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Um, hi everyone. Thank you for giving up your time this evening. I will try and keep it, um, as short as I can. So I'm not taking the evening away from you. Um, so yeah, I'm just gonna go through a few, um, of the conditions that you'll probably need to know about for, uh, the exam. Um, I have gone through all the, uh, past meds questions myself to get an idea of what they're sort of asking me about. So I've got that on the next couple of slides. Um, so topics wise, the next two slides, just sort of show you conditions that you need to know about, um, in the sort of like GP setting or what you might come across that's referred from GP into A&E depending on what you need the M SRA for. Um, so they're just for your reference. And what I'll do is I'll go through a few of the conditions and there's either a question following the condition or a condition followed by an explanation on the condition after. So, one of the major things that you probably will need to know about is the differences between osteoarthritis and rheumatoid arthritis. They probably will be two of the biggest conditions that present in a primary care setting and with complications presenting to uh orthopedics, um or rheumatology up in the hospital. And so that's just a nice little summary um diagram. And in terms of what you're looking on for on an X ray, you're looking for um the acronym loss. So um loss of joint space, um sub chondro sclerosis, subchondral cysts, um and osteophytes. Um and then a rheumatoid arthritis, it's pretty much the same, but you'll also get an inflamed synovium. Um What you're looking for in arthritis is it's usually affecting one joint uh on one side, not both sides. Um So it symmetrical and ra versus oa. Um And also one of the major differences between the two is that rheumatoid arthritis, you'll get morning stiffness, which lasts for a period of longer than 30 minutes and it's caused by an auto autoimmune condition rather than being a degenerative disease. So, osteoarthritis, as we said, degenerative condition most common in elderly patients. So you'll get something in the vignette like you've got a 76 year old lady who's presented um to your practice with increasing knee pain over the last two months and it's worse on exercise and she's getting some swelling and that kind of thing. Um So symptoms pain when they use a joint joint stiffness last less than 30 minutes, um, swellings, bony enlargement of the hands. Um So that's all your different kinds of um your Heins, um nodes uh causes are increasing age. You're more likely to get it. Uh the older you are um being overweight or obese because it cause excess stress on the joints. So, uh loss of the cartilage and then rubbing of bone on bone, overuse of the joint and the family history. Um diagnosis is by clinical diagnosis, seeing the patient and treatment can either be conservative. So um just leaving the patients see how they go analgesia, um exercise programs to help strengthen the muscles around the joint or surgery. So this is just a nice um summary of a sort of treatment algorithm in terms of what you can offer for a patient presenting with um osteoarthritis. So you're starting off in the middle with um advice for the patient, giving them some exercises, weight loss. So conservative measures then moving on to your paracetamol nsaids, you know, Oramorph if need be and then finally moving on um as you can see in the outer circle um onto joint arthroplasty um and other measures um such as support and braces for the patients. So first question, 55 year old man lives alone, complains of pain in his right knee, difficult to walk long distances. And recent x rays show signs of boy exam, mild medial joint and 10 and stable ligaments. BMI is 25. What would be the treatment of choice for this patient? The answer was paracetamol and topical nsaids, which is the one that everyone seems to be going for, you could give NSAID S by themselves. But obviously, we need to think about gastroprotection. Hence why there's also the nsaids with gastroprotection. But in your first instance, you'd probably go for the basic medications that you could go for, which is paracetamol weight loss, potentially. Um, but that patient is in the sort of normal BMI range. Um, so together that probably wouldn't be the option. So, yeah, paracetamol and topical nsaids. So, rheumatoid arthritis. So it's a chronic condition. Um inflammatory condition affecting more than one joint. It can also affect um the skin, the eyes, the lungs, the heart and the blood vessels. So you can get extra articular manifestations of the condition. You get joint, swelling, pain and stiffness as well as warmth of the joint. Um patients might present with excessive tiredness, weight loss, dry eyes as well as chest pain. Um You've got increased risk risk for women. Um or if you've got a family history, family member with rheumatoid arthritis is increased risk as well as smokers have an increased risk diagnosed by blood tests. So you want to look at their full blood count, the esr their crp um rheumatoid factor and then anti CCP antibodies is the one that you really need to know about. This is the most um sensitive and specific test for rheumatoid arthritis. And then you can get things like an X ray and then specific tests like an MRI and moving on from the X ray uh treatment, you're looking at disease, modifying anti rheumatic drugs. So things like methotrexate, leflunomide, hydroxychloroquine and sulfaSALAzine biological drugs such as Infliximab, um analgesia steroids, physiotherapy, and surgery if it's indicated for the patient. So this is some specific hand changes that you need to know about. So we talked about um Heberden's