of things, you know, and the mental health issues that arise from chronic diseases don't underestimate those okay, improve function over all well being like we just talked about. So any questions on rheumatoid arthritis? Okay. We're not going to go to the trouble. Have a question. Yeah. Sure. Sure. Yeah. Can you please just uh tell us about the detailed plan of management for rheumatoid arthritis, the Menest a and how we treat them according to the severity of the disease. Yeah. So yeah, that's, that's what I mean. You've just nailed it there. Um you treat according to serve the severity of the disease. Okay. So in the early stages, it may just be, you know, pain and inflammation but um to actually manage their is nice guidance, National Institute of Clinical Excellence. So if you look up Google, nice guidance on rheumatoid arthritis. It's all there is beautifully laid out. So that's where um it's very detailed and it tells you how to diagnose and the management and the blood tests that you need to do. But also it tells you about the disease, the Dumb Ard's, which is really important and that will need, you know, lifelong monitoring. So, patient's on methotrexate. So methotrexate is used is a dimard, which is used for rheumatoid arthritis for um uh to put the disease in remission that needs blood test, you know, um it needs initiation by a specialist. Uh that's a rheumatologist and then, then um ask GPS, then we will um take over that patient's care and follow up on their sort of they're monitoring blood test every three months. And if they have a flare up, you know, we will, we would seek advice whether they need steroids, etcetera, etcetera. But these are very specialist services. Okay. So nice if you look up. Nice. Nice dot org, UK. Um Just Google, nice, UK and rheumatoid arthritis that has everything that you need to know. Okay. Does that answer your question? Yes. Thank you. Brilliant. Okay. Um Any other questions? Yes. Mhm. I'd like to ask once the patient comes with a deformity. Is it possible to reverse it or all I can do is just relieve the symptoms for the Yeah, what was, and what deformity you you thinking about? Tell me what's in your mind. Um Something like, uh, swan neck or anything with fingers. Absolutely. So, yeah, we don't often see that now because obviously, um, it's very rare to see that. Now, when I first, when I was at medical school, obviously more than 2030 25 years ago, um, then you could, you, you could actually 20 years ago now. So we saw patient's with those deformities. Okay. And that was before, you know, demands are really sort of um available. And, um, so advances in medicine and the management and the, the of the pharmacology of it is, has really changed patient's care that we'd, I've, in my past 15 years of being, you know, as a GP, I've not seen a single patient, um, you know, younger than 60 65 with any deformity because we pick it up, we treat it and because of the D Mart's. Yeah, but going back to your question, um, they sometimes, I mean, you, there are some specialist, um, surge orthopedic procedures that can, um, take place, but it depends on, that's so, I mean, those have their side effects as well and, and the joint, it has to be assessed, you know, and decided whether it's the risk assessment is worth it or not. Is it gonna, what's, what's the sort of, you know, what's the probability of being able to use that joint? Um So really it is about symptom management also depends on how old they are. Um, if they're, you know, in their thirties, 20 thirties then yes. You know, surgery would be, um, uh, would be, um, sought advised on surgery but also, um, also depending on their occupation. So, very individualistic. But that's an excellent question. Okay. So, um, we hardly ever see those deformities now. Okay. Have you seen any deformities so far in your, in your medical, uh, teaching? No, not yet. Yeah, we have started the clinicals. So, so, yes. Yeah, I mean, I suppose you would probably see it in, um, in countries where, you know, the healthcare systems aren't that, you know, advanced where patient's don't have access to care. Um, and that's a very ethical, you know, unfortunately, ethical, you know, healthcare should be available to all human beings. That's what I believe. But obviously, you know, life's not like that, unfortunately. Um, so you probably, you may see it, you know, when you go on your electives to third world countries, etcetera, etcetera. So, but certainly in the UK, we, I certainly don't, I haven't seen this in, at least, you know, the last 15 to 20 years of my career, it just, we don't see any deformities is only the very old, um, you know, in their nineties and things like eighties now and nineties that when there weren't D mods available or, you know, um treatment a diagnosis, wasn't there any other questions? I have a question and I would ask the also mean disease and rheumatoid arthritis, which part of the joint. Exactly. Is it attacking? So, as you can see here it looks like, I mean, so I'll just go back. So, what, what would you say? Um, then it's every single part of it. Really? Do you see? Yeah. Sino V, um, it's the cartilage. It's everything, you know. Yeah. So, it is, it's a district, it's, you know, quite destructive in every sense. Yeah. Ok. Thank