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That's for the chatter is all. And I've run. Ah, you guys. You guys have trouble quick? Yes, In the chart. If you could give me very nice said good to be back. Uh, hope you guys all know me. So my name's Michelle, uh, one of the co founders of our ski easy. And I'm sure most you recognize you have a lot of lectures about a B or skis you teaching program on Very excited to be back teaching again. This'll week. It's gonna be on rheumatology, as I'm sure most feel level. Okay, so it's a continuation off our finals. Easy, Siris. Siris, which I hope you guys have been enjoying. We've been covering most of the sort of internal medicine specialties. Okay, we've been trying to recover as many of the medical specialties as we can in this sort of academic term. It was slowly start trying to come out of some of the other specialties as well, but hopefully trying to cover as much of the medical curriculum. So today is gonna be on rheumatology. Very important specialty. Okay. Can be quite complex for students to study. Yeah, but I hope they try and break down a lot of the key stuff you need to know as as an undergraduate. Okay. Particularly the stuff that's really important for exams. Okay, from Target is very is a very testable subject. Her kids, It's generally quite it's not too hard to study, but there's a lot of content to know. Okay, it's not too much attempt of contest, but there's just a lot of content to know in rheumatology. So again to into some basic concepts about studying rheumatologist in rheumatology is a specialty about complex or two immune diseases. Okay, it's coming. It's a complex fields. Okay. A lot of the diseases are very poorly understood in terms of pathophysiology. Okay, a lot of them are just idiopathic. Okay, I think we just don't know what causes them, Okay, but it's a very complex fields. Okay, So I wouldn't stress too much about trying to learn the intricate intricacies of all these diseases. Okay, cause that complex diseases from a in terms of pathophysiology okay, but learn the key aspects of thumb rheumatologist all about antibodies. Okay, It's all about investigations, blood tests. Okay, But even though it's all about the sort of investigations key thing to remember is that no single blood tests and diagnosed any rooms. Logic disease. Okay, No one antibody is diagnostic off a particular rheumatological disease again. We'll talk about what What I mean about in terms of use these anti terms off, you know, sensitivities and specificities and things. But just conceptually, they realized that no single test, no single antibodies ever diagnostic on its own off a particular rheumatologic disease. It's all about putting the blood test, the investigation, the antibodies in the context of what the patient is presented with, okay and contact end in context with other investigations as well as a said, Rheumatoid is very complex. So it's very easy to get bogged down trying to, you know, learn sort of specialist level detail with all these diseases. Okay, but learn learn the key aspect that they learned the principals. Okay. And obviously try and remember as many of the antibodies as you can because it's very testicle, okay? And finally, it's very complex specialty, okay? And I said have physiology is very poorly understood, but all of these conditions will have a lot of common features. Okay, In terms of clinical presentation, a lot of them will have very common features, very classic features that will always the almost always be seen with them. Okay, and it's being able to recognize the speech is recognizing the patterns in these conditions, recognizing this similarities between conditions and recognizing keep differences, That's what we call it is all about, Okay, it's all about pattern recognition. Okay, if you learn the principles, learned what's common, learn what's important to know about each condition. It used to be pretty confident answering most the questions that come up in me and talk to you. Okay, so before you move on, uh, let's see one. So we're gonna do our first FDA, okay? I have a quite a few s p s. But this first X ray isn't specifically rheumatology focus, but it's important. It's about It's a basic cyst that this expression, But it's important to get this bit of statistics out of the waste of the evidence clear on it before we start talking about some of the more chemical stuff unique in rheumatology. Okay, you shall give it 40 seconds here. Yeah, Okay. How? Call it that. So most of using a split the most of you and for B. The correct answer here is actually, uh Okay, So it's the question testing your knowledge of basically statistic. It's like a medical assistant sticks. And so I've got this two by two tables here. I'm asking. You want to see first if it's still okay? So three questions asking about this antibody test for new rheumatological disease. Okay. Such a blessing. A knowledge of, uh what? What does this specificity? Often off a test, actually. Me. Okay, So can you tell me what is what this pet specificity me? If you can define specificity for me, What do I mean by specificity of tests? Can anyone put down in the chart if you can? Can you define specificity for me? Number of two negatives yet. Okay. So if someone if something is is highly specific, it means that it's got low, false positive rates. Okay, We'll talk about what this means. What is the What's the equation to do it? How did you calculate specificity? Are you calculate specificity. What's the one of the numbers? Good. So it's the both part of false negatives. The truth negatives over the total night. People with negative you don't have disease Okay, So, Yeah. So the calculation here is 180 divided by the total people who don't have disease. So that's 180 plus 20. So the people who don't have disease, that's 200. So to complete specificity. Here it's 180 divided by 200. So that and then But as a percentage, that's 90%. Okay, so this test has a 90% specificity. Okay, so let's talk about what I mean by all these different terminology. Okay? Very important. Particularly because we're going to talk about a lot of different antibodies. It's important. That would clear on what sensitivity and specificity me specificity means. Okay, So terms of the actual calculations of specificity is the true negative. So 180 over the total negatives. Okay, So total negative, as in the people who don't have disease. So that's 180 plus 20. Okay, Okay, so we'll talk About what? This what? I mean by the actual different terminology here. Okay, so I've got this two by two table. So on the left, we got the test. If it's a positive test for a negative test above, we got disease so they actually have a disease or they don't have disease. Okay, so this is if it's known that they have disease or if they don't have disease. Okay. So, again, breaking down moods, more technology. If they have disease and the test is positive, it means that there are true positive if they they don't have disease. But the test comes up back as negative. That's a true negative. Okay. And then we come on to the some of the false one. So if it's a false negative, it means that the test is negative, even though they have, they actually have disease. Okay. And finally, a false positive means that the test is positive, even though they don't have a disease. Okay, that's what all these terminologies me. So if we start putting these putting all this stuff together, sensitivity, the actual calculation, it's the truth. Positives divided by the total number of people who have disease. Okay, SATs, t two positives plus false negative. So is the total number of people have disease. Okay, so it's two positives bus, false negatives. So that's what sensitivity means. Okay. And the key thing is that if a test has high sensitivity. It means that has low false negatives. Okay, because if you think about it, if you have high sensitivity, that means that the top number, the troop operative, is very, very high. Okay, so if the truth positive they're true positive rate is hardly with the test. That means that the actual vaults positive a false negative rate will be low. Okay, so if the test is has a high sensitivity, that means that if it's negative, it's gonna help rule out deceits. Okay, because it's picking up all the positive patients. If it's negative, that's when it's significant to help rule out disease. Okay, so it's kind of like a metal detector. You know, a matter of detective will help will pick up the knives, will pick up any of the you know, guns and things, but also pick up thinking about keys, things like toy cars and things in the bags. So it's it's gonna pick up, you know, pick up the disease, okay, but also pick up other things as well. Okay, so that's why it's only it's only really significant if it's if the test is negative. Okay, cause if it test is highly sensitive and you have. And it's a negative result in means that it's unlikely that they have disease. Okay, that sensitivity specificity is a bit different. Okay, so specificity is where you take the two negatives, and then you divide that by the total number of people who don't have disease. Okay, so if you think about this calculation, if this test is highly specific, it means that I will have a low false positive rich. Okay, so it's a highly specific means that it's positive it means that they likely will have disease. Okay, because there's a low false positive rate. Seven highly specific test. If there's a positive result on a highly specific test, that means that disease is slightly okay. That's what specificity means. Okay, pc. Really? Can. The difference is okay. This is this important concept for all the different antibodies. Will talk about sensitivity, low, low, false negatives, specificity, low false bottles. There's okay the way you can. I people often remember that this is with the snouts. Understand? Okay. So sensitive tests help to rule out disease specific tests helped to rule in disease. Okay, Because high sensitivity means low false negatives, high specificity means low false positives. Okay, Okay. Finally, there's some other things that you won't talk about too much. PPV said close. The predicted value is that basically, if the test is positive, how likely is it that they have disease? Okay, sets to positives over total positives. And if it's if you have high PPV, it means that disease is likely. Okay? And similarly, if you have the negative predictive value, that's the number of if the test is negative, how likely is it that they don't have disease? Okay, so you can go out that by the true negatives divided by the tops of negatives. Okay, so testis has a high negative predictive value. It means that a negative test means that disease is unlikely. Okay, that's the That's the basic sort of by the Texaco. By statistics we'll talk about Does anyone want me to go over any of that's okay? Because this is gonna be really important for the rest of the lab chair. He used to be really clear about what all these terminologies means. Okay. Okay. So I start talking about some chemical stuff and, uh, load up the pool again that I think most of your getting this song. Call it that it most of you and for B. And that is the correct answer here. So osteophytes get it. So So before you talk about it. So what's the diagnosis? A few guys come put down in the charts. Osteoarthritis. Good. Okay, this is osteoarthritis. Okay, so what else? You're right. Just so you have a patient here who is presenting with knee pain, Okay. This is a patient who has exist as a history off. Basically, we're interrogate history of knee injuries. Okay, so there's a history off joint damage. Okay? Patient has a high B m I A swell. So there's mechanical stress on the joints as well. He's all key risk factors for osteoporosis. So that that makes it. That's why it's most likely I'll start right to say, um, So can you tell me what is the significance off the morning stiffness? When is morning significance? Morning stiffness. Significant. What? What are you trying to get up with? The morning stiffness was the point of checking for morning stiffness. Greater than one hours. Rheumatoid arthritis. Very good. Okay, So people generally say 30 minutes. Okay. One hour. Obviously, it's more suggestive, but well, we'll talk about that. So we again coming out to the concept off inflammatory arthritis versus non inflammatory arthritis. Okay, osteoarthritis is a type of non inflammatory arthritis. Okay, Even though it has just in the name, it's there's not excessive information. Okay? It's a type of non inflammatory arthritis. And morning stiffness is not a predominant feature compared to other causes off arthritis. Okay, Comparator, inflammatory arthritis, which we'll talk about. Okay, So, less than 30 minutes off morning stiffness is typical of what common feature of a non