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around to it whenever and brilliant recording has started. Okay, So just to reiterate how this session is going well, this series is going to be going, so this is going to be a two part series. And this is part one. Also, apologies. I can't show my face. My well, my wife isn't the best right now, so I thought I don't want to put any chances on that, then, um, if at any point I cut off, please do let me know and I'll pick up from where you were last was. Okay, So this is part one, and we're trying to go through the painful joints as a main case. Uh, yes. Okay, So the the contents for today, we're going to be going through monitor properties, psoriatic arthritis and crystalloid your crystal properties, then osteo and rheumatoid arthritis. Spending the time on that and spondyloarthropathies again the whole mixed bag of presentations and then moving on to your more soft tissue disorders and the systemic sclerosis, both types. And finally, hopefully we'll have a bit of time for questions as well. And tomorrow. So, for part two, stay tuned for bone profile. Tests are going through what the bone profile is then going through the the different disorders that cause bone fragility and then also the ones that cause bone pain. And then how they look on the bone profile test and then move on to the polymyalgia rheumatic Lupus, as well as the various types of large and small vessel that you like. Mhm. And once again, I hope you have 200 units. So I'd like to start off with our first SBA, and I think the polls should be doing now. Negative. So we'll give you a round a minute or two just to see that we'll give it around. She say 10 more seconds and then Okay, so very interesting. We had quite actually quite a mix of different results, but yeah, so let's go through the scenario first. So it really is an elderly gentleman and very severe knee pain, and it's inflamed is mildly Parexel. However, he is unable to wait there, and I think that's something that's very important there. So when you ever see a red painful knee, okay, if in doubt, it's a septic arthritis unless proven otherwise. So bearing that in mind, then we need to think, How would we treat this patient? So you think? Okay, sepsis, let's give antibiotics. And whilst in most cases that would be correct. However, before we give antibiotics, especially in septic arthritis, we need to perform arthrocentesis the need. So this will involved. They see acquiring spinal fluid from the knee joint, often on under the guidance of ultrasound in order to get a sample and then to analyze the samples first. Before then. You start your antibiotics, I guess just because then you you can analyze for sensitivities and getting treatment accordingly. So let's just go through. What sort of arthritis is mhm? Yes. Um, okay, so again, your red hot enflamed joint whenever you see that except operators generally, the patient may also be Parexel, and technically they will look and well. And the main joints that particularly affected are the knee joints. One important way to potentially differentiate in your head, but not always is If someone's not weight bearing on that knee, you're probably more likely to think it's going to be operated in pediatrics as well. There's a particular set of criteria for the cholesterol criteria, so this is a the non weight bearing they've got a high fever. You also check the es are and finally a low white white cell count. Well, a high white blood cell count. Sorry, I think that's meant to say above 15. However, I'll add that in when I send out for you guys. But the point is above two of any of those criteria, and straight away you're more. It's more likely to be septic arthritis as opposed to transition to them in Pakistan. Sign of items, which would be the other main differential there, and in terms of your management again, you start your sepsis. Six. However, as I said before, obtain your sample first and then give antibiotics even if you're still awaiting results. But the important thing is to get that sample first. In practice, This may not be the case of it in your recipe is like that is that those are the guidelines. Finally, then you Well, the idea is you aspirated to dryness as well. Again, try and remove any of that problem bacteria any one any potential source of further infection, and if it's a prosthetic joint or if it's in an inaccessible area. So you're thinking your hip joints, even like yeah, mainly your hip joints. Also, some of the like the vertebral joints. Then you'd want to refer to orthopedics because they need to perform arthrocentesis in a sterile environment. In an operating theater, you give your IV antibiotics for two weeks, and then afterwards you give all around several months. Um, also, you could consider something called arthroscopic lover. So that's where not only you drain the joint dry, but you insert fluid into there, and then you completely washed it out, and the idea is to get rid of as much bacteria as possible. So but the point is, what antibiotics do you give? So that depends, right? There are two general organisms that cause septic arthritis, so you have your staphylococcal or your streptococcal ones to the staff warriors. So these are gram positive, so this is quite important, and it causes most septic arthritis cases, and particularly, this is in patients at the extremes of age. You're talking either your kids or your talking generally elderly, and the antibiotic is your flu. Clocks are still in. Also, in these patients, you might want to consider Is there any primary source of infection and like I don't know anything from, let's say, gallstones to potentially a fracture as well. And on the other side there's your gynecological arthritis. So this is gram negative, and this is normal in young adults and is typically due to a sexually transmitted infection or gonorrhea. So either that, maybe therapy in their history. Or they may just present and have a history of unprotected sex. And the key thing is to give them an FM treksohn instead. Because again, gram negative, you need to get a different antibiotic. Okay, Um, next we're going to move onto, let's say episodic, painful players on this right hip joint. Okay, so immediately, there's probably two diagnoses present. Very similarly, therefore, can get very confusing. So, firstly, let's