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All right, so let's go ahead
and get started with rheumatology. This is

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going to be a one of two
part podcasts only because rheumatology is just too

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dense to make this into one podcast, I broke it up into two before

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we get started. Thank you,
as always for the really nice comments the

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support. I really do appreciate it. All right, let's go get started

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with rheumatology. We're going to start
with probably one of the lowest heel topics

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for rheumatology, and that's five romyalgia. This is a chronic disorder of widespread

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muscular skeletal pain accompanied by other somatic
symptoms. So you're looking for fatigued cognitive

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disturbances, psychiatric symptoms. Etiology is
unknown, and the patho phiz is uncertain,

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so there's really not a lot to
know here. Just know that they're

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going to have some kind of chronic, widespread MSK pain combined with other somatic

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symptoms. So who you're going to
be looking for in the vignette is going

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to be women twenty to fifty five
years of age. It's much more common

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in women, and like I said, generally in the age range of twenty

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to fifty five, So the vignette
be looking for a young or middle aged

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woman on physical exam eleven of eighteen
to fine tender points. Let's talk about

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that because there's a little fyi for
that. So on physical exam person with

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fibromiologia, they're very often going to
have tenderness. This is going to be

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a multiple soft tissue sites throughout the
body. But with that being said,

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you likely have heard of this criteria. That's eleven of eighteen to fine tender

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points. This was from nineteen ninety
diagnostic criteria for fibromylogist, so it's been

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around a while. Basically stated that
if a patient had symptoms of widespread pain,

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was tender and at least eleven of
eighteen different areas when you poked them,

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essentially they had fibromylogia. This is
what I was taught when I was

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in school. It's still in a
lot of the literature, but if you

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got up to date and you look
at their latest information, their latest quote

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from up to date, they state
quote, we no longer recommend palpating specific

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tender point locations or enumerating the number
of tender points. The presence of such

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tender points was part of the nineteen
ninety ACR Classification criteria. Performing such a

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tender point examination has proven to be
impractical and clinical practice, So in reality

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still around may honestly still get tested
on it. And that's why I bring

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it up. It's an easy thing
to make an exam question out of.

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But there's newer criteria, the twenty
ten American College of Rheumatology Diagnostic Criteria,

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which you don't need to memorize.
I just wanted to make you aware of

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that, and then just kind of
I had to bring up the eleven of

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eighteen ten or points just in case
you're testing on it, but just be

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aware of the more up to date
info as well. All right, moving

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on diagnosis, this is very much
a clinical diagnosis. You're going to have

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normal lab tests. So that's the
hard part about fibromyalgia is there's no confirmatory

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tests or biomarkers. It's a clinical
diagnosis. You suspect fibromylogien patients with three

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months of widespread or multisite pain without
another identifiable cause, so you get lab

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tests, but this is just to
rule out your differentials. You mainly want

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to exclude systemic inflammatory diseases, so
get a CBC and esr C reactive protein.

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This is really just to rule out
another underlying inflammatory cause. Key thing

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to remember here is that all of
the labs and imaging are generally going to

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be normal and fibromyalgia treatment you start
with. Your servative measure is patient education

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including cognitive behavioral therapy. Exercise.
Low impact aerobic exercise actually has been shown

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to improve not only the pain,
but improves the sleep disturbances these patients may

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have. You also want to address
any comorbidities, so these things aren't always

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often tested on. What they're likely
going to ask you is the pharmacologic treatment.

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So if they ask you which medication
you're going to give a patient with

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fibromylogya, it's going to be your
TCA. So tricyclic antidepressants AM a trip

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DeLine So when most patients, you're
going to initiate therapy with a low dose

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of a tricyclic antidepressant and a trip
delane is the main one. There's some

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other options cyclobenzoprene a cent arise for
your exam, though I'd really focus on

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your TCAs in particular am a trip
DeLine. So in conclusion, little no

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for fibromyology. Just know the diagnosis
should be considered in any patient with greater

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than three months of wide spread or
multi site pain companied by other somatic symptoms,

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no evidence of another condition accounting for
the pain. Patient very likely it

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is going to be female normal labs. Treatment's going to be conservative initially,

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exercise, patient education, cognitive behavioral
therapy, and if you're going to give

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them meds most of the time,
it's going to be your TCAs. That