inflammatory arthritis is that it gets worse with exertion. Okay, Worst would work. Walking called classic creature. Okay. And in terms of x ray findings for osteoarthritis, we'll see one of the key X ray findings. And you guys just put something in the chat in addition to osteophytes. Yes, very good. I'm liking it. Severance putting lost. So case of the classic, you molecule, it's loss. Okay, so, yeah, you guys are listening to this things, Um, the loss of joint space osteophytes a condo. Cirrhosis. Very good. So contraceptive. Excellent. Okay, so that was the key X ray findings for osteoarthritis. Um, if you take some of the other options are bony erosions. That's classic for rheumatoid. Okay, what is the key? Arthritis. Where you get erosions. Okay, Pencillin cup deformity. So which condition do you get? A pencil and cup deformity with psoriasis. Be specific. Know you don't just get that with psoriasis. It's psoriatic arthritis. Okay, Chondrocalcinosis, which one do you get that with? PSEUDOGOUT. Explain. It's okay. We'll we'll talk about all these conditions and periarticular osteopenia. You get that with the rheumatoid. Okay, s so keep point. OSTEOPHYTE is an important radio finding in osteo front. It's okay. Now, this is a question as a second part as well. So if you guys quickly answer it, eyes short questions I won't give you too much time turns this one okay? Yeah. You guys know you also arthritis. Calculate that being most of you are getting it. Okay, So mostly you want for a and that is the correct answer. It's a quarter substance. Strengthen the exercises. And yes, a keeper thing is that first line management in osteoarthritis is conservative management. Okay, Exercise pain relief. Okay. Perfectly exercise. Okay. Mobilizing the joints. Improving muscle strength. Okay. Getting physical therapy involvement These are the key aspects of the initial management of osteoarthritis. Okay, before you start considering things like surgery and things, you want to first try to get the patient to mobilize the joints and increase the muscle strength to help stabilize the joints. Okay, then quadriceps. Strengthening exercises Particularly important. Okay, on darvocet is your therapist can help that access and visit that. It is very important initially in osteoarthritis. So let's talk about joint pain. Okay? It's just a conceptual basis. So we talked about eso joint pain. We generally think about joint pain in terms off in terms of the arthritis that causes doing penance either as an inflammatory arthritis, whereas in non inflammatory arthritis. Okay, it's okay. Can you guys tell me when you're taking a history from someone with joint pain? What other different things you want to be asking about to differentiate if it's inflammatory or non inflammatory? So we talked about morning stiffness. What else would you be asking about? Where's the better word? Walking? Good exercise. We've been symmetry. Very good. Okay. Number of joint. If it's legal. Articular polyarticular. Asymmetrical, symmetrical red hearts fallen. Good. Okay. Always important to think about with particular representing acutely with joint pain, systemic features, excellence. These are all important things to ask about. Systemic beach is more common in inflammatory pain. Generally is your vote. Other autoimmune diseases. Good morning. Stiffness, excellence. All important things are you thinking about? Okay, so I just listed some key things we want to be thinking about in terms of being actual history or things that they'll tell you and be been yet. So single best answer questions. Okay, so these are important things worse with movement in solitary. Uh, sorry. Worse with immobility is inflammatory. Worse with movement noninflammatory. Okay. Morning stiffness greater than 30 minutes. Inflammatory. Okay, because stiffness is the predominant feature, generally with inflammatory arthritis. Okay, Whereas it's not as predominant feature with non inflamed. Yeah, for I just like osteoarthritis. Systemic beach is more common with inflammatory arthritis. Okay. And Lantus common with non inflammatory arthritis. Okay, good. So it's a little diagram. A just to sort of help conceptualize how we classify different cause of arthritis. Okay, so we talked about no inflam to inflammatory. So the main cause of non inflammatory arthritis is osteoarthritis. Okay? Obviously, trauma can cause joint pain. It's well, but osteoarthritis is particularly common. Cause off normal inflammatory arthritis in terms of inflammatory arthritis, we further divided. It's caused by crystals. Okay, that's close by crystal deposition. The two main ones are Gout's and suit ago, which we'll talk about. Other closes up in front of our Fridays. Things like rheumatoid seronegative spondyloarthropathies, Lupus, septic, arthritis. Okay, so quickly on osteoarthritis. We've already talked about a lot of it. Okay, it's a where it's where you get destruction of cartilage. Okay, generally due to wear and tear. Okay. And there's not that significant inflammation happening. Okay? Just it's a wear and tear disease. Mechanical stress, mechanical problem? A. It happens in older people or beast people. People have pre existing joint disease, for example, that football players that multiple injuries, these are the key thing to be thinking about with away. Okay, so non inflammatory arthritis. So we talked about some of the key things that happened in terms of its gets worse with movement better, other better with rest Okay, worse at the end of the day, because of don't activities throughout the day, okay. And common areas are common areas of disease with a way is hips knees and decided to find your joints as well. Okay, which is different compared to rheumatoid. We get the IEP spare, okay, and you also get some Keep. Each is. It's called Heaven's and Bouchard's nodes, which we'll talk about. Uh, we talked about the loss. Okay, In terms of the extra x ray findings, the lost pneumonic is particularly useful to remember the key X ray findings and terms of treatment. So first line, non pharmacologic. Oh, okay. So exercise visual therapy, reduce weight control, obesity. Okay. And in terms, if you start going on to medical therapy, See, we think about pain relief. Generally, parachute smaller is usually pretty effective. Can you can try topical and said's a swell and then you can slowly move up the ladder. Okay on. If they're not responding well to all these therapies, then you can consider if they need a replacement. Okay, Joint replacement. Now key. The 40 g examination finding that osteoarthritis are these different notes. Okay. Bouchard's nodes and heaven and snowed. Okay, keeping is that. Heavens, nodes. Ah, so these above features that occur because of the osteo fights off because of the bone formation that happens in osteoarthritis. You get these notes, okay. They don't actually interfere with the function of the end, but the important clinical examination findings. So I guess the key thing to remember for your osteo, um, in a shins is that having been snowed swell up, that the distant fine Jill joints whereas Bouchard's nodes back see proximal interphalangeal joints. Okay, the way I like to remember is I like to think of a HB pencil, okay? And I think of the fingertips as the the lead of the pencil. Okay. And so HPV is a change. Heavens effects the distant to find your joints and Bouchard's vacc trucks more in defined your joints. Okay, if you guys have any other ways to remember that he's put down in their charts and put down your favorite your marks, remember that. But we will keep moving on. So we talked about osteoarthritis, then Now we're gonna move on to some other diseases. You said somebody would like to say BP BP for add you shots for approximately good something. SPS what you said today mainly because I didn't have as much time to do. The question is this time, but a lot of the Estrace will have importantly, any points. So hopefully they'll be useful unless you're getting it. So let's talk about that. Call it that good. So mostly got rheumatoid arthritis. That is the correct answer here. Okay. So you can see here it's see rheumatoid arthritis. Okay, so why? So we just talk about osteoarthritis, has a case off. No inflammatory arthritis. Now, I've described a clock face, and now you're basically off inflammatory arthritis. Okay, so this is a patient who has this. You have joint pain and swelling, and the key thing is that this is morning stiffness that last greater than 30 minutes. Okay. Is lasting an hour to have indicates that it's inflammatory arthritis. Okay, on so and I've also talked about some antibodies. So the key thing to remember is that anti CCP is a highly specific antibody seen in rheumatoid arthritis. Okay. Ah, rheumatoid factor is very sensitive. Ok? Can be It is you use usually positive rheumatoid, but it's also positive in many diseases. Okay, These rooms are, in fact, just because it says rheumatoid. These don't think that these are assumed. I was just seen it from sort of, right. It's okay. It's one of the most non specific antibodies had seen in so many different conditions. Okay, well, we'll talk about it a a same thing, Okay? It's a very non specific antibody seen in various different conditions. Okay, but it's negative. Okay, um, but we'll talk about what I am taking positive data on anti CCP is highly specific for rheumatoid. Okay, Tequila thinking is keeping his anti CCP. It's specifically rheumatoid arthritis, and it causes an inflammatory picture off off. Right. This is with morning stiffness. Greater than 30 minutes. Just about rheumatoid. Okay. Very important condition. Okay. Osteoarthritis than rheumatoid arthritis Are your goal standard conditions to know for rheumatology. Okay. Very important conditions very commonly seen in clinical practice. It's important that you guys are really comfortable, and, um, in discussing rheumatoid and approaching rheumatoid before finals. We're our scales for clinical practice. Okay? These are really important conditions. Know about your rheumatoid arthritis? Uh, it's an inflammatory disorder like we talked about. It's a systemic disorder. And the key thing with rheumatoid, the whole mark of rheumatoid is synovitis. Okay, the fax Sinovel joints throughout the body. Okay. That's the key thing with the rheumatoid causes information off Sinovel joints. So please learn your Sinovel joint anatomy. Okay, so you know which ones are the Sinovel joints on day? Decide that. That would help make sense. A lot of the different complications in, ah, room inside. Okay, uh, in terms of clinical features. So it's inflammatory arthritis like we talked about. Okay, Uh, classic joints that are affected on the pee I pee MCP joints. Okay. Very commonly affected, uh, in terms of C spine, cervical spine. Which joints are typically affected in the cervical spine? Yeah. Which joints would be affected in this setting goals? Fine. If I told you that effects. I know Bill joints. Which ones are the sign of your joints? Very good. Atlanta XL joints. Okay. So, classically with rheumatoid as an extra tickler manifestation, you can get up at plantar exiled, joint, actual joint information. Okay, so the C one C two joints so that can be involved as well with rheumatoid. Okay, I have a question on that soon. Um, d i p joints Very important. D i P joints is rarely affected in rheumatoid case, typically sped. That's very important feature and rheumatoid. Okay, joint deformities. We'll talk about some of the deformities you can get. Morning stiffness is very predominant in rheumatoid. Okay? I've talked to patients with rheumatoid, and they say that they have to wake up, like on our earlier than that. Then they then before, Just because that stiffness is so predominant. And they need to just move their fingers around from the fingers on the water to help loosen the joints. Because morning stiffness is really predominantly rheumatoid because it's an inflammatory arthritis. Okay, we talked about some of the extra particular amount of the stations in a bit. So the antibody, so rheumatoid factor is usually present, okay? And most patients okay, but it has slowed specificity. Okay. Sorry. I think I said, uh, sense to me before it's low spasticity. Okay? It's not specific to any disease. Okay, where's anti CCP is highly specific, Okay. And CC is fighting specific to rheumatoid. That's positive. Like I talked about. It likely means that they have rheumatoid. Okay, classic X rays. So room. So it causes erosive disease. Okay. Whereas other ones doesn't tend to cause erosions. Okay, So total is the key cause of arthritis, which will cause erosions okay and I've got some of the diagnostic criteria for you can have, which you can have a read about. Okay, so we're gonna talk about some of the deformity, so if you guys can put down in the chat what the deformity is on, uh, let