cover gap. The gout is caused by urine crystals. These crystals are formed from uric acid, and that's part of protein breakdown, and it's also similar substances as you're in your area. Um so, therefore, causes of about are typically high levels of uric acid and therefore enabling urate deposition. The best way to remember it is but the first the diuretics. But we can also mean diabetes. Why diuretics? Um, it can often cause uric acid. Well, you're curious that uric acid retain mint and diabetes again. Same thing as well, because it can damage your kidneys. Um, alcohol. I'm not sure the exact mechanism behind it, but that further does increase your your levels and high protein diet particularly. You know, he does eat a lot of meat again. That increases your risk of renal impairment once more. You're not able to get rid of that urea. Therefore, deposits and finally trauma a lot of tissue damage. Therefore, a lot of broken down protein and a lot of urine a release and then deposit. The main site of infection is normally the big toe. And you notice you notice that okay, which are lumps of almost well, not not quite fluid, but not quite split either. Something in between. These are these uric acid crystals just deposited and collected around that joint, and and that normally quite diagnostic about, uh and pseudogout This This time it's calcium and phosphate crystals, so these originate from the bone again. Calcium, Calcium phosphate is a large part of your bone. Um, and the main causes well, the biggest one is age, and definitely by far with age, you are far more likely to develop. To dig out of the trauma is also because and hyperparathyroid made more calcium and phosphate is released into the blood stream Hemochromotosis So, um, again, another another bone disorder, Um, and hypophosphatemia So, like low phosphate into your blood. I think that can also, um, that can also be one cause as well. And this time is typically the knee. That's normally normally because Okay, so next SBA, I'll give you again one or two minutes to read through it and we'll discuss them. Okay, I'll give you another five seconds and then mhm. Okay, So most of you went for a culture seen, which is indeed the right answer. So let's just look through it, Okay? So, firstly, after arthrocentesis, you notice that there's a yellow appearance. There's a fairly moderately right ways raised white cell count, and there's a larger neutrophil percentage. However, the crystals, their needle shaped and they're negatively by fringing. Okay, so that's immediately thinking gout. Um, also, glucose level is normal. It's only 93% of serum. Okay, so it's not that that different and, um, culture is obviously pending as it normally would be. And another important thing is this patient does have some level of chronic kidney disease with quite a low e g f r. So bearing that in mind, the common treatment options would be the naproxen, or culture seen, Um, which the naproxen isn't one of the options. I should have put that down, actually. But, however, therefore, for acute flare ups, you want to go for a culture seen, and what does that do That basically just reduces the level of your it acutely. And it also causes acute relief. All these flare ups. Um, your other options. Allopurinol. That's more chronic. IV fluids. Sicilian. It's unlikely to be a infection. Um, and we'll go through Why, um, methylprednisolone again. You wouldn't typically give intraarticular steroids at this stage until the knee replacement not yet indicated at this moment. Um, so what I've seen and so going through the treatment for each different thing is that was first EEG up began in order to, in order to investigate out personally, want to image of joint and a few few pathognomonic things. You're very articular. You'll hear just particular as well. They mean the same thing. But periarticularly particular erosions, so these are basically just broken down. Like almost, it appears as though, like an insect was bitten into the bone and then subcortical bonuses to see bits of darkened and almost bit of eating up bone like beneath the context of the bone. Um, synovial fluid is typically yellow needles and negative, so just remember yellow needles are negative, so there's, um, there's yellow and under polarized light. There's typically needle shaped, and they're they're negatively different agents, um, management. It's typically conservative, so just like pseudo gout, you'd want to add some cold packs. You want to rest the rest the joints as well, and address the risk factors. So alcohol is a big one, as well as that controlled diabetes and try and monitor renal function, and then in the acute setting, but either and said or culture seen and long term, you know, only address the risk factors, but then start them on allopurinol and keep them on it, even if they have another episode. So, food. I got what you want to do again in your X ray this time you say chondrocalcinosis, so you'll see more of a calcium deposition between the joint. I'll show you this in a second, by the way. But the way I remember is blue bricks are positive. So firstly, they're blue under back in like the brick, like one boy, like they're positive as well. So they positively, um, management, as I mentioned Copaxone, rest as well. Same as gout. Acute? Yeah. Naproxen and culture seen. Both seem to work as well for pseudo gout. However, if severe, particularly pseudogout, you might have to go for steroids. And you might have to consider leverages or washouts and long term again instead of allopurinol. You just want to continue the answers of the culture, seen, um, to try and potentially prevent it. However, you'd consider also the risk benefit analysis particular, since they're going to be quite old. Um, and the X rays for these are basically on the left. We have out, and as you can see, you in particular the big toe, you can see well that eating out appearance. So those are the most very articular erosions. And also you see, um, subchondral cysts. So if you look at where when the bone is, you've got the out of it, which is the cortex and subcortical and then beneath that cortex. If you have a look, clearly, you can see quite a few of my dark bits, dark patches. And that's where those cysts are, particularly around inflamed joints, Um, and then in your pseudogout, which is on the