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is fibromyalgia, all right, Moving
on to gout. So gout it's a

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very dense topic. I honestly could
have made a whole podcast just on gout,

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but I try my best to condense
this and focus just on the high

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yield stuff. So there we go. Gout is a condition characterized by hyperurasemia

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and deposition of monosodium ura crystals,
causing attacks of acute inflammatory authoritis. So

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I'm sure most of you are already
somewhat familiar with gout. It's a common

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condition, but essentially, you have
too much uric acid and the blood from

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a number of causes will go over
and this results in the formation of these

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sharp needle shaped crystals that can deposit
in the joints, leading to severe pains,

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swelling, effusion, And just so
you know, hyper eurasemia. While

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it's a necessary predisposing factor for gout, majority of people with hyper eurasemia actually

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never developed gouts. It's just a
little extra knowledge. You don't need one

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for the other and etc. Whatever, So you can have hyper euraseemia never

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developed GAUT. All right, let's
talk about risk factors. So there's a

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few different things that can trigger a
GOUT attack. There's certain people that are

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more susceptible to gaup male sex.
GAUT has a male predominant, so very

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likely in the vignette it's going to
be a man. Part of the reason

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it's more common in men compared to
women is estrogen actually has a mild euricosuric

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effect, so it actually promotes the
excretion of uric acid. So GAUT is

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very unusual in premenopausal women. So
male sex is a big non non modifiable

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risk factor. Another one is advanced
age, so that's another nonmodified I can't

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say that word nonmodifiable risk factor.
So you're generally looking for an older man

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in them. Yet, and then
we have our modifiable risk factors for GAUT.

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So these are the ones you should
be familiar with because this is more

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often tested on. The two important
ones to be familiar with is diet and

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medication. So let's start with your
diet. So puring rich foods is what

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you're looking for. So diet be
a triggering factor for gaut increase consumption.

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Consumption of purings which are found in
seafood, red meat, oregon meat like

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liver. Alcohol is another big one. They can all increase the formation of

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monosodium urate crystals, so be aware
of these foods. And the reason why

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it happens with puring rich foods is
because when puring that's founding these foods is

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broken down when it's metabolized in the
body, it's actually broken down into uric

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acid. So you can see why
the problem happens with these types of foods.

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So once the patients are actually on
urate lowering meds like gallopurinol, diet

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really doesn't play such a big role
anymore since these meds do such a good

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job of keeping muric acid levels under
control. But prior to diagnosis and proper

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treatment, diets definitely a key factor
to be aware of. And then there's

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medications they can increase cerum urate levels
and can increase the risk of a Gaut

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flare. And it's important to know
these meds because you may get a question

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like I did it describes a patient
with GAUT and they list of buns of

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meds and basically say which med should
you just continue in this patient? So

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should know your meds that can lead
to hyperurosemia and a potential gout attack.

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The ones that you need to know, the ones that get tested on are

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piazenamide that's a tuberculosis med, loop
diuretics like ferosamide aspirin, but low dose

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aspirin's odd one because it really only
triggers GAUT when it's taken in low doses

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like less than three hundred and twenty
five milligrams, like a lot of people

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take for cardiovascular prophylaxis. Higher doses
of aspirin actually have the opposite effect and

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decrease urate levels. Another one is
thiazides like hydrochlorothiside, and then a fambuta,

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which is another tuberculosis med So those
are the main meds to be aware

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of the ones that are commonly tested
on. The way that you're going to

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remember those meds is by remembering this
sentence. If you put too much seafood

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on your plate, you'll get gout. If you put too much seafood on

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your plate plat, you'll get gaut. So plate is the word that you

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need to remember. And plate stands
for the P stands for piazenamide, the

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L and plate stands for loop diuretics, the A and plate stands for aspirin,

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The T stands athisides, and then
the E a Thambutall. So remember

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that sentence, You remember the common
medas you need to know. If you

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put too much seafood on your plate, you'll get gallup, pure zenemie,

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loop diuretics, aspiranthisides, and a
thambutall all right. Clinical manifestations, they

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are going to have severe pain,
redness, warmth, swelling. That's very

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common. Usually this is going to
be isolated into one joint. Around eighty

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percent of initial flares involved just a
single joint. And then it's most common

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for its involve the lower extremities.
In particular, the most common area is

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going to be your first metatar sophalangial
joints, so the base of the great