me know what you guys think. So what is this deformity here? Yeah, swollen like deformity. Very good. Okay, this is this one active. Formative. It You can get a room inside. So you're getting hyper extension of the pee I pee joints, but flexion at the D I P joints. Okay. What about this one? Busted. What's this picture? Very good. Baton? Yes. Deformity. Okay. So bit different. Okay, so this way it's the opposite. You get in flexion at the pee I pee joints. Okay, but then hyperextension at the d I P joints. Okay, on this one's got to deformity. So one of their to deformities that you can see here he actually getting empty, be sub locks a shin, And because of that subluxation you're getting a little deviation is Well, okay, So you're getting subject station, and then you're getting deviation again. There's another abnormality that you can that that's there as well. Zicam. Birgit. Okay, there's a Z time here is 12. Okay, so two deformities in this picture, all the deviation, Okay. As well as empty piece, uh, block station and as well. And a Z from here. Okay, so you're getting hyper extension off the interval and your joints off the tongue. Okay, so these are the common, I say common. These are the key deformities in rheumatoid. Okay. And the key thing to remember is that these deformities are not reduced. Okay, So you contacts put the can back into its normal shape, okay? They're non reducible that the deformities. You can't change the deformities back become put pressure to put the deformities back to its original to the normal anatomy. Okay, that's the key thing with these deformities. And this is like, I feel diagram drawn by one of our committee members. Marais just summarizing a lot of the deformities. So Okay, so just a nice little revision picture of you guys. Next question is a little short, SPF, but importantly, any point, by the way, just wanted to highlight that. The previous question was, what's the complication off? Um, rheumatoid arthritis on the answer was lymphoma. I slightly I slightly change it. May it may be Yeah. Yeah, They Yeah, runs but in the chat. So, yeah, lymphoma is one of the complications that you get with rheumatoid arthritis. Difficult. No, not get this. Lymphoma Pull up. Very good. You guys have been listening. Get to see. I can call it that. So, what do you got there? So survive Collects. Right. Okay, so that is the correct answer here. So most of us for Smikle X rays so wise of a collection, So can you just put in the chart? What? What? Why? Why does this patient needs to buy cholextra before this patient goes on to have a CABG procedure? What's the importance of having the X ray done? Anesthesia? Okay. Specifically, why do you need the What are they going to do? An anesthesiologists important to have the X ray done intubation. Very good. Okay, so it goes around, and I before from major operation like cabbage. Okay, Corey, by buzz, there likely need to be intubated, okay? And doing intubation though hyper, they'll need a hyper extend there. Okay. And like I said about, um, it can affect the cervical spine. Okay, specifically, the atlanto axial joints. And it can cause if you have information that it can cause Atlanta axial subluxation. Okay. So you can get some flex a shin off the Atlanta Axial joints on that, And that's particularly dangerous if you're gonna hyper extend the neck. And if they have, um, Atlantic actual joint involvement, that could be particularly dangerous. Okay, because that can compress his spinal cord at the level of the C spine. And that could be catastrophic for the patient. Okay. Very, very obviously. Very dangerous. Okay. Beginning. Ah, spinal cord compression of the C spine level. Okay, so So this is why important to check of their Atlantic actual joint involvement. And you do that by just doing a simple radio logical from before you do the intubation. Okay, that's why it's very important. Okay, The key thing here is that route room token cause a plant actually subluxation. And that's why I imaging should be done prior to net type books. Set hyperextension such as the intubation that you have to do for, uh and anesthetics. Okay, just a little summary table summary slide on all the different types of extra articular manifestations that you could get rheumatoid. Okay, I'm not gonna go through all of this, okay? It's just for your revision, but these are all the different sort of complications that you could get. Okay, so remember, rheumatoid is a systemic disease. Okay? It's not just a disease of the joint ache and fact, the entire body and load the different systems. So because it has so many different complications, when you're treating patients with rheumatoid, you're going straight. You aiming to achieve remission as quickly as possible, Okay, because it has so many different complications. Okay, but can you guys tell me what is the common, most common extraarticular manifestation of rheumatoid? Out of all of these, one of the what's the most common one out of all of these are all of these different symptoms I've listed in which of these is the most common one. Nadia looks very good skin. Okay, So rheumatoid nodule is our team are the most common extraarticular manifestations in case of these, um, so these nodule nodule that you can get on the bony prominences cases back the elbow started on the knuckles. There is the most common extraarticular manifestation. Okay. Ah, what else? Out of all of these symptoms, what's the leading cause of death in rheumatoid? What's the leading cause of mortality? Cardiovascular disease. Very good. Okay. Ah, what else? Uh, out of all of these anemias, which is the most common anemia that you get in rheumatoid. What's the most common enemy you got really bad arthritis and anemia. Chronic disease. Okay, so that's the most common anemia that you get in. Uh um, rheumatoid arthritis. Okay, good. So, going to move on to treatment of rheumatoid again? It got a little SPF. You guys it? Yeah. Think I'm I think I'm out of it. I think I made the escape of it too easy for you guys today. You guys are all getting it. Yeah. Okay. Over there. Good. So most of you got it's a D. That is the correct answer. So stop methotrexate a few months before conception. Okay? And the key thing here is the route. Methotrexate's say it's It's a type of demons. Her case of demons are disease modifying anti rheumatic drugs, mainstay of managing and correcting the course of disease and rheumatoid arthritis. Again, methotrexate is a type of synthetic day mark which is generally first line with rheumatoid. Okay, anything to know about? It's very important to know adverse effects of a lot of the treatment options in rheumatoid and an important adverse effect of math a drug say there's that it had. It is highly teratogenic. Okay, so it's very highly stronger social because in both defects. So if, if so, if people want to conceive, it's very important to that there, well established off mathematics. Methotrexate. Okay, before that, you start consuming. So that's why if they're on methotrexate there, but it's very important that they're on effective contraception. Okay, because it's very strongly associated with trata necessity. Tractor Genesee. Okay, again, methotrexate is high. You teratogenic effective contraceptive is needed for at least six months after treatment. Okay, um, in terms of the actual timelines, it varies. Okay, but generally, six months is quite accepted so quickly on rheumatoid arthritis management. Okay? It so far in terms of controlling the pain so you can do basic pain management, okay? And said's and dropped a close relative. It's severe. It's just a couple of joints involved. You can do steroids. Okay, but these aren't going to change the course of disease. Okay. Things like and said's steroids, exercise and things. They're not going to change the actual course of disease and improve outcome to rheumatoid. The drugs that actually improve outcomes and rheumatoid arthritis and change the course of disease are the demarte drugs. Okay, so the disease modifying anti rheumatic drugs. Okay, so these are the first line drugs. Okay. On generally indicated you could do a score called the dust. When you get schools, that helps characterize how many joints are a bold and about 20 generally would start the months. Okay, But the key thing is that the miles of them things that will change the course of disease and improve outcomes in your right side. Okay, Uh, usually it's in combination with steroids. Okay, but remember, steroids don't have a role long term and rheumatoid, because steroids both break down bone. Okay. And rheumatoid arthritis, you're already losing bones. The steroids are not good excessively in rheumatoid arthritis. Okay, So generally use steroids as a type of bridging therapy, okay? And biologics. So biologic drugs. So these are increasingly being used and increasingly being researched. They're generally used. It demos, the synthetic demons and or effective. Okay. But you can also combined demons with biologics, Okay? And they're often very effective that way. If you combine a demon with a biologic agent that often provide more efficacy for the patient, Okay. Remember I told you, because of all those complications of rheumatoid, it's important to achieve remission as quickly as possible because that that's why I often patient will immediately be started on demotes. Okay, So don't just think that you only start being moms if they have x ray changes or, you know, they haven't got any deformity. So why should I start it? Okay, you start the dream a deMars to prevent all of these changes. Okay, because rheumatoid has so many different communications. Okay, we got a little tables to summarizing all the different drugs, the different deMars and biologics. Okay. And the different important things to know about them. So remember methotrex a highly traffic jam it to pathogenic. Okay. Also toxic to the liver and lungs. Sulfasalazine should be avoided if they're G six pd deficiency. Okay, but generally it's safe in pregnancy. Okay, Uh, until it's a map is a type of biologic agents on the portal thing to remember with Gina alpha inhibitors is I should check it. They have, uh, any any TB infection, Okay. Because it can cause reactivation of place and TV. Okay, good. It's a little summary to embolus comparing osteoarthritis and rheumatoid location. We talked about these two conditions in good detail. Now. Oh, you guys are really clear about them. But let's when I move on to some other disease. This about another recipe, if you guess. Okay. Stubborn ish. Okay. Okay. So a split are between b and C. Slightly more. One for C. Correct answer here is actually be okay. So, yeah. Tell me, what is the diagnosis? That What is he likely Diagnosis? Yeah, very good. Okay, so this is, like, this is presentation of acute gout, so Okay, most likely acute gets okay, So gout, so guts. Condition characterized by excessive you acid levels needing to joint pain. Okay, Usually got will affect the first metatarsophalangeal joints. Okay, The big toe. Okay, So this patient has swelling in the big toe can keep this. Factors are things like, Well, the renal failure. Okay. Kidney disease, high cholesterol levels, renal stones. Okay, so So can you guys tell me what do so classically with gout you get your assets were no stones. So what do you like acid? Renal stones? Looked like on an X ray. From what are you going to see on a next film for your gas and renal stones? Negative. None. And I need it. But I'm talking about the renal stones. Not there by a friend in nothing. Very good. It's a It's a trick question. Okay. You're not going to see your gas and renal stones on a on an extra problem, Okay? Because they're radio loosens. Okay, so if they have uric acid renal stones, you should do the CT KB without contrast. Okay, that's an important thing to remember. You're casting renal stones you don't see on X ray pump. Okay. Uh, so the other thing. So this is patient. This is an acute picture. Okay, this patient is presented acutely with a hot, swollen joints. Okay, painful joints. So the key thing with anyone presented with acutely hot, swollen joint is that you actually worried about septic arthritis? Okay, you were that you were worried. Really worried. If they have an infection in the joints. That's why that's the most important reason to do an aspiration. Okay. For the acute, the hot, swollen joint cause you want to rule out an infection. Rule out septic arthritis because that could be very dangerous. Okay, that has a lot of complications, obviously. Septic off practice. Okay, um, so that's the main reason to do it. Uh, can you tell me what's the problem with Why don't you check your acid levels for patients with acute gout? What's the problem with checking uric acid levels? What's the reason why? Why? Why is that no use to check your gas and levels