right. And if you look at between the two bones in that joint, normally it's meant to be quality. You can see why. This you can see that, um, hum calcinosis of the cartilage and that shows that these crystals that are within the cartilage in with in that joint um so here's just a cheat sheet that I used to help help understand? You know your fluid. So I want to spend too much time going into it just because you're going to receive these sides anyway. But the key thing is, if if you're worried about septic arthritis, the important thing to look at is a percentage of poly what percentage neutrophils percentage, like poly. And, like Valium, Uh, I forgot. I forgot PM stands for basically a granule size you're looking for. How many of them are neutrophils, and if they're high, there were very high. More than 75%. Um of the white cells being your neutrophils, then you're thinking sepsis and also your white cell count will be very high. Um, on top of that, glucose will be very low as well, or only 50% of serum. If you're looking at the crystalloids your crystal arthropathies, whilst everything will be moderately raised, particularly, you'll notice the crystals that we talked about. And then finally, osteo osteoarthritis. There won't be any major changes from normal and like, that's just because there's nothing really to act on from those results alone. And hemochromatosis, the main thing that you probably notice is that it will be Not only will it be red also, generally, you will have a slightly higher neutrophil count as well, but yeah, Okay. Next SBA again minority for it. Oh, and I am so sorry. There's the X ray. I'll, you know, I'll end up call and restart it. Unfortunately for the both the X ray and the stem on the same side. Okay, I'm giving you the 10 seconds or so. Okay. The most of you actually went for methotrexate A the you you went for topical diclofenac and or like the appropriate. So let's just first look at Stan. Um, yeah. So it's a relatively middle aged already, and then it's over two years. So it seems to be more chronic rather than you know. And it's particularly worse when she first wakes up, however, then improves only 15 minutes afterwards. Okay, so I'm quite mixed up the generally to differentials of mind, osteo and rheumatoid. Now let's look at the extra. So first thing the noticed is D I P s o distal, um, and intermediate challenge your joints. Um, they actually appeared to be well, they need to be quite abnormal. And then looking at that, it appears to be not only does the joint space would be quite shrunken, but also there's almost this flattening out of the joint with bony process is just extending all the way out the looking like what we call osteophytes. Um, and just judging from that picture picture alone is more likely to be osteoarthritis. And therefore, if it's osteoarthritis, your management typically starts at a topical, non storyline anti inflammatory. So therefore Mm Yeah, it is. Firstly, let's go through the differences between these two conditions because they can be quite confusing. Uh um Hum osteoarthritis pursing the key. One important to understand is it involves your distal, um intermediate found your joints, your diabetes alongside your P I PS, your carpal metacarpal joints and your knees. Um, there are a few characteristics signs as well that you may have seen on the X ray. So it's heavy burdens on Bouchard's nodes. And the way I remember too, is that the evidence is higher. Bouchard's is below the evidence is a new D I P and Bouchard's on your pee I pee, Um, and typically there is morning stiffness. However, it, um it resolves quite quickly afterwards, but it worsens with movement and improves with rest. Um and yeah, the short lasting morning stiffness, typically around 20 minutes. They say the key things are is normally a symptom asymmetrical. There is crepatis. So I'm sure in the exam you you know, you know what practice is, where you can feel that creaking joints, and there's no real difference between gender, and it's normally in the elderly. The middle aged and order rheumatoid, on the other hand, know VIP involvement. It's mainly your pee I pee mtp joints. Um, and the characteristics signs us one necking zed shaping, which I'll show you in a bill. And normally there is a longer lasting period of morning stiffness. However, this, like osteoarthritis, improves with movement. Um, the key feature that you want to look for is normally bilateral and is symmetrical. So if you see, let's say one joint on one hand, inflamed, you will see that same joint, on the other hand, also inflamed, Um, and the other part is they get inflammation. It well, it was more clearly inflamed rather than, let's say, in osteoarthritis, which only at the late stages we see some resemblance of it. Um, and demographically, it's normally younger women, so typically around 20 to 50. And as I said, it's more common in women as well. Um, so here's an example. Here's an example of Bouchard's and heavens nodes. Just some notice how it's very characteristic. And those spots, and when feeling it, it doesn't feel like like a dumb A. It actually feels quite bony quite hard. And compare that to the rheumatoid, in which you've got quite a few different for deformities. Have the common ones you got. You're you're not yours. You've got actually what you see out of the book is civilization. Yeah, and that can cause all the deviation. Your fingers point towards your owner. That's quite advanced. Also, you can see either one neck deformity or bloating the deformity, and they're both the opposite. So it's one neck is where your proximal phalanges get some hyper hyper flex and your once you get some hyper extended, as in Bhutan. Yeah, it's the opposite Worthwhile. Worth remembering that, But to be, to be perfectly honest, you probably won't see many of these signs that frequently now because normally rheumatoid arthritis picked up quite early, but still always a good like PT question that they asked. Show you a picture of one of these hands and they need to. It's pretty diagnosis. Mhm. So now we're moving on to investigations. Um uh, yeah, in your factory. One acronym I remember is lost, and this is the audit, which you normally see. The change is, the first one is you're going to be your loss of joint space, and most of the people probably already have that then osteophyte