you. Yeah. Right. So we'll move on to osteoarthritis. So osteoarthritis is a degenerative joint disease, degenerative means wear and tear that. So by using it, you know, um uh actually, by not using it, you still get it, but it's a deejay as we get older and we get, and we're um, we get frailer, osteo oa osteoarthritis can degrade cartilage, okay, change bone shape. So these things that you need to know, degrade cartilage, change bone shape and cause inflammation, okay. So cartilage, bone and inflammation resulting in pain, stiffness and loss of mobility. All right. Um And this is one of the biggest courses of, you know, total knee replacements, total hip replacements in the UK, wear and tear. Okay. And it's quite debilitating actually, um, and very healthy interviews, even if you're skinny as a stick, you can get osteoarthritis. So it's not just a disease of, you know, obesity, although losing weight really does help, you know, if you are overweight, but it can happen in, in very, um, you know, I mean, as I said, you know, it happens, it can happen in athletes and things like that. Okay. So the grades cartilage changes bone shape, leading to inflammation. Inflammation causes pain, stiffness and loss of mobility. And you get that morning stiffness as the day goes on as you get up and you get more and more mobile, you know, as you're walking around more and sort of, then the pain often goes or is relieved. So, what are the causes symptoms of treatment? So, it's, uh the symptoms are pain or aching and a joint. Okay. And it's a, it's quite a weird pain. Patient's describe it as sort of an ache or a stiffness. Um, so hence a joint stiffness, um, limited range of movement, okay, because of the stiffness. So if people are sitting down for too long in, if they're in the office there, sitting down too long, they'll get up from the chair and they're like, oh, you know, stiffness, it's stiff, you can't move it and it's normally happens in the, in the knee. Very, very common in the knee and hip. You get limited range of movements, which should, um implied to you that when you do physical examination, you know, that's, you will find limited range of motion movement, um, clicking sound when a joint bends, not always okay sometimes. And um a lot of you will have clicking, okay. I always had clicky joints. Um, you know, when my knees with crack, you know, and I would, you know, click, crack, whatever you want to call it. That doesn't mean I'm going to end up having osteoarthritis. Okay. It's just one of those things. So that's not absolute, but it is an association. It's not an absolute symptom swelling around the joint. So you will see that, um, when you compare the two joints, there will be swelling. So, for example, one knee may have osteoarthritis, the other may not. Okay. So you compare the two, you get them stand up or, um, and it really is, you know, it can be a lot thicker, the joint, it's inflamed, it's, it's swollen. Um, and there's muscle weakness around the joint. Okay. That's really important, muscle weakness around the joint. So think about if there's muscle weakness, what the treatment could be. Okay? Somebody tell me what, what they're thinking, muscle weakness around the joint. If that's one of the issues. What is your therapy? Brilliant. Yeah. Okay. So what I would like you to start thinking about is that, I think about when you're looking at the symptoms, start to think what, what would the treatment be even before you read it? Okay. So, muscle weakness, what, what treatment do we have for muscle weakness, physio movement, you know, exercise really important. People with osteoarthritis cannot just, you know, sit down and not do anything they should be moving. Oh, osteoarthritis may affect different parts of the body in different ways. Okay. So, again, you know, the most common are hips, knees, fingers, you get the habitants out, it's of feet. So this is what happens. Okay. You've got the articular cart and the uric cottage there. You've got the, I don't really see that. So the Meniscus there, you've got normal joint space and then you get these spurs, these bone bits, bony spurs there. Like shards of glass. Yes. Think of it like broken, shattered glass. their bone spurs. Um, cartilage. Last at, look at that lovely cartilage. Yes, sponge. Um It's, it's, you know, being, being worn down. Um And then the joint space is narrowed so the bones will rub against the friction against the bones. Um So, you know, you should have a nice sort of gap between there where the cartilage is here and it's like this, but then it goes crunch, crunch, crunch and that's painful. It's a diagnosis. So, um it's def it's medical history, okay. Um And uh and physical examination lab test. Um So the lab tests are, I mean, you can do a joint aspiration, but it's very unusual that we do that now. I mean, you can, it's based on the history and the examination X rays. Um So be careful with x rays in the sense that um the page it may present with really, you know, moderate to severe, uh symptoms of osteoarthritis, but the X ray doesn't actually show much damage. You know, it doesn't show what we just said here. Um, what we showed here, it doesn't show that much, it doesn't keep up with the changes in the symptoms of deterioration. So, just because