in acute gout? Yes. Most a lot of patients that uric acid levels don't actually go up in the acute presentation of guts. Okay, so a lot of the uric acid actually just precipitates in the joints, okay, after actually cause the pain. So that actually acutely uric acid levels might not actually be rates. Okay, so that's actually not You don't actually get much diagnostic value and checking uric acid levels acute. Okay, You can check the check it later. Later on. Okay. Once they've been treated acutely, but in the acute phase, your acid levels don't have much diagnostic value. Okay. That's what is most important to check you and joint aspiration. Okay, Now, on the internet. So, yes. So, in terms of learning process, septic, arthritis must be ruled out in any acutely hot, swollen joints. Okay, but the joint aspiration will actually diagnose the gout as well. So until the next session, this is basically asking about what? What are you going to see in the joint aspiration for gout? Little again. So this is this is a testing If you're really clear on what's actually seen and got in guts. Okay. On the aspiration around, you only just post the feedback, like, quickly for people. Yeah, I'm just okay. You must have got it. Very good. Good to see most of you getting their questions. Right. So I hope you guys a letter letting and revising. Well, uh, yeah, mostly. You got this answer. It seems so negatively by refrigerant needle shape crystals. Okay, so gout is one of those crystal disease is Okay, So we talked about inflammatory arthritis or gout is it causes an inflammatory arthritis, but specifically, it's a type of crystal deposition disease. Okay. And so on aspiration. You see crystals and the classic description of the crystals. Is that that negatively by a friend in needle shipped? Okay, that's it is sort of buzz word to remember about gout's. Okay, so that's what gout is characterized by so quickly on gout's. Okay, so not going to go spend too much some of this but gout key things is that it's caused by excess your acid levels. Okay, so there's many cause of excess uric acid levels. For example, renal failure. For example, if they have human allergic malignancies causing access, turnover and certain foods can increase your casting levels as well. It's rare in premenopausal woman because estrogen can increase excretion of your acid level of uric acid. So it's actually quite red. Premenopausal woman. Okay, and there's various different triggers for gout. Okay, precipitating factors for gout. Okay, particularly diarrhetics like furosemide and thighs. I directors there very common triggers forgets. Okay, so very important to recognize. And if particulate hospital stepping kinds of peaches so usually gout will affect the big toe, the first metatarsal well, and your joint against the most common joint that's affected okay, on down. Even though it causes more of acute gout, you can get your patients can go on to have chronic gout. Okay. Where they chronically have high uric acid levels and you get features Are two fights a guarantee to fight, so skin manifestations. Okay, if they have to fight, that's all. Ski. If you see a patient has got a total, if I that means that they probably had gout for a good 10 years or so. Okay, so if I don't just appear suddenly, okay? It's a sign that they've had gout for a reasonable couple of years. Okay, we talked about stones or uric acid stones that radio Lucent okay, on an X ray film. So CTK you be without contrast is is the gold standard. Okay, um, in terms of diagnosis. And remember uric acid's they're not They're not checked acutely. Okay, you check it a couple of weeks after the attack. Okay? That's when you can properly assess if they have high levels of blood uric acid, joint aspiration to keep things. You're doing the aspiration. Rule out septic rule out accepting joints. Okay. White cells would typically be elevated, and the key buzz word is leadership crystals, which are negatively fire friends. Geant under painful eyes like playing for lice lights. Okay. Now, on the other hand, we also have okay. So quickly Talk about management. I've got a swell. So initially pain relief. Very important. Okay. And said's first line. Okay, too acutely. Control that pain. Okay, if they're not, you can also use colchicine as well. If they have renal insufficiency and says a contraindicated, you can try coaches in. Uh, what's the main side effect of colchicine? What's the common side effect of colchicine therapy? Yes, but down in the shot. Diarrhea. Very good. Okay, So, uh, coach seeing classically will lead to cause diarrhea. Uh, crime cut. So in terms, So that's the acute management. Okay. Now, chronically, if you want. You wanna If you want to lower your cast levels, there's certain drugs that you news okay. To reduce your gastric levels prophylactically to prevent stones in the future. So there's various different drugs. Other punal is the most commonly used one because it's it's cheap, and it's pretty effective. Okay. Ah, in terms of the actual indications to start things like allopurinol, there's certain criteria that the patient needs to meet. Okay, The big one is that if they had more than if they had two or more attacks in the past year. That's an indication to start things like our Purell to lower uric acid levels on key thing with allopurinol you started about usually start it at least two weeks after the acute attack. Okay, Usually. Okay, um, bit. And that's because they might people say that it can worsen the initial flare up. Okay, so it's always generally considered best practices started a bit later on after the acute attack. Okay, but if I've been, if they've been established on allopurinol. So it takes already been started on allopurinol therapy, and if they get a flare up after that, then you shouldn't stop the ALLOPURINOL. Okay, In that situation, you can continue it, okay? And there's various other agents that you can use to lower your a casted level, so as well. Okay. Ah, good. So those are the other crystal disease, So pseudo gout is the other type off crystal disease. You really need to know. So So what Gout's got? You're getting monosodium uric crystals, whereas with pseudo gout, you get different crystals. You get, um, calcium pyruvate forced state crystals. Basically. Okay. So gout is monosodium. Your It's pseudo gout is calcium powerful states. Okay, you don't need to know too much about this. It's not. It's very poorly understood disease, but key thing is that a generally affects the big, bigger joints. Okay, Like the knees. Okay, so where has gout typically, at best? A toe. Okay. On. In terms of the in terms of the diagnosis, the key buzz word to remember with pseudo gout is positively buyer for engines running board shaped crystals. Okay, that's a really buzz word statement to remember about pseudogout. Okay, And chondrocalcinosis is an important extra finding with pseudo gout. It's a swell. Okay. Yeah. You know, I'm gonna emphasize those words again. Okay, so this is Ah, this Ah, picture off sooner. Guts. Okay, so this is ah rhomboid shape crystals. So these are wrong. Boys shape crystals and again pseudogout on aspiration. They could. The crystals looked like rhomboids, and they're positively by refrigerant under pain pill. Right. It's light. Okay. Whereas with, uh, normal got a case of gout, you get needle shape. Christmas dose. Okay, so you see little needles here and they are negatively by a friend. It okay, So gallant causes strongly, negatively by a French and crystals, whereas pseudo gout causes weakly positive crystals okay. Weekly positively by a friend like crystals. Okay, Uh, someone, that's what This by refreshment mean s o ah, you know, by the effort by a friend is referring Teo. It's to do with some complicated physics. Essentially, the China came polarized lights, which only allows, like to flow in one direction. And they're sassing which direction the needles are. Ah, aligned in with respect to that pain. Polarized lights. Okay, It's very complicated physics. Uh, honestly, just remember, what the Well, just remember the words. Okay? Just remember, if that positively negatively by a friend and you don't need to know too much about how fire if engines actually works. Okay, good. Okay, Now, this is a little summary table on interpreting joint aspirin. Its and I'll assist. Okay. Not going to go through all of it. So I guess it just the table some rising out to interpret it. Okay. He things to remember is that if they have an inflammatory arthritis, okay, if they actually fluid in the inflammatory in the joint is because of inflammatory arthritis. Um then the white cells will typically be above 2000. Okay, So 2000 is the is the really important number to remember with inflammatory arthritis. So if it's more than 2000 means that they like to have information, if it's more than sort of 50,000 on the white cell count, it probably means that they have a septic joints. Okay. Might means that they would like to have an infection in the joints. Okay, so that's a key thing to remember. And remember, with guts and pseudogout, you can get crystals. Okay, Good. There's a little summary table on a lot of the conditions we just talked about now. Okay, So just one of the selling points. I have a read when you get the slights. I'm not gonna move on to some other diseases. So we talked about all of the common joint pain presentations we're gonna We're gonna move on to some other stuff. So have ago. Yeah. Yeah, I think I've definitely made Yes. Yes, To eat if you guys today. Okay. You guys are still finding feel any points useful. Okay, let's call it that. I think 90% of you got the right answer here. So most of you 90% of you went for B. And that is the correct answer. It's a seronegative spondyloarthritis. Okay, so we're gonna be to see her next spondylarthritis of what we're going to be talking about. Okay, so they're referring to a group off conditions that, uh, basically affecting the spine. Okay, so, spondyloarthritis, they will generally a factor. Spine typically. Okay. And seronegative zero means antibodies and negative. So there's gonna be negative for most of the antibodies. Okay. Particularly rheumatoid factor. These are conditions that typically will affect this mine and then negative for most of the antibody rolls specific antigen or two antibodies, particularly rheumatoid factor. Okay? And I told you all the antibodies are negative. Classically, they affect these sacred electrolytes, Okay? And they tend to cause more of an inflammatory arthritis. Like we talked about the inflammatory arthritis usually will. It will cause morning stiffness. Okay, so it's worse in the morning. Okay, as that's typical for all inflammatory arthritis, okay. And again usually affects this. It will typically affect the spine. So if you can get back pain because of that as well. Okay, So we're gonna talk about Syria next spondyloarthritis can. The key thing to realize is that they're referring to a bunch of different conditions conditions, but they all have a lot of overlap. Okay, there's a lot of common features between ALS these different causes off a seronegative spondyloarthritis. So again, seronegative spondyloarthropathies are from of these are referring to conditions that cause arthritis in the spine and are negative for rheumatoid factor. Okay, to remember, Rheumatoid factor is a very non specific antibody. Okay, so it's positive and unloads a different condition. So So because it's positive and so many conditions, that's why it's very is. That's why it's very significant when rheumatoid factor is negative. Okay, because if it's negative room room, So in fact that that's actually have names, it's quite significant. Okay, so these conditions are negative for rheumatoid factor, and that typically it back in the spine. Okay. And they generally referring to four different conditions. Okay, so and spond I'm closing Spondylitis. Psoriatic arthritis, reactive arthritis. Onda IBD associate it off writers. Okay, these are the four conditions which will cause a seronegative spondyloarthritis. Okay, So can you tell me what are the common features between all of these conditions in terms of sleep in terms of the umbrella term off seronegative spondyloarthritis one of the common features between them. What if there's a what if you can. You guys just less common things that you see in all of them. Uh huh. Yeah, actually, be 27. Good case of most. Most patients with these conditions will be HLA b 27 positive good and decides is good. So and decide to so information off tendon insertion points. That's, ah, common features. Well, school writers are good eye symptoms. Very, very common with all of these. Okay. And get it can happen in all of these conditions. Okay, You could be like this. Good. Yeah. There's a real good good, good points. Asymmetrical, powerful