formation. So that's where the bones start forming around the joint, and you can do you normally see that's well that invade the joint space as well. So control, sis. So beneath your Congress or beneath the cartilage, you see large black black areas. Where is your sis? And then finally subchondral sclerosis. So rather than seeing like a fixed white line, you start to see like chips and bit's taken out of that white line beneath them in that joint space. Um, so in terms of management, first things first. Do not tell them to stop moving the joint. They still need to keep it fairly mobile. However, they need to do it with the physiotherapy, and they need to make sure that the movement is fairly low impact as well. Um, so swimming is often the recommended form of exercise for them so rheumatoid a bit different. So firstly, their diagnostic criteria, it's actually well. It's agreed by the American College of Rheumatology, and if you require more than six points equal to more than six points firstly, your joint distribution wasn't able to include the whole list that basically looking at is it symmetrical is in many different joints serology. The important thing is your anti CCP antibodies and your rheumatoid factor. However, there are there is seronegative rheumatoid arthritis. So it's not a given. But if you have these antibodies antibodies Sorry, your prognosis is worse. Um, and to the point of which I think even tighter. So the level of rheumatoid factor in your blood and we'll if you have rheumatoid arthritis, is proportional to the severity of your disease. So it's quite important to remember that. And the symptoms will. This is a chronic condition. So these symptoms will be going on for at least six weeks if not longer. Um and yeah, s are CRP will be raised, but I'm sure you'll figure out most room rheumatology conditions. They will be raised anyway. Um, X ray so similar to osteoarthritis, there will be a lack of joint joint space. However, um, there will be, well, more widespread osteoporosis or more widespread thinning of the bone, particularly around the joint. And you also have your just articular periarticular erosions, particularly picking out at the, uh at the at the joints and finally your subluxation. So this is where basically, it appears as though the the entire line of the joint has been completely gone. And that's how you end up with all the deviation with your. In that case, you're intermediate. Phalangeal joint is pointing in a different direction the joint below that to the to the proximal. Okay. And in terms of the extra articular manifestations or rheumatoid arthritis, I normally try to come up with one for one pneumonic, which is no, nothing crops, Um, so I'll go through each letter over firstly, and as you're not yours, you'll see these rheumatoid not your on your elbows. But it can also be in the form of ulcers, particular mouth forces and vasculitis as well come next week. I'm sorry tomorrow, um, and osteo process. So as we as we saw rheumatoid arthritis can cause you're thinking of the joint. But also there's they're going to be taking essentially steroids. Steroids are also major. Contributed towards that the Felty syndrome this is it's rare, but it can be quite severe. But this is where you have rheumatoid authorities with a low white cell count and splenomegaly. This is classic triad, and also this can it can either be due to the syndrome or it can be due to the just generally the immune suppression, but they're probably gonna be more at risk of infection. So the idea is for Felty syndrome. You want to treat the rheumatoid arthritis better, so if if they have it, you just need to up your treatment. Um, in terms of monitoring for infection, though, you just need to keep a stronger eye on them and make sure that we give them, like, good advice that if they do develop hill there straightaway that come in in terms of cardiac. So that's your first see. So increase the risk of the skin, car disease and pericarditis. I do a lot of rheumatological conditions and then pulmonary again, something that's wide spread across quite a few rheumatologist rheumatological conditions is your pulmonary fibrosis as well as also pleural effusions just And this is not only due to the disease, it can also be due to the methotrexate, which is something else to bear in mind. And in terms of your ocular symptoms, you can develop that episode arthritis, hepatitis and conjunctivitis so and hereto conjunctivitis speaker, which is very characteristic of rheumatoid arthritis. But it's something that's worthwhile covering when you get a chance just to google it and just have a look like, and I mean, there's also a carpal tunnel syndrome. And that's an increased risk and as well as other neuropathies and even psychiatric symptoms such as depression. Um, okay, Firstly, this is generally the treatment the treatment ladder for osteoarthritis. You start off with your topical like depression, attack the topical and said's low risk of the You can then escalate that up to oral medication. So the paracetamol. But realistically, you're taking oral regular naproxen or ibuprofen, Um, some some strong insides. And with that, they carry their risks. So I did the tip in here, but if they're over 45 you want to probably give them a PPI. Otherwise, you are increasing the risk of diagnosis also worthwhile bearing in mind and said they they can be really toxic and especially if someone's got a chronic disease or developing a K, you need to stop that. And the other thing to bear in mind as well is there are hypertensive. So any risk of cardiovascular disease you might want to just, um, I would perform a medication review. Excuse me. Sorry. Um, then you can step that up to opiates and intraarticular steroids. So, opiates you're normally starting off with, like codeine and or, um, or however the point is, they're meant to be quite effective. Pain relief, the provider Quite effective pain relief. And you can also give intraarticular so as such as prednisolone. Um and then that can, um that can work for up to several months at a time between between injections and then finally surgery. Worst case. However, I had to put this in their post Cove ID. Yeah, Waiting list. I think. My GP. Well, the GP that I'm doing placement I told me was, like, two years or something ridiculous like that. So realistically