nodes and Bouchard's nodes. Um They're for osteoarthritis and then you get some more specific ones in rheumatoid. So they've got a swan neck deformity. Um And the Boutonniere deformity which involves ulnar deviation of each of the digits. It. Um And then I've just included a little summary diagram of um how you would go about therapy for patients with rheumatoid arthritis, like when you would add things in monotherapy versus combination therapy. Um And what you do when the disease is established, this is quite a good slides know and it's from nice guidelines. So another thing that you do need to know about is the treatment of hip fractures. Um So you probably won't get patients presenting to a GP setting with a hip fracture and sometimes you might as an anomaly, but most of the time they'll present to any. So your elderly patients having had a fall, um, you know, potentially with a long line and thinking about rises as well. And what you need to distinguish between is the fracture that is intracapsular, aggressive fracture. There's extra capture and that's just related to the blood supply. So for your intracapsular neck of femurs, you will be doing a half hip replacement. And for your extra capsular, you're looking at doing some kind of fixation like a nail or a dynamic hip screw. And what you can also consider is if the vignette says something like you've got a 78 year old lady, she's independent, still does all her activities of daily living has a fall. She's got an intracapsular neck and femur in her, you'd probably consider a total hip arthroplasty because she's still potentially got 1520 years of her life left and she's very independent. So you want to give her the best chance of getting the best function back for her hip. So for her, you'd probably go onto a, a sort of total hip arthroplasty as well. And then in your younger patients, sometimes you might have to consider um replacement of the hip joint as well um to give them the best function. Um So again, another little diagram um that just shows you the different types of uh fractures that you can get. So you're one, you're two and your three, you're in that sort of intracapsular range and then your extra capsular is four and five in terms of how you would fix them. Other arthritis related conditions that you'd need to know about. Um is psoriatic arthritis that's inflammation, inflammatory arthritis that occurs with um psoriasis or skin changes, ankylosing spondylitis, which is inflammation primarily in the spine. And that is when the patient will also present as HLA B 27 positive. You've got sle which is an autoimmune condition affecting many systems in the body. As summarized in the diagram on the right. And the classic thing that you'll see in that is the butterfly red rash appearance across the cheeks, which will be included somewhere in that vignette. And then you've got gout and pseudo gout and that's caused by excess uric acid versus calcium pyrophosphate crystals. So, uric acid is gout and the calcium pyrophosphate is pseudo gout. So next question, you've got a 28 year old woman who visits her GP complaining of pain in her joints um previously sought medical attention for the issue. But high BM I was deemed the cause. She had a joint effusion in her knee and a limited range of movement. She's um the M CPJ in her right hand appears swollen and her fingers have sorted like appearance, left hand shows nothing. She's tested positive for HLA B 27 and has ABP of 100 and 38/87 and 10 of 36 7. What is the most probable diagnosis? So, yeah, the answer is psoriatic arthritis. Um I see a few people have kind of put ra and septic arthritis. So if we look at each one in turn, if you're struggling to decide between two, go through each of them. So it probably won't be osteoarthritis because she's 28. So we can probably safely rule that one out. There's no suggestion that she's had a history of gout. So I'd be quite confident to say that it's not gout. Um, then you're left with septic psoriatic and ra, so if we look at septic first, yes, she has a decreased range of movement, but her temperature is 36 7. So it's unlikely to be septic. She doesn't look as if she's clinically septic. Um So then that leaves psoriatic and ra. So yes, it could be ra but the point in the question that they're looking towards um is the sort of sausage like appearance um which I think lead you towards um psoriatic uh arthritis. Um So yeah, that's the answer for that one. So what is septic arthritis? So it's a very serious joint infection that has to be treated as soon as possible. Um It can be caused by infection, spreading from another part of the body. You can have it from penetrating injuries. So something from out to in um and you can also get it with joint replacements. The most important thing to know about with joint replacements is any pain presenting back to your clinic that have a um non native joint are presenting back to you with a non native joint. And your suspecting septic arthritis, they must only be washed out in theater. You cannot do an aspiration of the knee joint in a prosthesis and because you will introduce infection and you'll create that biofilm that becomes very difficult to treat and shoot the bugs attached to the prosthesis. Um So patients who have a swollen hot and red joint with extreme pain on movement, the most likely cause is staphylococcus aureus. Um and investigations, you can do a joint aspirate imaging um to look for effusion, say it's knee effusion within the knee. Um and blood tests to look at your crp your white cell count, et cetera as well as probably putting on uric acid just to like go if someone presents it with a picture shown on the right. So next question, seven year old girl from Sierra Leone, two