arthritis. Good. So all these conditions, even though they typically affect the spine. Okay, typically, some of these don't typically affect the spine. Commonly, it some of them tend to cause more of a peripheral arthritis. Okay, but these are all important points, Doctor, like this is well, very good. So this place is some part of months. Okay, so all of these can involve the spine. Okay? And when they involve the spine, typically the effect. Secret I Leptin's case of sacroiliitis is a common thing. All of it's okay, but more commonly, you get it with ankylosing spondylitis. Okay, Is run the hallmarks of an expand. Okay, But you can get on all of them and decide is can happen in all of them. So particularly, the Achilles tendon is commonly affected. Okay, so you get information of acting the Achilles tendon and that can potentially rupture. Okay, Doctor, like this information often Entire finger. Okay, so you get sort of the so called sausage digits because it it causes inflammation of the entire finger HLA b 27 So but all these patients will be positive. HLA b 27. Okay. So even though they're negative for most of the antibodies that can be positive, they usually positive HLA b 27. They all can cause a peripheral arthritis, which is typically a legal articular. Okay, on asymmetrical. Okay, well, I say symmetrical things like angst Bond 10 can cause sometimes a symmetrical is good, but the key thing is that they're legal articular, okay. And steroids are often not effective for these conditions. Okay? Usually it's things like NSAID, um, and sides are usually the mainstay of initial pain relief for the I'm off right This. Okay, good. Okay, so we're not gonna talk about all of them. Okay, But we'll talk about ankylosing spondylitis and beat, because that's that's the most important one to remember for exams. And Oskar's in general. Okay, so I'm closing spondylitis. So it's a condition that's mainly primarily affecting your spine. Okay, It's a prime primary format feature of expand is stiffness. Okay, you get stiffness in the back. Okay. Commonly affects these sacred electorates. Okay, That's the hallmark features of angst. Bone is sacroiliitis. And the typical story is that it's a young, young male smoker who gets but lower back pain. Okay, that's the classic story for ankylosing spondylitis. It's okay. So I told you stiffness is the predominant feet again. It's typically worse with rest. Better than exercise. Often because of the sick. It's just a pink and radiate to the buttocks is well, morning stiffness is inflammatory. Okay? And like all the other conditions you can get and decides us doctor like this and peripheral arthritis as well. Okay, uh, you can also get extra articular manifestations. You get cardiac involvement. See and get a V block the allergic regurgitation. Okay, um uveitis. Okay, so uveitis So information off the usually anterior uveitis we can get things like red. Painful. I photophobia okay. Uh, pulmonary fibrosis. Okay, so get fibrosis off the lungs. Can you tell me what he which parts of the lung usually are affected with come in with expanding terms of bony fibrosis? Very good. Apical apical and areas of the lung. So case it's usually the top parts of the things they usually affected. And I'm closing spondylitis. Ah, which which other condition can cause a pickle? Fibrosis? What other condition? Thinking other says other specialty is what? What else can cause a pickle? Fibrosis. TB. Very good. Tipper Closest also causes a pickle. Fibrosis. Okay. Drugs, pneumoconiosis, coalminers Pneumocolon. Yes. This is well okay. TV is a very important cause off apical fibrosis. Okay, because, uh, TB, basically TV loves the air. Okay, so it's ah, Arabic bacteria. It tends to go. Oh, and top parts of the lungs have a lot of Bentyl A Shinzo TV usually affects the top up like this. Commonly Okay. HLA b 27 is not diagnostic. Okay. Even though most patients will be positive, even healthy people. About one in nine. Also, people will actually have be he. Actually, I'm not sure about the percentage, but a certain percentage of the population of the healthy people will be hit with a B 27 positive. Okay, so it's healthy people, and a lot of healthy people will get back pain anyway. So actually, be 27 is not diagnostic okay, even though most patients will have, it's no diagnostic X ray. Findings are important. Okay? Classically, people talk about the bamboo spine with ank spond. But the key thing to remember is that bamboo spine is a very late finding and and closing spondylitis. The kids. If patients have gone to get a bamboo spine, that means that they've had ankylosing spondylitis for a long, long time, untreated generally on D. So it's actually a late stage of disease of ankylosing spondylitis. MRI's generally the most accurate. Okay, it can actually detect a lot of the changes, um, very quickly and very ah, years before the actual actually would be able to do detective okay treatment. So it's generally exercise very important in ankylosing spondylitis on and said as well if they're going to get a prophylactic itis. So the last one you can get peripheral arthritis as well. Like all of the other ones, you can try the months to manage the peripheral arthritis. Okay, good. So I was I'm closing spondylitis. So I have another asked me if you guys were moving on to some other diseases. Yeah, I think I would probably end up going fishing around 6. 45 or so out. What? We have another preclinical session coming up after it after me. So hopefully finishing good time for that. So if you guys want to tune into that as well Uh, yeah, most of you getting this one as well? Yes. I don't said so. Actually, be 27 is approximately found in 8%. People see it. It's actually be 27. A lot of a lot of hatred. Ah, lot of healthy people will be hit you a B 27 positive. Okay. And a lot of people will just get some. We'll get back pain at some point in their lives. Okay, so HLA b 27 is never diagnostic. Okay. Okay, so I call it that very good osteoporosis again. most You've got this. So this is a patient who has clearly has a hip fracture. Okay, so do you guys, This is going into a bit of orthopedics, Okay, but and I we have a little bit exception coming up soon as well, but this is ah, classic description for a hip fracture. Occasion is a patient who has, um, as clearly has a hip fracture. Okay, you can see the destruction sentence line. So this is the hip hip fracture on DA. Classic description for hip fracture is, um, shortened externally rotated like Okay. On one of the key risk factors. Four patients going to get hip fractures. Is Austria process okay? Affecting the affecting the boats. Okay. In fact, in the joints so and smoking is also a risk factor for osteoporosis. So this is why this is why correct? Answer is osteoporosis has osteoporosis is a key respect. Their four fractures in general. Okay, Plus And the thing is, remember that blood test of generally normal with osteo process as well. Okay, so keep keep any point. Osteoporosis is a key respective for hip fractures and fractures in general. Okay? And blood tests are typically normal with osteoporosis. Okay, compared to some of the other bone disorders. Okay, so this is some recite on osteo process. Okay? I'm not gonna go. Ah, you were running a bit beyond on time. But in terms of keep things off your post, is it just referring to softening of the bones? Basically. Okay, dude, reduction in bone density. And because that reduction in bone density you have high risk of fractures. Uh, treatment of osteo process mainstays to give this phosphinates. Okay. First line generally is alendronic. Okay, so I don't like I said So we talked about this and gastroenterology a couple of weeks ago. But the really important thing to remember about alendronate is that it can cause you suffered rectus. Okay, that's a really important thing to remember about on alendronic acid. So can you guys tell me one of the different things you advice patients who are taking alendronic acid? If you're prescribing alendronic acid to them, what are the different things you're going to advise Them sits upright for 30 minutes after taking it. Very good. Okay. Glass of water. First thing in the morning. Generally fast before you sleep. Okay? Empty stomach. Yet all the important things to tell a patient before prescribing alendronate to them. Okay, Because this arthritis is very important. Very common thing that happens. Okay? And yes, that's osteo process. And like I said, with osteoporosis, blood tests are typically normal. Okay. Whereas with a lot of the other conditions, like a lot of these other conditions that affect the bones, you have different bone profiles. Okay, So have a read of this table. This is basically summarizing a lot of the different bone profile Ramadi's I can get with in terms of disturbances, too. Calcium phosphate, a low p parathyroid hormone is stable. Basically summarizes a lot of the investigations for all these disorders. Okay, so every try make sense of it. I'm going to the next question. Yeah, can call it that. I think you must have. You had to go. Good. So Okay. I think I've got I finally got an SPF of then you guys a bit of a bit of a split between C and E, and your cancer is actually be okay. It's a bone profile. Okay, so let's bring your son. So we have a patient who has a history of shoulder and hip pain. Okay. With stiffness. Okay. And this patient also has a history of unintentional weight loss. No history of any neurological symptoms, headaches or visual loss. And a bunch of blood tests have been performed, including erythrocyte sedimentation rate. So Okay. So clearly, with a lot of these answer options, I'm trying to get up the likely diagnosis state being polymyalgia rhuematica. Okay, because of the pain and stiffness back in the shoulder and hip go to's. Okay, that's a predominant feature of polymyalgia. Okay, on D, But can you tell me what is the cracker and to hear bone profile? What? What do you really checking for with the bone profile? What's the reason for checking the bone profile here? What? What would you try and rule out here? What else would you try and feel? That agility fracture. So, yeah, there's actually a good point. Rule out cancer. Cancer. Good. What do you trying? What particularly would you look at with the bone profile in terms of the cancer day? Myeloma again? My mom had high calcium. Very good either. Casting. Okay, that's a really important thing. You wanna be checking your, uh, checking in the bone broke. Okay. You want to be checking the calcium levels? Well, because of malignancy, things like myeloma. That's an important differential to be ruling out. Okay? Things like they're like you said. Lytic bone lesions. You want to be? You want to really check that calcium level initially? Okay. Even though they're still top, their friendship here would likely still be polymyalgia rhuematica. You still want to be ruling out? A lot of these common present a lot of these presentations like malignancy. Okay, So hypercalcemia should be initially screen for and ruled out, okay. And by just doing a simple bone profile, a blood test. Okay, now, we got an expert of the question again. Have to go. Similar question. Yeah, I think I've done you guys again with this one. Okay, cool it down by the second. Okay, let's go to that. Okay. This is the discussion. Got some important learning points. Okay, So most of you want for see? Okay, So all prednisolone and it very understandable. Why you Why you went through that? Why you went for that. But correct answer is actually he Okay, so check a random glucose levels checked. Round of glucose levels and dexa scan. Okay, so let's talk about this. So cases a important learning point in terms of, um, just general clinical practice and clinical medicine in general. So this is a patient who has similar presentation is the last. That's what Last one. Okay, history of shoulder hip pain, stiffness, much describing polymyalgia rhuematica. Okay, particularly because of the elevated center. It's okay. These are classic features of polymyalgia rhuematica on D because one of the big rest with polymyalgia rhuematica is sort of complications associated it with It is a giant cell arteritis. Okay, so information off the temporal arteries, which has a potential complication of causing visual loss. Okay, that's one of the big complications with it. But I told you that there's no visual loss here. If there was visual loss, then that would mean that you need to give intravenous methylprednisolone. Okay, but there's no visual lobster. Okay, so this is your simple calling Milder, rheumatic. A. Okay, most likely. Okay. And the mainstay of managing polymyalgia rhuematica is to give all prednisolone okay. And that's why most of you probably went for all of our nest. Um, but the key thing is I people problematic will be If you don't, they're