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toe, and this is known as
podagra. So if you hear podagram mentioned

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it's gout of the big toe,
so remember that term. It's of course

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possible to have it in other areas
the knees and other common area ankles,

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but focus on that first toe podagraph. That's a really important one, all

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right. So as a recap clinical
manifestations of a gaut flare, be looking

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for a description of severe pain,
redness, warm swelling, likely going to

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be the lower extremities most often the
base of the first toe podagra. All

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right, So for diagnosis, there's
two things that I would be familiar with

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for diagnosis, Arthur a centesis that's
the main one, and then you have

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your imaging. So Arthur a sentesis. This is your best test. Definitive

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diagnosis can be made with Arthur sentesis
in real life. How many patients are

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actually going to let you stick a
needle in the toe that's hurting them so

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bad? Even a vet she makes
them scream, It's questionable, But if

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they ask you. The best diagnosis
tests on the exam, Arthur sentesis is

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eighty five percent sensitive and one hundred
percent specific for gaut and what you're looking

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for under microscopy when you perform an
Arthur sentesis is negatively biofarringent needle shaped crystals,

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which is a characteristic finding of monosodium
urate. So again I'll repeat that

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because it's very very important to know
this. You have to know this.

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They're going to ask it. So
aspiration of the synovial fluid of the joint

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and a patient with gout is going
to show negatively by your farringent. It's

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really important. It's negatively bierfarringent because
it differentiates it from pseudo Gaut, which

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will go over next. And Pseudogaut
is positively buy a furringent. So again

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negatively buyerfarringent needle shaped crystals. You
have to know that, all right,

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So I mentioned that Gaut is negatively
by a farringent and Pseudogaut is positively by

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afringent. I do have a trick, not really a trick, but just

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an easy way to remember. One
is positive, one is negatively buy a

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furringent. So Pseudogaut has a P. Gaut does not. So Pseudogaut is

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positively buyer farringent positive with a P. Pseudo Gaut with a P. Gaut

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was negative buyer furringent. So if
you can't remember which one is negative or

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positive. Just remember which one has
a P in the name only pseudo gaut.

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Therefore it's the one with positive with
a P buyer furringeent. Just an

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easy way to remember that, all
right. So what about X ray?

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So I mentioned before imaging does play
a role. Imaging isn't really super high

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yield except for the fact that if
you see an a vignette they mention anything

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about overhanging edges or margins with a
punched out appearance. These are characteristic findings

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of the erosive appearance scene and it
joint with the patient with gout. Normally,

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this is long standing gout. So
if you see that the back of

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your mind, just kind of remember
that overhanging edges or this erosive appearance on

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x ray that can be long standing
in a patient, long standing finding sent

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a patient with gout on imaging.
So really I would just focus on your

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author of sentesis, but just kind
of have that in the back of your

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mind, all right. So those
are the things I think you should know

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for the diagnosis for the exam.
In real life when you're practicing, very

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often the diagnosis of gout is just
going to be a clinical diagnosis made upon

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the history of the exam. There's
even a diagnostic rule chart if you want

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to look that up. Not important
enough for the exam, but just basically

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a point system that helps make the
diagnosis in the absence of an Arthur sentesis.

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All right, So one last thing
that you might be saying to yourself,

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what about measuring uric acid to help
make the diagnosis. We're talking about

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diagnosis. We know, you know
increased uric acid hyper eursemia. Why aren't

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we the uric acid levels? So
it turns out that up to forty three

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percent of patients with acute gaut flares
they're actually gonna have normal or even low

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serum urate levels. And part of
the reason is because the cytokinds that are

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released during an acute attack, they
can actually lower the urate levels. So

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measuring uric acid levels not a good
idea during an acute attack. So when

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are you going to measure uric acid? Best time is two or more weeks

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after the flare has completely resolved,
and measuring uric acid levels it's a good

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tool to measure the response to treatment
once you have them on a prophylactic agent

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like alipurinol. Obtain uric acid levels
to make sure the treatment is working at

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suppressing the uric acid levels in the
body. So to reiterate, don't measure

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uric acid levels during an acute attack. All right, let's talk about our

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treatment. Let's start with acute first
and then we'll talk about chronic treatment.