week history of painful left leg. Um She's homozygous for sickle cell disease on exam. She's febrile and there's bony tender over the left tibial shaft blood show hemoglobin of 6.9 grand positive copi osteomyelitis of left tibia. What's the most likely responsible pathogen? The most likely response we've got is staphylococcus aureus. Um And the next most common is non time free salmonella. Um Is anyone able to send a message in the chat as to why they thought staphylococcus or and why they thought salmonella? Yeah. So we're saying salmon all to this patient having sickle cells. So again, look back at the vignette. So it's very clearly saying someone from Sierra Leone is homozygous for sickle cell. So, yes, normally, staphylococcus aureus is probably the most common pathogen for um osteomyelitis. But given the history, it's most likely to be the salmonella as the cause. Um So that would be e so then you've got osteoporosis. So this is a condition which weakens bone over time and makes it makes them more likely to break. So patients will present with fragility fractures. So those hip fractures that we're talking about. Uh most common injuries are also broken, wrists, hip fractures and spinal fractures. And it will be elderly patients more common in women and patients on long term steroids, uh inflammatory conditions, those in the family history and those with the low BMI. So we had a 15 year old boy with Duchenne muscular dystrophy on long term steroids actually presented following a fall after playing rugby at school and he had an intracapsular neck femur fracture. So it can happen in any age group, those with long term steroids. So, diagnosis is by a dexa scan of the whole body and your treatment is with bisphosphonates to prevent bone resorption, biological drugs, calcium and Vitamin D supplements because these patients will be lacking in those on hormone replacement therapy. So, a 60 year old man discovered to have hypocalcemia during routine blood test for CKD. He's got a medical history of polycystic kidney disease and it's anticipated that the low calcium results is a complication of this. What abnormalities would you anticipate? And his other lab values. I'm pretty sure the answer is E for this one. Um And it's because when you've got decreased calcium, your pth hormone increases to start increasing calcium and Vitamin D concentration, which can cause secondary increase in phosphate. Um as well as the increase in alp. Um But yeah, this is a slide just to know. Um if you learn by tables, this is a pretty good um way of remembering things. Um So you've got all the different conditions that you need to know about as well as the calcium phosphate and um alk phos levels. Um So next condition is temporo arthritis. So, it's conditions where the arteries at the side of the head become inflamed. Uh Main symptoms is you get frequent severe headaches, pain or tenderness at the side of the scalp, jaw pain, when eating or talking and visual issues. Diagnosis is by a temporal artery biopsy and bloods. Um But even if a patient presents to you and you're suspicious of giant cell arthritis, you want to give them the high dose steroids to preserve their vision. Uh because what you can get is you can get skipped lesions within the temporal artery, which means that if you biopsy a part of at art that doesn't have uh the inflammation in it and you don't think they've got the condition but they do, they could end up losing their vision. So it's very important if you've got a high suspicion for it, giving them steroids So treatment is with high dose steroids, then they go on to low dose for a maintenance period. Um, and then you get low dose aspirin, no suppressants as well because it's a condition of the um, immune system. So next one year old woman, 80 worsening headache for one day, she noticed it, um, uh, pain, sorry, not pauline significantly worse when she was brushing her hair. She always complained of pain in her jaw when talking, which of the following investigations is the gold standard test to confirm a suspected diagnosis. So the answer of the gold standard to diagnose is temporary biopsy. That's what the majority went for. Yes, you could do E SR and C RP. But without the temporary biopsy, it's only gonna tell you that you've got some kind of inflammation somewhere without giving you the source. Um So, one of the conditions that you need to know about as well is spinal canal stenosis. And it's quite important to know about this in relation to patients who also might present with called equina. Um So this is narrowing of the spinal canal usually in the lower part of the back which causes compression on the spinal cord most commonly due to osteoarthritis. And the common age age to occur is 50 years. Plus with women being more common than men. Other causes can be a narrow spinal canal injury to the spine. A tumor which obviously impinges on the spinal cord, rheumatoid arthritis and previous surgery, patients will present with neck pain, sciatica, numbness, tingling, cramping, weakness, loss of sensation in their feet, loss of sexual function, loss of bowel and bladder control. So, it's important to distinguish this from ca diagnosis is by an MRI and treatment is with uh, physio analgesia and sometimes surgery if decompression is needed. Um, as a final option, usually in the vignette, you will get something about a patient who's slightly older pain in their lower back, relieved by standing up and leaning forward in comparison to sitting down because it helps um create a bigger space in the spinal canal for the cord to stop the impingement from recurring. And this question. Um So 4749 year old man, difficulty walking, experiencing pain in both calves and feet, um, pain