going to start all prednisolone. You're going to be giving steroids for a long period of time. Okay? That's why it's important to check their glucose levels. Okay, check that. They're not already hypoglycemic. Okay, Check of it's okay to give stories. Long term. Also, dexa scan. Okay, because steroids have started to melt. Started going to melt bones. Okay, there's a risk of officer process. Long term with them. Just also important to check. Baseline, do a baseline dexa scan as well before describing steroids. Like prednisone. Long term. Okay, because Because this patient doesn't have Ah, this is order the emergency. Okay. There's no visual symptoms. There's no neurological impairment initially. So, um, this is not an emergency. You have time here, okay? There's no reason to rush to give steroids into this patient, okay? Because you have time. It's not an emergency. So it's okay to just do these basic things before you start steroids? Long term. Okay. The key learning point for this fashion is that this is not an emergency, okay? And so before starting learned long term steroids, you should check. Look, those levels checked their risk of osteoporosis. Okay, good. Okay, so the question basically toe toe ask you about polymyalgia rhuematica. Okay, so that's so quickly about P m a s a p m a, uh, key things remember is that it's a disease off all the females generally. Okay, middle age, all the females and the whole Markoff PMR polymyalgia is that he gets my algebra acting the proximal limbs. Okay, these shoulder pelvic girdle. Okay, typically symmetrically. Okay. And it's it's predominantly. It's, uh, stiffness. Okay, you don't get weakness or atrophy with it. Predominant feature is stiffness. Okay? So often they'll say, difficulty reaching up to comb my hair and things or difficulty picking up the place on the top of it covered and things like that. Okay, because it's just stiff. Can they? That's that's the key predominant feature with polymyalgia. Okay. And typically it's worse than mornings again. Often lost more than ronaiah. Okay, Just like a lot of these inflammatory presentations that's worse in the morning, okay? And the classic association with polymyalgia is the giant cell arthritis. Okay, we'll talk about you. See, that's a very strong association with polymyalgia. Okay. Uh, we have some diagnostic criteria here. So the key blood test finding and pulling imagine is elevated. Said rates. Okay, So elevated. PSA, I said if they have high ear, so that's very suggestive off polymyalgia. Okay, on treatment of polymyalgia is steroids. Okay? If they if they are not responsive to steroids, you should really question your diagnostic diagnosis. Okay, cause steroids are usually very patient, are usually very responsive to steroids. Okay, Usually it's a little prednisolone 15 mg. Okay. I mean, if you're going to stop, if you're gonna start steroids long term, you should also consider giving some bone protection with things like this phosphinates okay to protect against osteoporosis. So I told you that one of the key associations off problem algia is giant cell arteritis. Okay, So what is giants arthritis? It's a type of basket litis that predominantly effects the really big arteries, particularly the temporal artery. Okay. And the key thing with that temporal artery information is that's one of the branches is the ah, around the country and baguettes. If you have information that you obviously the big risk is visual loss. Okay, Visual impairment. Okay, that's that's a big worry. With joints, arthritis. It's vision loss. Okay, A common symptom. You get headache, scalp tenderness. Okay, so there, after they come the head of my complaint of pain draw claudications important feature of giant cell arthritis. And again, vision loss is the big thing you're worried about. Okay? Because it can be irreversible. Okay, so you get irreversible vision loss, because off the giants of arthritis. Okay, so that's why if they have any symptoms of vision loss, Okay, Visual impairment. Patients need intravenous steroids. Okay? They have signs of visual impairment you need to get You need to refer them to ophthalmology. Expect as you can again. They need to have high those corticosteroids on. They need some intravenous steroids as well. Okay, that's very important. Okay? Because the vision loss can be irreversible. Okay, that's giant cell arthritis. Okay, keep it related to polymyalgia. And, um, joints, arthritis in terms of diagnosis, Generally, it's a clinical diagnosis. Okay, If they have a history of polymyalgia and they're presenting with signs of visual loss, that's that's a clinical diagnosis of giant cell arteritis. Okay, but you can confirm it by doing a biopsy. Okay? And you can take a biopsy of the temporal arteries But often biopsies will be negative because you're getting drying limited information. Okay, as in the information happens in sort of skip lesion so often. Often you can miss you could be negative. Okay, So the key thing is that the body shouldn't delay steroids based on me. Biopsy. Okay, if they have. If you have a clinical suspicion on D. C A. Give the steroids. Okay, Good. Next batch. Okay. Now we're gonna be talking through some bit more, uh, hard core rheumatological stuff. Bit more tricky of stuff is still so And this is a bit of a long SK, but have ago. Yeah. Don't ask. You give PPI cover with steroids, so you can't. So yeah, steroids can also cause the peptic also, so yet if they're going to be on steroids long term, Yeah, it's often good practice to prescribe that PPI. But a swell good points is that tricky SBA I get I just give you a little bit of a hint be today. The questions are seeing which of the following is most diagnostic. Okay, I e Which of the following is the most is going to definitely confirm the diagnosis here. Okay, Okay. call it that. Okay, there's Ah, trick. It is a tricky SGA. Okay, so most of you And for be okay, 66% of the went for B. Correct answer is actually D. Okay, so this is probably going to confuse a lot of you. But the key thing in this SGA is that asking which of the following is most diagnostic? Okay, as in which of the following is definitely going to confirm the diagnosis here. Okay, So can you tell me what is the diagnosis based on the symptoms? What? What's the patient have? Sugar is very good. Okay, Some people say, Yeah, sugar in some people say shotguns. I'll just say sugar in. So Okay there. Um, I'm not too sure what the actual correct way to pronounce this, But this is a classic way. This is a classic description off sugar in syndrome. Okay, So in terms of wise, the shit Children signal is a condition characterized by dryness. Okay, everything is dry in sugar in syndrome. Okay, You're getting dry mouth, dry eyes, dry vagina. Okay. So that this is a patient who has basically a year problem with a dry vagina. Okay, so there's vaginal dryness, then that's what's causing the disparity. Purkinje a case of pain, painful intercourse. Okay, Pain during sex Onda. So I told you that this is unlikely to be a sort of gynie gynie cause of pain. Okay, Their menstrual periods are normal. No vaginal beating, no hot flashes, no menopausal type symptoms. So he unlikely to be a guy need presentation off this. Apparently, it's more likely to be sugar Children syndrome based on some of the other things. So sugar in center was associated with other altern, um, diseases such as primary biliary cholangitis. Okay, on, because it's the key thing is dryness in your sugars and only get they're not able to produce saliva properly, so they get really dry mouth. Okay. And I've told you, this patient has brought a two liter bottle of water. Okay, so I don't know how many of you see people just carrying around two liter bottles of water to the GP. Okay, that's not a common thing, okay? And it's important to just pick up on that sort of stuff when you start practicing again. They're carrying. Why? Why would they be carrying a two liter bottle of water. Okay, so and again, it's because of the dryness. Okay, dry mouth, Okay. And sugars. And you can also cause arthritis. It can cause an inflammatory arthritis. And I've probably said this Ah, lot of times today I get too many times. Do you guys probably getting annoyed, But but And find your arthritis is worth worse in the morning. Okay? Please don't forget that. Okay, So this fish, this scenario off Children syndrome terms of the investigation says so. Three typical antibodies, positive and sugar syndrome is anti road antilock. And your body's okay. Those are the typical antibodies, which will be positive. Okay, but they're not the most diagnostic, Okay? Because they can be positive in other conditions as well. Uh, can you tell me, what else can these antibodies be? Positive And what else can anteroom until I be positive in Lupus? Very good. Okay, so these antibodies can be positive in Lupus is well, okay, actually, Sure, Miss Tests is a one is one of the first line investigations in Children syndrome. Okay, so you measuring the tear production, okay? And because sugars is characterized by dryness, you have lack of tear production. Okay, luck off like remission. So she must test Will show that. Okay, they have lack of lack remission. Okay, but the the most diagnostic and the most accurate test to really confirm the diagnosis is to do a biopsy. Okay, on you take by. Why do you take a biopsy from the lip? What's the reason for doing a left biopsy? Why wouldn't you just do a biopsy off the big, big one of the big saliva? Guns like the prodigal. And what's the point of doing a little biopsy glands will bleed. Know said there's another reason why don't you? Why wouldn't you do a parotid gland biopsy? Why wouldn't you do a submarine people? A gland biopsy? Why wouldn't you do as sublingual gone back to see? Why do you do a biopsy of the left? Maybe a gland backpack See face? I live? No. It's the reason is that the actual problem insurance syndrome is that it affects the minus little saliva glands. Okay. It doesn't affect the big saliva glands like the like, the prostate gland, like the subway. Go go on like the sub Monday blood gland. It's affecting the minus live saliva glands. Okay, They're really, really tiny ones that actually produce the slider. Those are the ones that are getting affected and shuts. It showed in syndrome. Okay. For example, the really small ones that you get in the lips. Okay. That's why you didn't take the biopsy from the lip. Okay? Rather than porotic gland biopsy. Okay, so that's where you do a little biopsy. And generally, biopsy is, in general, where you're looking at the histology bad going to be the most diagnostic. Okay, that's what the correct answer is. Let's see. Okay, It's a difficult question, okay? But it's really important living points with regards to shake on syndrome. Okay, good. So So I regard biopsy is the most accurate here. Okay, so it's not saliva gland. Technically, it's a little biopsy by your checking in the saliva glands in the lips. Okay. And it's not commonly performed. Okay, cause usually you can confirm the diagnosis clinically, but with anti road until antibodies and by doing a sure miss testicle. But let biopsy is the most accurate test to confirm diagnosis. Is it okay if you're really unsure about other diagnosis, then you can do it. Okay, Good. Okay. So should consider. I'm not gonna go through all of this. Okay? But again, sugar and syndrome, it's affecting it characterized by dryness. Okay, so it's ah, fax. The lateral dancy can't produce tears properly. Effects T minus saliva glance. Okay, so the really small saliva glands, for example, in the lips. Okay, It's associated with other autoimmune diseases and also has a risk off non Hodgkin's lymphoma. Okay. Specifically, it can cause ah associated with a B cell, lymphoma, diffuse B cell lymphoma, clinical features. You can get dry eyes. Okay, Dry mouth. Okay, So you've taken the often complain of difficulty speaking difficulty tasting food on because because life is really important to have clear a lot of the bacteria and the teeth and things people that there's a higher rates off dental infections in general. Okay, dental cavities and carries and things on done the poor dental hygiene. Because of that dryness the case, that's an important thing with sugar in syndrome. Okay, it's important to me optimize that dental health personal dryness can lead to dyspareunia and authorial. Gee, as well is very important. Okay, Alternative body. So anti romance, a lot of really important ones, and sugar on syndrome. Okay, there really classically elevated a again, A very non specific antibody. Okay, but most patients with sugars will be positive in a in A, but anti were on anti lot of the most specific ones for sugar in it. And first line, really, investigation for sugars is the Sherman's test. Okay, so measure the tear production, Okay, but