is there, but it's going to be very difficult to get it done. Um, and the rheumatoid arthritis. Okay, Um uh, I'm sorry, the title of Clipped. But firstly, you start off with the modern monotherapy. So some have listed three of the most common ones. Basically, hyroxychloroquine is used for more milder cases. Was methotrexate just having a higher risk profile? But having potentially higher benefit profile is used for slightly more severe cases of I have put a big asterisk because some rheumatologists, they generally just prefer one as opposed to another, and also is very much a patient preference, risk benefit kind of thing as well above that alongside your chemo, potentially or above it. If it's not controlled just through that therapy, you want to also give you steroids as a potential analgesia and anti anti inflammatories. And you can also build that up to steroids such as prednisolone, um to then try and provide that anti inflammatory relief. Um, important thing to note is use the last 28 score to then try and monitor the disease progression, and it's worthwhile. Just having a look at what that is involves a variety of different questions, as well as a full exam of these 28 different joints and examining those joints and then that produce finding an assessment to see how severe rheumatoid arthritis is. Um, and the aim is to try and bring it down as much as possible. Um, above that, then you can go through immunotherapy is so the first time is infliximab. Uh, rituximab is more your anti B cell and about, except, that's, um, that's kind of like an anti TNF, except it's more a soluble receptor, so it doesn't provide the side effect profile and and finally about that, it's surgery. And again, something is normally very rare because we do now have a good treatment that can treat most cases. Yeah, it's always an option for the worst case scenarios. Mhm. Okay, I'm not sure why that I did that, but Okay, so now we're looking at juvenile. We're looking at juvenile Juvenile. So what this is, is it's less of one condition. It's more like an umbrella to live for several different conditions that are very poorly understood. But they decided to create more together, and they can. And they treated fairly similarly as well. Um, so the criteria is, um, there's swelling in more movement reduction again elevated. Um, but yeah, the idea is in multiple joints, but it says multiple, but it can also be in one joint, so yeah, and it's over six weeks as well. So again, more chronic. And they have to be under 16. The fairly vague criteria, But yeah, and there are several subtypes so systemic there's not really any specific joints necessarily, but it's often just pain in many different joints. Most of their joints, um, then there's post the articular that's in a few of them for polyarticular er in greater than four, but still quite specific joints. You know, polyarticular is actually quite a similar pattern to the rheumatoid. You could even say and yeah, they're kind of So this is Well, I think they're still debating which ones are which. So, yeah, Um, still not not that well. Understood. Um, in terms of history, I just sent for a diagnostic criteria. If they're Pyrex sick, you're thinking more systemic. And also, they'll have a pink Trunkal rash as well. Um, so yeah, there is. There is normally pointing towards that, um, in terms of your risk factors are normally normally women girls, and they're normally quite young as well. And there's quite a few associated genetic markers as well along side, the family history and your investigations. So you typically want to screen, like, particularly your f b CS LFTs and you like, and you also want to check your antibodies as well. Um, then what put down mass as, um however, is a complication of particular systemic, um, of systemic juvenile idiopathic, um, arthropathy. And the idea is often they can go quite anemic. So you want to try and just monitor that as well in terms of the management. Okay? Systemic. You want to give hardcore, um, steroids. So you look at your I d or your oral and this method peninsula as well rather than just the peninsula, but long acting, um, strong steroids. Also, you want to consider your mean in your logic again, this is probably a specialist decision to do that pussy. It's interesting. The steroids with the methotrexate, the or some kind of immunotherapy. And then Polly, it's more like rheumatoid. So you also give a D marks from the rheumatoid, and then you stepped up accordingly. Um, so, yeah, next year, whenever you sure give another 20 seconds or so. Okay, um, again, quite a wide variety of different answers, but let's just go through it. Um, fairly young gentleman had current lower back pain. Okay, so it's not what? And so far, we've already tried physiotherapy, and, uh, let me know if I cut out. By the way, I know my internet is not the best. So you do do let me know. Um and, um, also naproxen and ibuprofen. I haven't, um They haven't really been able to help it that much. Okay. And then the point is X ray is sacred. Then we need to figure out how we want to best manage this. Let's see, um, we need to we step up treatment if it's, um if it's no longer just working with the naproxen and ibuprofen. So this first thing, it just seemed to be more of an ankylosing spondylitis picture and then step up from just answer. This alone is then going to be straight to immunologics. Um, and let's move on from there to our envelope. Mm. So spondyloarthropathy is associated with this one, this one genotype, which is HLA b 27. And that meant to be there. But the key conditions that with in this environment is ankylosing spondylitis and reactive arthritis. There's undifferentiated and spondyloarthropathy, which I don't think we need to know that much about whether that can be quite confusing itself. And then you're juvenile. Spondylar arthropathy is slightly different from juvenile idiopathic arthropathy. Then enter empathic arthritis, which is IBD associated infantry, boxing associated and mhm. And then finally, um, psoriatic arthritis. Um, so just go through your c. Um, sorry. Um, it is It's quite it's quite weird. To be fair. Part of it can be rheumatoid, like some presentations really can be. Others can be far more all ago, so they can be more asymmetrical. And they can be You can say a bit more osteoarthritic like, but it just