disappears completely after he sits and rests for a few minutes. And he has found that leaning, sorry, sitting down, not standing up, leaning forward, helps him with what further for the pain returns? No primary medical history and no physical exam, no abnormalities, probable diagnosis. Yeah. So diagnosis is lumbar spine stenosis. As I said, it's got that little bit in the middle, the leaning forward and the sitting down helps with the pain because it helps create extra space within the spinal canal to allow for comfort. So, bone tumors is something else we need to know about. So patients will present with pain, it's not associated with movement and it can be worse at night. Um They may present with a palpable mass. Um It can also be present as a pathological fracture. So, if a patient has a fracture within a bone, like a lytic or sclerotic lesion, it could present as a neck of femur fracture because of the lesion within the bone and investigations would be X ray MRI or a bone biopsy. And so the diagram on the right apologize because it cuts off some of it, it just shows you the different types of bone tumors that you can get. Um and whereabouts you get them in relation to metastasis is the epiphysis of the bone as well. So 13 year old comes to a doctor with a five month history of achy pain and swelling in the distal part of her left thigh. She's got a family history of retinoblastoma was in good health. Otherwise, an xray of her knee shows a sunburst pattern and a triangular area of subperiosteal bone in the metaphyseal region of the femur. What's the most probable diagnosis? So, next condition is something called polymyalgia, rheumatica. So this is where patients get stiffness in the morning which can last longer than 45 minutes. They get extreme tiredness, weight loss, depression, loss of appetite. Um, most patients are that they are diagnosed with over the age of 65 and it's more common in women than in men. Um predniSONE is the main treatment to help with any sort of inflammation that the patient's getting. Um but they can also go on to develop temporal arteritis. So it's quite important to be able to recognize that early. Um So the diagram on the right, just um is a quick summary of um how you would diagnose and what sort of treatment that you can give for the patient and why it happens. So, next one, so related to spinal canal stenosis, we had ca equina syndrome. So that's where there is dysfunction of multiple lumbar and sacral nerve roots of the ca equina, which is where the spinal cord spreads out um at the bottom, uh like a horse's tail. Thus the name um So what can cause it is spinal lesions and tumors and causing compression infections around the about they're called equina lumbar spinal stenosis. So it can cause Chin syndrome, but this is where it's important to correlate the clinical findings and how long the patient has had the clinical findings for um birth abnormalities, POSTOP spinal surgery complications and spinal anesthesia. So patients will get urinary retention. So it has to be more than 200 miles to be considered urinary retention for catheterization where I work. Um urinary or fecal incontinence, anesthesia from front to back weakness and paralysis of more than one nerve root pain in the back of the legs or sexual dysfunction. And diagnosis is your history and exams your clinical findings and then you'd probably move on to getting an MRI for the patient. If you were concerned, a CT, if you didn't have access to MRI and treatment is urgent or emergency surgery for decompression. If it's indicated, most of the patients that come through the door will probably just end up getting um pain control im and physio of some description. Um They don't tend to have compression of the cord or if a patient presents, they've got compression of the chroa on their skin, they don't have any clinical symptoms. There's no indication to do a decompression at that point. So next one. So two other conditions, one of the most commonly occurring as median lateral alis of the elbow. So, golfers and tennis elbow that comes up several times in several different ways to do with um what movements the patients have difficulty with. Hence this question, 4648 year painful, eryth fluctuate, swelling with the posterior elbow, no history of trauma in good health and has full range of movement. What's the most probable diagnosis? Ok. Yeah. So like bursitis and that's because it's, it's an usually occurs as well of a traumatic um a traumatic, so there's no injury preceding and the development of the swelling over the bursa by the elbow. Um and patients also probably have full range of movement. So, sl E is another condition. It's the most common form of lupus. Um It's an autoimmune disease where the immune system attacks its own tissues causing inflammation, affecting the skin, uh lungs, brain blood vessels, joints, um patients present with fatigue, skin rashes, fever, pain and swelling in their joints. Um And it comes in flares. Um and the treatment is immunosuppressants hydrox and it's hydroxychloroquine which um you need retinal screening for before you start the patient on it and prednisoLONE. So next one, uh so your foundation doctor need you um task to assess a 26 year old man who fell on his right ankle whilst intoxicated. According to patient, he was able to wait where after the incident and continued his night out where he woke up with ankle, swelling and pain. You saw minimal bruising and swelling, but there was general tennis and good mobility. What imaging modality would you recommend in this case, this one would be uh I've got a slide I think to explain this to the next one. No imaging. Um This is because the patient from the vignette, he's mobilized on his ankle