the X ray's normal does not mean that they don't have osteoarthritis. Okay. Um, MRI is by far the best. Okay, because then you can see the cartilage damage, you can pick up other things. Um, any tears, anything like that, blood tests, blood tests more to check for vitamin D deficiency check that there is an um coexisting inflammation. So, rheumatoid and osteoarthritis obviously can coexist. So you're looking for other things. Ok. So blood tests baseline, making sure that you know, other things, um the calcium isn't up. So you, you know, you're thinking about a hyperparathyroidism, you know, hypercalcemia stuff, all of that kind of stuff. That's what you're looking at. Blood test. There is no definitive blood test for osteoarthritis. Okay. But you do blood test to um, to look for and exclude other things and correction sort of vitamin D. Um I'm checking for calcium making sure it's not high, low et cetera. Any questions on that? No. Okay. Happy. Right. So what the risk factors? What do you think the risk factors are? Can anybody tell me age, age? Yeah, absolutely. Anything else? Overweight? Overweight? Yeah. Brilliant gender. So being female. Yeah, this location, this location. Yes. Well, dislocation in past injuries. Yes, fractures, fractures. Yeah, open fractures. Yeah. Age joint injury. So excellent overuse. Okay. So this is why athletes, I mean, it's, it's paradox really, isn't it? Athletes are really, really fit and then, you know, but because sometimes because of overuse of joints, you know, they train so much okay. Um, obesity. So even like a 34 kg weight loss can really, can really improve symptoms of osteoarthritis of the knee in here. Okay. So lifestyle measures are so important. Don't always go to as, as doctors, especially at your stage. You, you know, you always think about medicines. How can I, what can I give? But actually look at the patient lifestyle measures, you know, how much exercise, how much is your weight, you know, what can you do to help yourself? That's really important. Um, Moskos calot also, um, if they've got any other sort of, we're talking about any other musculoskeletal issues, um, like hyper extend, hyper mobility, etcetera, etcetera, things like that. Um, wheat muscles. So if there's any, any degenerative diseases, muscular disease is going on, um, genetics, it does run in families. So if your, if your grandparents have got, you know, if it runs, if you, if your grandparents have got it, you're, you're likely that you're more, it's more likely that you'll have it then. Um, but depending, you know, um, gender, female, more than male and environmental factors. So environmental factors such as what, what do you think? Humidity, humidity? Yep. So we know that people who have osteoarthritis, especially in the UK So when it's really cold, my patient's will ring and say, oh my gosh, my joints are really hurting and I wish we could give them a holiday abroad but we can't. So, and that's, and some people, I mean, some of my patient, especially when they're osteoarthritis got really bad. They've actually moved abroad to sunnier climates. Um, and to be more active because what if it's sunny, you're going to be more active, Um, for some patient's, um, occupational factors are not mentioned here. So the kind of job that you do? Okay. All right. Any questions so far? No. Okay. What, what medications, any medications, what would you give them? So you'll start with symptomatic relief. Yeah. That chance in which, uh, stay or comes up. Yeah. Simple analgesia. Okay. So you start with analgesics like paracetamol. Um, um, we know that paracetamol is probably nice guidance. So again, if you look at, um, nice dot org, UK, the first line of treatment, well, it's not the first line but, um, for medications wise it's analgesia. Okay. So paracetamol, um, nonsteroidals, uh, um, don't forget nonsteroidals do have side effects. Okay. So I got to be careful with these. Yeah. So they cause, um, so you have to take a, what cautions you need to take with nonsteroidals. What do you have dot I'm sorry, I'm in Brazil. Yeah, you can cover, um, it, Brazil. Um, why would you, why would you be wanting to cover them? At Brazil, this jet image, the stomach, yeah, stomach. So stomach gastro protection. Again, that phrase gastro protection, new language, gastro protection. Um, so and patient with asthma, be very careful, you have to take a history of asthma. Um um that's why you always have to do um, a proper history, medical history, drug history, past medical history, you know, and even if they had asthma as a child and they're, they don't, you know, it can trigger off asthma attack. So ask them to be aware and, and if there's any problem with breathing, then, you know, obviously to contact the doctor with local services. Okay. Counter irritants. What does that counter irritants? Meanings means that, you know, anything that, that would be affecting the joints such as work. Um, so yeah, I'm not really counter irritant. So I suppose things like, um, uh, the topical treatments like the I brew gel and things like that some people do use, they find it, um, therapeutic. Um, the evidence on, on, uh, topical treatment isn't significant, but I suppose it's a massaging bit that really does help cortical steroids. That's, you know, if