yeah, So some are very more like rheumatoid, and some are less like rheumatoid and then some from their own various different subtypes as well, which of which they normally fired? On top of this, the key part of this, um, diagnosis, there must be psoriasis or there must be some family history of it. Um, and that's those important questions to ask. So I've listed the five subtypes, but the key thing is this. Arthritis multivitamins that's severe type. And they normally fix the hands as well controlled. And should be, um, you know, and the key thing is, there's telescoping. The thing is, um, which is basically where the skin that folds up a lot and it looks like a telescope. And there's the arthritis, the sausage fingers. They look. They look huge. And the idea there quite characteristic of, um, psoriatic arthritis. And then there's also the nail changes. Are you looking at everything from Uncle Uncle Isis? Nail pitting and foster nail loss and hyper keratosis. That's thickening, abnormal thickening of the nail as well. And investigation for that is firstly, on an X ray, you'll notice the insulin cause deformity. But what that means is basically, the bone is wider at the base, and then it thins all the way into the joint. Um, and this is normal question in a severe case, Uh, if you see that it's not quite characteristic of psoriatic arthritis on top of this, the important thing is rheumatoid factor is negative, and you use the cast for classification. I can't remember what every letter stands for the It's a commonly used classification to try and diagnose, um, psoriatic arthritis. It looks at everything from like the joint swelling distribute to, um, psoriasis or nail changes. And so it's quite comprehensive. And then, finally going through the management, you start them on NSAIDs. So, um, and then, depending on what their subtype is, you consider either if you want to start them on the market and then treat them similar to rheumatoid, or you could consider more immunological therapy, and you can also consider the steroid injections as well. Um, yeah, and that's an example of arthritis. Multi plans notice that the fingers seem to be quite folded a lot and and shrunken a bit. So it's called, Um, that's why it's called telescoping Another. Another term for that is opera glass hands. I'll be honest. I don't I don't quite understand why it was called, uh, and I never saw that. If if some of you see it and you let me know and you're just on an X ray, you can see quite a bit that pencil pencil deformity. If you look at some of the dreams that you can see, it's thinning towards that joint space. Yeah, so now I'm moving onto, including scandal latest. Um, you're typically it's information, and it starts at the base. And, um so your SED join. And then it wakes up the spine. And this information is them particularly prominent in your your your interview triple joints where they start thickening and they start losing the flexibility. And then you get fusion, which is called bamboo spine. Um, so, yeah, particularly young man, and there's a lot of there's morning stiffness that's quite characteristic, and again, that's sacroiliitis. So that's the information there and the key thing is improved with exercise. Um, Schober's test again as part of our well, part of our goals exam? Yeah, there's been reduced for infection. And alongside that you'd have some increased, like infection. And And you also have more drastic I process. So you notice they they they arch the upper back a lot more, and they lose their lumbar low doses as well. So in order to compensate this, those to be have the leg spent a lot. And quite often they can also present with new problems because of that. And, um sorry. Um, that shouldn't have said increased cervical flexion. Generally, the cervical spine movements are very reduced as well, especially as it goes up there. Cervical spine. Um, yeah. So X ray, check the pH between seven senators and then you want the MRI of the spine, especially normally you physiotherapy trial and says, and then your improvement. You go to MRI of the spine and then you want to also do a chest X ray, too, because you're looking for a place called fibrosis. 111 big complication of, um um of them was, um I think with the lightest, So I got a question in the chat, which was, would you not try them on the market? And then you would do if they had peripheral disease, so and d mods. And then I had a look at this. They're not actually that effective for, um Well before the spine itself. Rather is for any purple arthropathies from, um including Look at this. So therefore, if Ansaids don't normally work, you often just go straight for, like, more hard hitting, um, parte hitting therapies, especially steroid injections and also your immune logics. And the other thing to bear in mind is because in steroid injections, especially frequent ones you can develop, sometimes develop further complications in, and we're in an area that's quite inaccessible as well. Even you've got your spinal cord. Um, if sometimes it's preferred to try and go for immunological therapy, um, and complications the way I remember it. Just remember you raised so your typical versus mentioned to get the, uh, regurge have, you know, block. So, you know, heavy cardiac symptoms as well. You can pick a peripheral arthritis as I mentioned. And then you've also got anterior uveitis so funny enough that's also it's like a different and associated so it would be worthwhile exploring that if you've got a history of uveitis. Um, Achilles tendonitis. Yeah, normally, quite a lot of pain. Pain there, Um and yeah, um, amyloidosis, which can cause further complications and quarter equina syndrome, particularly because of the stiff spine just compressing on to the spine onto the corner corner corner. Okay. And now reactive operate. So he, um well, he, uh, let me stamp was talking about real active. Active arthritis is 3 to 4 weeks before this infection. Unless or 3 to 4 weeks before the symptoms start. They'll normally have a history of an infection, and I normally be either a g i o r g infection. I think this isn't an exhaustive list of all the bacteria that can cause it. However, I think is the most common ones. So shigella, salmonella media and your symptoms. Therefore, I remember it. As you can see, p climb a tree. See you got you got