a biopsy can be done to really confirm the diagnosis. Okay? And there's very streaming options available, but you can have a read about next question. Okay, so we're gonna be talking about Lupus now, so I have a have a go. Okay, So someone said in that case, what are the big guns? Compensate for the lack of saliva. Yes, that's exactly right. So that's why one of the one of the other clinical features of sugar in syndrome is parotid gland enlargement. Okay, you can get bilateral project landing large one because they minus lively glands are not producing saliva because that's why you get prostate gland enlargement because they're trying to compensate for it. Good. Yeah. Okay. Rule for it. There is a pretty yeah, most of your. Okay, So we have this little thing b Indeed, the character answer here is be okay. I examination. Okay. This is really important. Okay, Very important to know. Clinical practice for patients on hydroxychloriquine therapy. So wise, I examination important for patients on hydroxychloriquine. What is one of the adverse effects of hydroxychloriquine? Yeah, maculopathy retinopathy. After as that's a big A big adverse effect off hydroxy chloroquine. Okay. And the key thing is that the retinopathy with hydroxychloriquine is that it could be irreversible. Okay, you can get irreversible. Britain opathy with hydroxycloroquine therapy. So that's why it's very important to I regularly monitor their regularly check their eyes, okay, regularly examine them. And because if they have any signs off visual impairment, it's important you have. You have to stop the drug, okay? Because the actual visual loss can be irreversible. Okay, so that's why I examine it is a very important hydroxychloriquine therapy type two appointments. One of the mainstays are one of the currently available therapies to manage Lupus, but and again, restaurant is one of the adverse affects. Okay, so we'll talk about Lupus now. So can you guys tell me who is Who is this character? You guys know? I'm sure most I'm sure. I'm sure. A decent percent. But I'm sure most of you will know this guy House. Very good, Doctor. House Doctor Gregory House sick. And I'm sure most of you ever watched. House will know the famous saying it's never Lupus. Okay, because I think the Lupus is that it goes pretty much anything. Okay? It's one of those diseases that scares a lot of people because it can Actually, it's a really weird disease, And I can cause it can affect so many different organs and be very, very non specific. Okay, It's ah, very dangerous disease. Okay, Because it can affect so many different organs. Okay, so it's, ah, difficult condition to comprehend. But if you understand Lupus, it's one of those conditions. It's means that you've really understood amount of medicine. Okay, Lupus is one of those conditions that's really important to know about. So I'm just gonna try and cover some of the key aspects about Lupus. Okay, So Lupus is a multi system disease like we talked about. Okay? It is a part of physiology. It's we have you lose tolerance to your body's own antigens. Okay, So you got It's a systemic chronic autoimmune disease affecting multiple different organs. Okay, now it comes up there. Coke, A features, You hear everything okay? Taking pretty much cause it can cause so many different things. Okay. Arthritis is the most common symptom. Okay? Typically, it's a symmetrical arthritis, but it's ah, it's part of the diagnostic criteria. Real disease. So I'm still most of you went to the nephrology talk Will really will know that Lupus is very strongly associated with closing. That frightens. Okay, that's a really big thing to be aware of with Lupus. Because frightened, which is a big cause off mobility in patients with Lupus on it can affect a lot of different things. Okay, get hematology soldiers or allele says on neurological disorders, you get Lupus affecting the brain and get seizures and psychosis and things really important. Classic dermatologic. A finding and Lupus is the Malar rash. Okay, so, uh, this is a classic picture. So you mail a butterfly distribution rash? Okay, Which which spazzed a nasal labial foes. Okay, so you see the sparing of the nasal labial folks here, And that's because, and typically, the theater actual rash is caused by sunlight exposing and and then easily before you have a shadow there. So the someone doesn't typically strike the nasal labial folks. Yes, that's why I often the don't get the middle rest there on. Also, can you just tell me so famously? People say that people with Lupus, the British population, get get a rash on the right side of the face. Whereas the American population who have Lupus typically gets the rush on the left side of the face. Can anyone explain that? Why do British people typically get a mail? A rush on the right side of the face for us. Get a rush on the right side of the face for us. American people tend to get a moment left side of the face. Okay. Very good to driving. Okay, you guys, so a bit of general knowledge special. But I really feel driving the right so commonly, they'll, uh, get the rash on the right side. Because sunlight okay, windows are not very good at protecting you from a lot of the UV race against, and yet, uh, wrapped in the right side and Americans will get on the left side of the face. Okay, good. So there's the antibodies. Okay, these two, This is important. Okay, so a in A most patients with Lupus will have a positive ana. Okay, That's a really important thing. Is to check in Lupus or a onda. It's really sensitive. So if they don't have it, if they have negative A it means it's highly unlikely that they have Lupus. Okay, that's very important. Okay, negative. And a pretty much rules out the diagnosis of Lupus. Okay. Complement levels are checking C three C four. So complement levels are really good from monitoring disease. And usually during active disease, you get low complement levels. Okay. Antidouble stranded DNA and anti Smith antibodies are the most specific antibodies for Lupus. Okay. And so they posted. But both that. That's probably diagnostic criteria. Importantly, anti antidouble stranded DNA correlates, particularly with Lupus nephritis. Okay, if they have high antidouble stranded DNA and low complement levels that you should really check if they have Lupus and a fright, it's okay. Should do a year and houses to do a urine dipstick and check if they have Lupus nephritis. Um, treatment. So you don't need to know too much about treatment options for Lupus. Okay, It's a bit beyond the scope of knowledge of undergraduates. Okay, general advice at voice. Avoid sun exposure. Okay. Make sure patients have a good sunscreen on all those all the time. Okay. Prednisolone and hydroxycloroquine are used for flare ups. Okay. And the lows? Different complications like a Lupus can. Lupus is a dangerous disease. Okay? It kills a lot of young people, so it's very important for patients to be educated to regularly take that medications regularly be really compliant with avoiding sun exposure. Okay, cause Lupus kills young people. Okay, so it's a very important disease. Okay. So as a quick run through of Lupus Ah, about another question for you guys. Quickly. Okay. You slightly going to be going a bit quicker now just to make sure that there's a we're finished on time for the creature and easy session, uh, we might have to skip through some of the last questions. This is this a question? Really? Testing your knowledge of antibodies? Okay, the in antibodies in rheumatology, so I'll call it there. Okay. So you had a big slipped. Okay, so this is a question. Just testing your knowledge of antibodies. Okay. So correct as his anti histamine antibodies. Okay, second guys, tell me, what is the diagnosis here? What is the diagnosis was basically presentation. Drug induced Lupus. Okay, so we're still on the topic of Lupus here. Okay, but this is specifically referring to drugs. Drug induced Lupus. Okay, so a specific drug causing peaches of Lupus. Okay, so, hey, a common drug that can cause Lupus is hydralazine case or drug use for And cardiac disease. Cardiac disease is onda common features of drug induced Lupus or things like fever, malaise, arthralgias. Okay. And the key thing with drug induced Lupus, which is different from normal Lupus, is that drug induced Lupus doesn't typically affect the kidneys. Okay, so the patient's creatinine is normal, and it doesn't typically affect the brain. Okay, so the neurological examination is normal as well. Okay. And the key thing to remember with drug induced Lupus is not be common. Antibody. The really specific antibody for drug induced Lupus is anti histone. Antibody is okay. That's the really specific antibody for drug induced Lupus. Okay, um, the other ones can be so anti the other side of the NS. Just normal. Lupus. Okay. On DSM, the other one. And the Smith again. It's normal. Lupus antigens. Once we will talk about it for inflammatory myositis. And do you want are MP? That's for Lupus. Normal Lupus as well as mixed connective tissue disease. Okay, so most acidic antibody, both drug induced Lupus is anti histamine antibodies. Okay. So quickly. Drug induced Lupus. It's caused by it's not cool specifically by anti essential. Changed our kids to start. The antiyeast own antibodies are most specific. Okay, It's no, actually caused by It's caused by the drug, obviously, um, and it typically doesn't affect the brain or kidneys. Okay. I like nice. A nice little on your monitor to remember The different drugs that can cause Lupus are is chimp. Okay, so see, for carbamazepine hate, for I dramas mean I for ison eyes it. Okay. And vixen mob And from minocycline I minoxidil. Oh, and pee for penicillin. Mean and procainamide. Okay, so these are all common drugs. Okay, If you want to remember three, I'd say. Remember, hydralazine remember isoniazid on. Remember, procainamide a case of remember procainamide is a type of, um, it's a type of anti arrhythmic. Okay, It's a type off of on Williams fine with it. Volumes cast one anti arrhythmic. Okay. Procainamide. So there's those other three drugs that strongly associated with causing Lupus. Okay, good. Okay. I'm probably going to rush through some of the other the remaining sessions now, but, uh, try and get through much of as become about. If I probably just rusted the teaching size, I'll just let you guys answer the SBA. So you you have the opportunity there, and CS Bs and one spend too much on the teaching size just to make sure you finish all the time. Okay, Uncle of that. A bit of a split between C and E c and D, most of you and for D, and that is the correct answer. So ct angiography eso quickly Tell me what? Is he likely diagnosis here? Yeah, Ducky ask you after, right? It's I guess. Probably. What? I'm trying to get out with this one, Okay. Stocking type of large vessel vasculitis. So this is a patient like I'm sorry. No, I haven't told you the nation woman, but come in an Asian woman. It's a type of large vessel vasculitis typically affecting the sort of aorta again affecting branches of the aorta. Okay. And classically, patients present with, um because you get you can get information off the aortic or you're able to vessels get up early and claudications pain. Okay, So pain worse with movement, Okay. And you get post is that are not palpable again. You can also get bruit is over the subclavian artery. Okay, because you're getting information off those big blood vessels, okay? And gold standard to investigate this type of arthritis. There's a CT angiography. Okay, that's the gold standard to investigate the disc type of us collectors. Okay, Biopsies of biopsy. You're not going to biopsy if the you're not gonna remove a big brunch off the aorta. Okay, too. And check down microscopic. It's just too dangerous. Okay, sir, best investigation is to do a CT angiography. Okay, Okay. So don't talk about basketball is quickly. So basket like this. It is just conceptually think it's just information of blood vessels, Okay? And there's lots of different causes or vasculitis, but there's a lot of there's. There's a lot of common features with a lot, all these vasculitis, all these different basket little these okay? They can all cause fatigue, malaise, weight loss, They can all cause a prepare excalations. Okay, All can cause joint pain. And they can all cause a modern you right. Cyst multiplex. Okay, so mononeuritis multiplies that it's a confusing word, but it basically means that they can if they can get they can get lesions off lives, but in different locations. Okay, so they might get a medium live palsy at the same time. I was having a common problem. Nerve palsy, for example. Okay, that's what I mononeuritis multiplexes. And generally if to manage basket like says, it's steroids and immunosuppressants, I get pretty much the mainstay of managing all the different