it's really severe. Um, and again, if it's really, I mean, this, this is when it's, you know, when it's leading sort of disability and things like that, that's platelet rich plasma, which you probably don't need to know, but you need to be aware of and probably in your, in your careers going forward now. You, it will probably become more of a treatment just like demands did in my sort of a career. So, treatment and management, the most important thing. His strengthening exercises, okay. What, what, what are strengthening exercises does anybody know? So, physio, so, you know, if you don't know, you just say right, okay. And you can google them, the patient can google them. Here, we refer to physios, we sign, post them to online um resources but walking, walking, um resistance training. So anything that builds up the muscles, okay. And remember these are sort of people who are sort of middle aged, but it depends on how fit um as in like, you know, cardiovascular um fit they are and also, you know, that they're not going to fall over. Some people start running, they think they have to start running and then they obviously do more damage. So you have to tailor it, their, their exercise regime has to be tailored. Um which is really important. So the most important thing that they should start off with is, is, is walking. All right. That is actually strengthening exercise. It's very low impact. Um um and then they build up range of motion exercise or stretching. So yoga and Pilates is very, very good. Um swimming, um aerobic or cardio exercise is really important also for weight loss, but movement, anything that's going to move, move people balance exercises. So, you know, uh anything like, you know, if if they, if they get really severe pain at the beginning then things like tai chi, all of those kind of, um, I don't know, all of them but, you know, sort of the low impact. I'm over. Oops, somebody's baby. Oh, okay. Weight loss. Very important. Okay. So, what's that, what does that show you? What's this, what's happened here? Is it regeneration? But it's a, it's a knee replacement. Yeah. Okay. So, surgery. So, a joint surgery? Okay. Yeah. Look at that destructive joint. I mean, you can hardly do anything with that. The pain off. So, yeah. Okay. So, joint surgery and that's one of the most common reasons for total hip or knee replacement osteoarthritis in the UK. All right. I'm not sure we've got time for gout. Can I quickly go through gout in 12 minutes? Any questions on? Oh, a, ok. Gout. Um, sorry, I have a question. Uh, these manage these management treatments. Do they work for people who are fit when you say, um, what management treatment? Which ones? All of them? Yeah. Like for people who are exercising all that? Yeah. Yeah. So, obviously, I mean, people who have, who are, who are very active and they're, they're osteoarthritis. Is this? Yes, then the assessment will be that they probably will need a joint surgery. Okay. So you, you, um, work them up to see how much every patient will be different. So, some people are totally inactive. They will, they will, you know, they will not do any X, they just don't do any exercise. So that's what you start off with. Okay. But if you've got an X ray or an MRI that shows this, I mean, no amount of ex obviously exercise is very important. But, and if they're very active then really their option is this. So it's, it's where they present to you at which stage they present to you that you work them up and you decide whether, and it's not really ask, it's rheumatology or the orthopedics, it's not GPS, but specialist orthopedics or rheumatology. If it's that kind of joint, then there's, you know, no amount of exercise, um, uh, will, will help so straight onto joint surgery. Okay. Does that answer your question? Uh, I have one more question. What if our patient is, uh, really active? Uh, he walks everyday but he still has, uh, pain emergent pain in me. Yeah. So you would actually refer them to physio to make sure that they understand what kind of exercise, you know, weight loss, etcetera, etcetera. So it is a very holistic treatment plan. Um, and it's, but again, you know, if the osteoarthritis, their pain is really significant and it's affecting their activities of daily living there. ADLs, then there are, there are, there are options for, um, sort of advancing treatment and that's what the rheumatologist would advise they would assess them. But at the end of the day, it would be, you know, reassess, refer for MRI and see what the joint looks like. So you have to do imaging to see, even if they're really, really active, you need to see what the joint looks like because some people do, I mean, it's in credible they have such, they're very, really, really active and then you look at their uh their Mri's and you think, how can they be doing this? Okay? Because their joints are so, uh, you know, destroyed. You think? My goodness. Um, but you know, pain thresholds, etcetera, etcetera, different levels of activity. So you have to really work. Patient's up according to their symptoms according to their activities, according to their current state health state, you know, they're diabetic and they got heart disease and also on imaging. Okay. Uh Sorry, I have a question. How does the trans my