conjunctivitis your arthritis, and then climb a tree as your oligo arthritis. And it's it's it can vary. But rather than being more rheumatoid love, it's more in your large joint, such as your knee and your hip as well. And because of value, it stops you from doing those large scale movements. So how do you treat it? It first The 1st. 1st, you just want to rule out any other rheumatoid condition. And then it's normally quite self limiting. However, sometimes lasts a long time. You can You can give you cancer, AIDS and steroids to try and treat the symptoms and reduce the information. Otherwise, it's just a case of waiting. Um, I'm so sorry. I'm hoping mostly didn't see that, but yeah. Next s t A. Give another 20 seconds. Okay, No new cancers. So, you know, I'll just end it now, so yeah, some of you may have seen the answer already, but let's just look at the history. So, firstly, it's a young Jewish woman. Um, who as well dysphasia dry eyes arthrology. Um so? Well, not not really that longer history. However, the key thing is dysphagia and dry eyes quite you know, alongside arthrology again, not not really a common combination of of symptoms. And another thing to bear in mind is dysphagia is normally quite a common presentation for a dry mouth like in 11. Basically, I'm going to tell you this is a shot grounds, um, syndrome. And typically there's dry mouth and dry eyes, and it's so severe that can actually cause dysphasia. Um, I know this is a very short stem, and believe me, I wish I didn't see any STDs that looked like this. Unfortunately, there are so many, and they're very common. That's why I thought I'd be a bit harsh in terms of it. Still, I think a lot of you did get it or that that might have been because I saw the answer. But it's Children's disorder and therefore to diagnose it, particularly because of the more the dryness of your extra problems. The best way to do it is to insert some filter paper into your eyes and then wait five minutes. And that's Schwimmer's test. And the idea is, if it doesn't rise to a certain level, then you can diagnose them with Sjogren's. So I'll just mhm yeah, aside from being quite painful to try to pronounce, uh, in terms of physiology, it's, um, typically an attack of your extra crying lines. So normally you're slow. Every lines also, um, your eyes as well and ignore. So, um, also cause dryness of the vagina as well. So it's either primary, so there's no known other condition associated with it. Or it can be secondary, particularly to rheumatoid arthritis and Lupus and systemic sclerosis. And it's normally in younger women or postmenopausal one, um, looking at your signs. Writer Conjunction. Lighter, Sicker. Another word for very dry eyes. And as you may remember, it's actually very similar to to rheumatoid arthritis as well. Um, so there is a bit of an overlap there, and there's a storm, so they're very dry mouth, the point in which again you will get you well. They can develop dysplasia. They can also develop dysarthria, so difficulty speaking and often a lot of dental complications also develop vaginal dryness. Um, as I mentioned and it's it's rheumatology. There's gonna be arthrology. And given the extra crying attack of these glands, there will you will notice some swelling, especially in Let's say, your carotids, which you can pop it, and so that I mentioned the shortness test. That's your main investigation. However, your antiviral and your anti l. A and, well, antibodies well, normally be positive. You also want to screen for, um, rheumatoid arthritis and SLE and management. It's normally supportive, so you want to give artificial tears and you want to give artificial saliva. Lubricants just help manage their symptoms, even give pilocarpine so that normally increase the secretion as well. And that really does help the eyes. But aside from that, yeah, just if there's a secondary treat that and it's normally just waiting for it to self resolved and my oxytosis um myositis sorry. Um, so this is information of your stride and muscle? I'm not sure. In PCs uh, muscle. We have smooth muscle administrative muscle, which is cardiac mosquito. So this presents with proximal muscle weakness, which is very similar to the polymyalgia rhuematica, which will be going through next tomorrow, and, um, that form you want. It's a screen port, a cath and spiritual involvement, particularly since those muscles can be very badly affected. And that's when you major concerns with it. So normally, ask about our patients and you want to ask about shortness of breath, you know, looking at your cardiac and your respiratory histories. So the key sign we'll sign splashing, you know, markers that you'll see you'll see Muslims. I would be elevated, but I've listed a lot of them. But even you don't even if it's just your CD eight MGs are probably indicates it's going to be some kind of inflammatory disease you invest in. Investigate that further with e mg. So that's basically what you electromyographs. You put electrodes on your skin to move or you stimulate movement, and then any abnormalities they come up under that MRI. Um, so I'm sorry, I I think I should have put these under investigation, but, yeah, MRI. You'll see muscle edema and you can take a muscle biopsy. And that's normally diagnostic. There's also quite a few antibodies as well. Um, Antigo one particularly involving the respiratory complications. Also my two and A and A, and it is positive in a lot of room for logical conditions and management is high Dose IV Prentice learn, and then afterwards you just taper it down. If that doesn't work, you give more immunosuppressants and immunological just to try and really control that information. But the idea is you want to make sure that they don't develop those cardiac or those respiratory complications. Um, and now the two main types of my bursitis. So your policy and with them, uh, and you may want to try to differentiate between the two. So the best way is the Polymyositis, and it's also remark, psychosis and irisitis. I sometimes get a handle on that, but it's, um, firstly, malignancy is a big one. Contribute to our association with it, so you want to be trying to screen for any cancers. Also, there's a lot of new cold erythema, um, which is more so the polymyositis And there's more middle age when, however, with with them I scientists then