types of vasculitis. Okay. And in terms of, uh, slightest, we divide them as because is a lot less of a slight Is medium Best of our scratches or a small glass of us like this. Okay, little summary. Silent, tacky osteoarthritis. Okay, have a read when you get the slides. Ah, but I'll that you guys have a good This s t a very short SBA. Yeah. Okay. I'll call it the, uh, sorry. I didn't give you much time for that one with this one time. So most everyone for a tractor out, his actually be okay, So polio present dose. It's a type of medium. Best of gastritis. Okay, so your inflammation off medium sized blood vessels. Okay, The key thing with poly arthritis know dose says I can affect it, can get it's very non specific. Okay, Because you get symptoms based on whichever blood vessels are being affected. Okay. For example, if you get if it affects the music therapy, but vessels, you'll get knees and Tereshinski me, which can lead to palpatation. It can affect their blood vessel growth kidneys between the two. Uh, real real failure. Okay, The key thing that polyarthritis nodosa is that it will typically spare the lungs. Okay. You typically don't get information of blood vessels in the lungs. Okay, so that's why the crackdown, his pulmonary hemorrhage. Okay, cause you don't It's not polyarthritis know. Said typically won't affect the lungs. Okay, So, pa and typically spares the lungs. Okay, that's a key point. But PM there's some decide on polyarthritis nodosa. Okay, so I haven't read when you get the slides. Onda in terms of the other vascular today. So there's a group of ankle associative vasculitis. Okay, So vasculitis affecting really small, that vessel. So again until for the sake of time, I'll just let you guys have read of it, okay? That these are all these sort of ankle associative bus Lexus on da. Just. I was gonna test you guys on the all of these different antibodies, but this is a little slide. Summarizing all the different antibody associations you need to know from finals. Okay, we've talked through a lot of them, but it's a little summary side you guys, which is hopefully going to be useful for your revision. Okay. Little visual aid to remember, rheumatoid factor and a and A that really non specific. Okay, so that's why I love them. A lot of conditions will have positive antibodies for these ones, but certain antibodies are very specific. So that's why they're only specific to certain conditions. Okay, So have a read. Have trying to remember this diagram. Okay, hopefully will be useful for a revision. Okay, We got two more SPS and then we're done. Try and finish this quick as I can. Yeah. J o call it there. Think, think most of you on tips. The the alkaline that so most of you went for the Fed A pee again, but we went for C pregnancy is actually a case. A captive pro. Okay. So quickly. Can you tell me what is the diagnosis? That What is this patient presenting with? Yeah, this patient has very low. It's okay. But, uh, most of the key thing that the patient presented what's the emergency thing that you need to manage immediately. Right now? Yes. Labrador Marino crisis. Okay, this is Ah. So let's break this down to this. A patient who has systemic sclerosis. Okay, um, systemic sclerosis and features off the so called crescent drum. Okay, so this patient has speech is off. Rain or phenomena. Okay, So skin make changes in the digits History of gold. That's percent. Like he said to do with the fibrosis, the esophageal disease that you get with crest syndrome with systemic sclerosis. Okay, on the key, one of the key emergencies that patient with systemic true assisting get is a renal crisis. Okay, so they can get, um, a sudden hypertensive crisis because of the renal crisis. So they have massive hypertension with a massive acute kidney injury at the same time, nose up on this is This is very dangerous. Okay, they can. This is a really high court. This has a high mortality rates. Okay. On the chemo agent step to manage the real crisis into stomach sclerosis is to give an eastern emitter. Okay, so and remember, a senator is generally the end in ill. Okay, Well, uh, pro. So the the only one that ends in April is captopril. And that's a type of a Cymbalta. Okay, so the key step in managing renal crisis and systemic sclerosis is to give an ace inhibitor. Okay, Nifedipine is useful for managing the rain or phenomena. Um, but the most important step here's to manage the renal prices. Okay, so that's why I captopril is the correct answer. Okay. I was going to test you on some of the signs. Okay, but these are all some important signs off systemic sclerosis. Okay, So calcinosis probably fibrosis is common. Okay, Can damage. It's a problem. Cause of morbidity, rain or phenomenon. So skinnier to the fingers. Telangiectasia is affecting the skin. Okay, So dilated capillaries and sclerodactyly is a really tight hardened skin. Okay, These old classic clinical features off systemic sclerosis. Okay, Uh, little summary sliding systemics closest again. Not gonna go through it. Okay, Keep, uh, I won't say quickly is to remember that. And remember the antibodies. So with the some explosives, you can either get limited system explosives or diffuse, limited systemic cirrhosis. It was limited. It means that the skin involvement is just purely distal. Okay, if it's diffuse, it means that the skin involvement is it's infecting proximally as well. Okay, Uh, in terms of the antibodies for limited systemic sclerosis, the antibodies are anti centrum me antibodies. Okay, They're really specific for limited system. Extra says. And the anti topoisomerase antibodies are anti 70. They're really specific for diffuse systemic sclerosis. Okay, I have a reader of some of these cocoa manifestations. And here's the sort of key differences between limited systemic sclerosis and diffuse system excuses. Okay, Okay. Lost SBA here, and then we'll be done. Okay. I think most of you got this one. Very good. You guys, you guys have been really well today. You guys are No. Mostly you've been getting the answers, right? So it's good to see if you find it useful, but loss s p s o. The correct answer here is he which mostly rentals, a muscle biopsy. And so let's break this down. So yes, quickly. Tell me, what is the diagnosis here? Him after my eyesight is very good. Okay, so it's a type of inflammatory myositis. So why inflammatory, my scientist? So this is a patient who has a proximal muscle weakness, okay, with just in the shoulder muscles, Okay. And it's primarily myopathy. Okay, you get information of muscle. So you're not gonna get any sensory problems with it. And the key thing with tomato, my sight is is the skin findings. Okay, so you get dark populace on the dorsum of the hands, so those are referring Teo gotten populace okay. And rat purple discoloration of the eyelids. That's referring to the heliotrope brush that you get with the matter. My sight is, and the key antibodies with any inflammatory myositis either demand to my eyesight is a polymyositis are the anti Joe antibodies. Okay, those are the antibodies which are really specific for, um, inflammatory motorcyclists. Okay, The key thing is that I'm asking you which of the following is most diagnostic. Oh, yeah. Okay, I eat. Which of the following will definitely confirm the diagnosis off the matter. My scientists and of all of these muscle biopsy will definitely confirmed the diagnosis. Okay, so generally speaking, biopsies are always going to confirm disease. Okay, because you're looking at the you looking under looking at the astrology. Okay, You're looking at it from a pattern of in terms of its topology. Okay, first line, so creatinine kind of levels will typically be elevated. Okay, so the first line test, but muscle biopsy is the most diagnostic. Okay, I'll give the most diagnostic value. Okay, so this is a summary side inflammatory. My eyesight is so generally it's proximal muscle weakness. And so you get proximal muscle because with polymyositis or the matter myositis but with demanded, my sight is you get keys, skin findings. So, like a heliotrop rash as well as fortune topicals. Okay, so he's ah, he literally crash. And here's some of the doctors popular. Okay, those are key skin findings. Okay, That's it from me. So you went really quickly towards the end. Uh, it was just because of the time you have some post section notes for you guys. As we have some notes on septic arthritis, some notes on psoriatic arthritis. No, no, no. Some reactive arthritis. Little bit on some of the vascular disease which we don't have time to talk about. No, they're already not. Phenomenon on dure. That's it. So that's what union today. Guys, I hope you guys find it useful. We covered a lot of stuff in rheumatology. Had tried Teo cover as much off the content. You need to know for finals. I could hope you guys enjoy that. Hopefully, you guys enjoy the SPS and, uh, learned a lot. You guys did really well on the SPS. Thanks a million piece about the feedback from there so you can get access to the slides, and, uh, that's know we can improve the sessions, but yeah, if you guys have any quick questions, I'll be happy to take. Um, I can go through them quickly. We have have to step. We have to start our frequent easy sessions until have to sign off on a bit. But, um, yeah, if you have any urgent questions. Dude, do you leave them in the chart right now? Or if you want, I'll join the preacher and easy session. Ah, and you can ask me a gasping any questions privately, if you want. In terms of time, am I able to explain the link between G see A and Polymyalgia Rhuematica had. Unfortunately, I'm not. It's also have particularly looked at okay, in terms of why patients with polymyalgia rhuematica get giant cell arteritis. Okay, It's just it's a very, very, very strong association. Okay. It's, uh I think it's about 50% of patients, 50% of cases of GCS associated with polymyalgia. Okay, I think it's some type of Gracia. Okay, But I'm not I don't I don't have a good explanation for, ah, part of physiological basis for that. Yeah, I might be good to have a read about that. It's sulfasalazine the only one which isn't too wrapped a cardiogenic. Okay, so for rheumatoid, So, uh, sulphasalazine is the one which is used in pregnancy. Okay, with Ah, yeah, you should give full it supplementation with that as well. But definitely the key thing is that you shouldn't give methotrexate. Okay, That's the key thing. Okay. And as well as, um, flutamide, you shouldn't give those type of drugs to pregnant patients. Get the sulfasalazine. Is safe in pregnancy. Okay? So when investigating PM on question. I'm white. Check Blue Coast level. So the key thing is is that, you know, investigating polymyalgia that you're you're checking your give it, you're going to start. You're giving steroids long term. Okay, so that's why you want to check? Because that was before hand. Because steroids will increase glucose levels. And potentially, they're going to lead to diabetes. Secondary diabetes, if they already have. Ah, high glucose levels. So that's the reason to check glucose levels. Okay. Ah, yeah. Alan. Yes. We gotta switch it. Yes, I think one more question and then we'll sign up. You guys have any 18 1 otherwise. So we'll stop the recording. I think that the feedback form has been sent. So you get you can get the recording. Ah, well, I can hopefully cover the I can try and cover some of the ones which I went really quickly in another session sometime in the future. I guess I could do a repeat of the session and focused on some of those conditions at the end, which I had to go through a bit quicker, but yeah, thanks for tuning in today, guys. Mixed. Go to into our pre Clinique's the session happening in exactly two minutes. So we will be seeing your, uh ah, son of right now. Um, yeah, rib entree. We end the meeting and then join again so that the recording's on metal. Anyone on anyone in committee is still here? Yes. Initially you could. That would be brilliant. Um, my, my, the host right now. Um, no, it's the prevent. Yes. Under meeting. No. I'll give you something. Recording metal. I can't No. A magnet for your medal and stop the recording. I didn't hear a county the about that right? Until that happens, if you guys have any questions, you know, take advantage of this current time. Yeah. So how do you use Midol? So that was pretty easy to use. So if you just make an account, you just have to make an account, and everything will automatically just scare uploaded to your accounts. Like all the certificates, all the slides and things if you just size. If you fill out the feedback from all the sessions, you can it help automatically? D it's an automated system toe automatically up those all the certificate and stuff into your own personal like out. So it's really easy to use. So you highly recommend them engaging with a