injections work actually as a treatment? How do the class? I don't know. I'm not a specialist and it's so early, you know. So, um, it's something that, you know, it's out there. Uh, there's still trialling, I think. So. Look on the nice um, dot org website. Um Yeah, that's a bit beyond this, uh, this, um, chat at this presentation. But good question. Okay. Can I do go out in 10 minutes or race through this? So, gout is a common, it's very, it's much more common than we think it's calm. It's complex. It's a complex form of arthritis that can affect anyone literally, it's characterized by a sudden. So remember these symptoms sudden, whereas the other two are gradual. Um, well, not always sudden, severe attacks of pain, swelling, redness and tenderness in one or more joints. Most often the big toe. Okay. So red hot swollen joint, a single, red hot swollen joint. So I've often seen it in this, in the toe here or the ankle or the elbow. Okay. Symptoms are that there's just so much inflammation and pain and also you can get it at the base of the thumb. So intense, it's just the worst pain. Um even having like if you're lying in bed and the and the light sheet is on your, on your toe, that it just feels like a ton of bricks on your foot. Okay. That's how painful it is. Um And once inflammations die down, there's lingering discomfort, there's inflammation, limited range of motions and redness. Okay. So you can't move it. It's red hot and tender. So if it was this thumb, really red hot tender and it's like I can't move it, I can move these, but it's like really painful. I want to have it in a fixed position. It's so sore. So it's an inflammatory arthritis. You get uric acid crystals um within the joint space, okay. A build up of uric acid crystals. So um you can do joint fluid. We don't do that anymore because it, it leads to infection. Um uh can cause infection. You do a blood test for what blood test do we do? Thrill gout. The serum uric acid. Brilliant. Yeah. Uric acid, okay X ray imaging. If you're lucky, you'll be able to see, you will be able to see the crystals. Uric acid crystals, you can do an ultrasound um and also ct okay. So um so the risk factors are red wine meat which contain pure and so it's really that um and um you can even get gout ito fight on that ear. Um And it's the urate crystals that cause that and look at the deformity of the joints really red hot and hot um treatment I should have asked you. But anyway, it's um five minutes ago and, and said colchicine and cortico steroids. So, uh let's have a look, I think I'll probably stop there because it's quite a lot. So carpal tunnel syndrome. Um Remember it's the median of um tingling pain in the hand and forearm condition occurs when a major nerve to the hand, the median nerve is squeezed or compressed as it passes, travels through the wrist underneath the fascia. Okay. Underneath, there's a flash, it's like a tunnel and the median nerve gets compressed and that's common in pregnancy. Um So symptoms, it causes numbness, tingling and burning, moaned. It mainly in the thumb and the index fingers and middle and rings. So there's a numbness there. Um occasional shock like sensation. So, Paris and also paraseizures, radiated thumb and index, middle, ring finger's weakness and clumsiness in the hands. You just don't feel like you've got a good grip, um dropping things. So that's where the medium nerve goes in through the tunnel underneath the fascia. Um And I'll just go. So causes are women and older people more likely to develop the condition. It's genetics, a repetitive hand use, hand and wrist position, pregnancy, health conditions. So lots and lots of triggers. Okay, thyroid, diabetes, rheumatoid, um all sorts of things. So physical examination, you'll know this. Um So just uh look at, look up, you know, these uh examination signs and symptoms, although they're not specific coming, I just, you know, the history is very, very important. Examine the patient's hand. So you've got Tinel sign, surveillance sign, test sensitivity, weakness in the muscles around the base of your thumb, atrophy in the muscles around the base of your thumb. Uh tests uh these, these tests that we just talked about. Um but you need to do other things, blood tests, okay, blood tests and a good examination. Um And then Xemg is very important. Um and the treatment is non surgical bracing or splinting and said activity changes. So change of how you use your hand and you probably, you know, depending on your job occupation, always ask about occupation, um steroid injections um and that wrist support. So, like I said, look at the patient when they walk in, if they've got that. That's a big clue. Surgical. So you get the carpal tunnel release. Okay. And I think that's it okay. Any questions? Sorry. The last bit was very rushed but the two, I mean, got you do need to know about. So please go to a nice dot org to get a few more, but there's nothing that replaces seeing patient's okay. The history that you take from patient's will, will embed your learning and then you read up about the cases. Okay. Any questions? No. Ok. Well, thank you everybody for participating. Yeah. And I really hope you enjoyed it and learned something. Okay. Thank you so much, Doctor Hassan. Thank you. Good luck. All of you.