mentioned a n A is more positive. And there's a very specific malignancy is there's a long acting about ovarian, and the main things are a particular rush and the Humatrope rash. And he's corporal particles. That's more derma myositis more exciting, otherwise, fairly similar. But polymyositis this is a bit less specific. Um, yeah. Okay. Next s t a. Okay, I'm giving you five seconds. All right, so you can see the item. So I mentioned Crest symptoms just Unfortunately, I didn't have that space in the stem to say that however, ignoring the crest symptoms part, there's numbness in the fingers and toes. Okay, um, and as well as that, the blood test shows anticentromere positivity. So, um, quest, I'm, you know, is plasmosis. Um is esophageal dysmotility as well as cardiac till until angioectasia. So quite a character report symptoms. But the idea is that, looking at that, they have limited systemic sclerosis. So based on that, then particularly the concern is with regards to numbness and fingers and toes. So what was one good way to manage that? And I think most of you did get it right. So it's sildenafil, also known as Viagra. And this is one of those occasions in which there is another use for it because Viagra in itself is basically dilator. So it can also work to violate the extremities of your fingers and be. And that way it will prevent, like the numbness with Reynolds and also the the concerns that often people have. Let's say let's say that I'm losing sensation completely or even having more frequent infections now. Okay, so I'm just going to give an overview of systemic, slower system first looking at limited systemic sclerosis, what you're talking about. Normally it's limited in the sense that you only see it unless the the hands feet in the face. And that's not going to be raining your Raynaud's phenomenon to be the president presenting complaint. Um, so you look for pulmonary hypertension as well, because that's very even what we're strongly associated with Crest as well, and your anti centrally antibodies like that's one that's one bite mark is what you want to look for. So quest again, the best way to remember it? The calcinosis so they'll normally have quite a fairly high calcium ray nose esophageal dysmotility. So probably complain of dysphasia difficulty swallowing and then start back till the difficult to describe it. But you'll you'll notice that their fingers they're almost appear to be fairly webbed. It's worthwhile. Just do a quick Google. See what that looks like until angioectasia, also known as spider levi, uh, again in an abdominal exam. We normally look for that and normally, normally is. Let's say you only just one or like none at all. You'll see quite a lot, particularly around the afternoon, and that's quite characteristic. Um, of the so diffuse is more of a full body involvement in terms of so many so many obvious symptoms on top of that you have when you have a different antibodies and 20 s or 70. And also anti anti antibodies as well. And your system, which is a lot worse. Um, so just to have a story which is like, this tightening of the skin and you also do have it with limited Um, but it's more widespread. You also far more worried about acute renal crisis, particularly with regard to BP and going into a k I and yeah, steroids, um, steroids can sometimes. And what you were saying that as well. And which is why you need to be careful there. So in terms of the, um your cardiac and your lung complications as well, you want to be constantly managing that whether that be regular lung function test and also a regular echo as well. And yeah, arthrology, unfortunately, is also worse with diffuse. So management sildenafil is from, you know, to try and yeah, to try and decrease ability to I got a question to ask him. Can gtmo want to do that? I imagine it can do. However, I imagine some clinical trial was done and it just coincidental work the best I unfortunately, don't know, but yeah, um, in terms of BP, you you want to keep it very tightly monitored, Um, and give an ace inhibitor if needed. But the key thing is, just monitor these patients because whilst there is no cure in, like the key prognostic target that you have just to try and reduce the frequency of these complications and try and manage and invested possible Yeah, I've got another table. I'm not going to go too much into it, but it's basically most of your neurologic, um, particularly common one that you'll see in rheumatology. Just try to summarize them quite neatly here, actually, since I'm not going to, like most names sound either the same or just like completely foreign language. So I just thought, If you know, if you're able to see any neurologic, actually think about what it does, then it might just help. Um, it might just help you a bit better, understand the mechanism action behind it, and maybe you know why it's easier that way again. Um, there's a slide should be sent out to everyone, So feel free to have a look at that. And aside from that, that's the end of the session. And, yeah, we're back on traditional time. So there's some a few just key points that to take away the reading. I joined a fever. Just it's acceptable practice. Okay, just, um, until you've been proven otherwise, just treat it as if you're septic arthritis and just, um, trying to find out. Yeah, and if one is old and if there's an oligarch arthropathy worse with movement, it's osteoarthritis there, young, it's more symmetrical and improve. The movement is rheumatoid. And if you get this strange combo and you're not sure which, um and there's a history of psoriasis, then it's sort of a family history of psoriasis. Psoriatic, um, as an information young man. Well, that's it's more in the stem, uh, SBA stem as the information young man again like the ankle is spondylitis. Give them and said, um, dry mouth, dry eyes, Autoimmune mystery. Yeah, like it's probably gonna be surgeons. And then, finally, my eyesight is like with the rash is a dermatitis is without a rash that's more likely to be poorly and then just for both of them, just give the prednisolone and try and try and manage it from there. But yeah, aside from that, let's see. And and that's the There's a feedback link. Um, please do fill in and please do be honest with your feedback as well. Anything's appreciated. I think we got time for a few questions.