the night before. And yes, there's swelling and pain, but they're saying that he's still got good mobility on it. So he's unlikely to have a fracture, could be some kind of soft tissue injury or a ligamentous injury. But in terms of imaging for the bone, it's not indicated in this scenario which I've shown here. So these are the rules um that you need to look at. So on the last review, it's when patients got tenderness at A or um B and an inability to weight bear immediately after the injury and in the emergency department. So, because he's weight bearing, we've not needed to do an X ray. That's been the indication. Um And on the media view, you've got your indications for doing um an x-ray there as well. So 56 year old man recuperating after experiencing initial bite of gout, he continues to experience some persistent discomfort in his big toe, no predisposing factors and no signs of gouty to five. And at what point would be appropriate to initiate uric acid lowering treatment? Yeah. So the answer is once his symptoms of acute gout have resolved. The next slide I go through gout. I've also got a um algorithm for treatment. Um So gout's where there's urate crystals that accumulate in the joint causing intense pain and inflammation. Risks are diet increased weight, medical conditions such as hypertension medications such as ace inhibitors, family history. Um males are more common in females in recent surgery and diagnosis is by joint aspiration. So, a patient will probably present to GP and get referred to any that have a swollen knee joint that's hot, to touch and painful uh blood. So you're looking at your uric acid and an X ray to look for any effusion in the joint. Um Treatments is with your typical nsaids, colchicine or corticosteroids and preventative measures. Um such as allopurinol Oxistat and probenecid, which helps remove excess acid. So this is a treatment algorithm which I think it got off. Um nice. So I would just have a look um going through that in terms of when it says start management of treatment and first line, second line. So, Pseudogout it's due to deposition of the calcium pyrophosphate crystals. Um It's commonly seen affecting wrists in the knees. You get sudden intense joint pain, swollen joints, risk of the affected joint and can be caused by hyperparathyroidism, hypomagnesemia, hyperphosphatemia, hyperthyroidism and hemochromatosis diagnosis again by joint aspiration, um which will show the calcium pyrophosphate crystals. And treatment is again with the colchicine anti-inflammatories and steroids. And this is just a nice little summary slide of the differences between gout pseudo gout. Who gets it, what the risk factor is how they present um and what you see on the crystals. So, next question, 60 year old man complains of worsening pain, swelling in both knees with stiffness and decreased mobility. He's got painful wrist joints with nodules at the proximal and distal pharyngeal joints which have developed slowly over the past two years. What's the diagnosis? That's most likely? Ok. Yeah. So the answer is osteoarthritis. Um What leads you to that is uh probably the age of the patient. Um He's got pain in both knees, decreased stiffness, decreased ability in the past eight months. So a longer time period. Um He's got nodules um at the proximal and distal and pharyngeal joints um which probably the different nodes that we spoke about. Um, so that's pro and, and given his age, probably more likely to be osteoarthritis than rheumatoid as a first presentation. So 56 year old man GP, complaining of numbness and tingling in his thumb, middle and index fingers, this is beginning to interfere with his work. He has a history of hypothyroid which takes thyroxine. Other than that, his medical history is unremarkable, which nerves are likely affected. Answer is the median nerve. Um So that's the main nerve which gives the sensory abnormalities over the thumb, middle and index fingers, as it says in the question. Uh So these two slides just summarize the nerves that you need to know about in their courses in the upper limb as well as in the lower limbs. I'd suggest just having a quick look at them. And the last question, you've got a seven year old girl who's referred to ps emergency department by her GP with a four day history of fever. She's got bilateral conjunct addiction, maculopapular rash across her trunk and erythemic extremities. Her chest is clear and her heart sounds are normal. Her abdomen is soft and tender and her lips look cracked and her tongue is erythematous, no palpable lymphadenopathy, which following blood test results would support the likely diagnosis for the patient. Yeah. So the answer is the uh thrombocytosis that we see in Kawasaki disease. So the final slide just is a quick summary of Kawasaki disease. So someone's talked to me before it to remember the rash. If you think of um, your points of contact on a Kawasaki motorbike, um, is your hands and your feet, er, which is where they get the rash. It affects Children under the age of five, they get a temperature lasting for five days or longer. Rash, swollen glands, drying, cut lips, strawberry tongue is one of the main signs as well that they probably say right inside the mouth and the back of the throat, swollen hands and feet and red eyes treatment is with IV IG aspirin, which is the only time that you can give aspirin in Children um because of the risk of Reye syndrome. Um and corticosteroids complications can be cardiac issues and causes our genetics or infection. I just want to say thank you again to everyone. Um Thank you everyone. II give it firstly to you for coming. I also thank you for R Rachel to give up her time. She's put a lot of time and effort into making these SLS.