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So before we start with treatment and
the meds, always make sure you address

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lifestyle changes less beer, less meat, seafood, lose weight. Not so

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much test it on, but just
good to know for real life. All

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right, let's talk about acute attacks
first. So for an acute attack,

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there's three meds or classes that you
need to know. End sets, steroids,

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and culture scene. They all work
and quoted from up to date,

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we suggest oral glucocorticoids, end sets, and culture scene as equivalent first line

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options. So basically, you just
have to decide which agent will be your

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best for a patient, considering the
patient's comorbidities and other factors which I'll go

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over. So let's start with our
end sets for US, so end sets,

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neproxin, endomethsin. Those are some
commonly used ones. A potent oral

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nd set like neproxin or intomethicin.
They work really well for GAUT. They're

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generally pretty cheap, so they are
used very frequently, but you have to

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be careful in using these in certain
patient populations. So they're going to give

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you a patient with an acute GAUT
attack, They're going to list a bunch

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of meds and they're going to ask
you what you'd pick. You have to

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look at the comorbidities the patient has. You don't want to use end sets

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and a patient with core renal function
and active duad and ologastric ulcer. Even

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in some types of cardiovascular disease like
hard fact failure, there's some other contraindications.

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Obviously, allergies and sets can combinatet
use of antiquagulance. But the three

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that I focus on for the exam
bad kidneys, bad heart, bad GI

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tracked. Don't get tricked in a
vignette when they give you a patient with

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gout asking which meant to pick before
you pick the proxy and make sure their

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GFAR isn't like twenty. So again, end sets are a first line agent

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for a cute GUT as long as
the patient doesn't have chronic kidney disease.

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Generally, a gfar less than sixty
and acute ulcer or certain types of cardiovascular

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disease, but really focus in on
the chronic kidney disease because that's normally what

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they're going to give you in the
vignette to try to trick you. Okay,

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00:14:35,320 --> 00:14:37,639
let's talk about our glucocorticoids next.
They come in a couple of varieties,

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oral, intraarticular, so like a
steroid injection, all depends on how

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00:14:43,480 --> 00:14:48,039
many joints are involved. They work
really well, and what's really important,

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they can be used in patients with
moderate to severe renal insufficiency. So keep

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that in mind. If they give
you a patient that has chronic kidney disease

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and they have nd sets and steroids
in the answer choices, make sure you're

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choosing your steroids and not end set. All right, So who should you

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be careful prescribing steroids too? Obviously
you're poorly controlled diabetics. This is really

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important. Steroids can and will cause
a pretty significant spike in blood sugar,

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00:15:09,799 --> 00:15:13,320
so it'll be really careful with your
brittle diabetics that work and the chronology.

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I see this all the time.
Patients come in, their blood sugar is

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00:15:16,320 --> 00:15:20,159
perfect. They get some prednicess on
on their blood sugars through the roof,

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00:15:20,240 --> 00:15:26,080
so be really careful in patients with
diabetes. It's it's not an absolute contriunication.

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00:15:26,080 --> 00:15:28,200
You just want to be careful with
that. Also, be careful in

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00:15:28,200 --> 00:15:33,960
patients that have an ongoing infection or
post op patients because gluca cortochoids can increase

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00:15:33,000 --> 00:15:37,679
the risk of impaired wound healing.
So remember steroids are another great treatment option

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00:15:37,720 --> 00:15:41,200
for acute flares. And I'll say
it again because it's really important you can

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00:15:41,600 --> 00:15:46,320
use this in patience with kidney disease, because that's likely the question you'll get.

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00:15:46,879 --> 00:15:50,159
Let's talk about Culture Scene next.
So this is probably the least used

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00:15:50,159 --> 00:15:54,919
option of the three. Culture Scene
is effective for acute flares. But what's

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00:15:54,000 --> 00:15:56,799
unique about it that you really need
to remember it can actually also be used

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00:15:56,840 --> 00:16:00,200
for chronic management of gout. And
it's the only men that can be used

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00:16:00,240 --> 00:16:04,759
for both acute and chronic cases of
gout. Although it's certainly not the preferred

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00:16:04,840 --> 00:16:07,720
agent for chronic gout management, but
you can use it for that. To

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00:16:07,840 --> 00:16:11,159
just so just know that really just
two things that would know for Culture Scene

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00:16:11,600 --> 00:16:15,080
one, like I just remember you
can use it for acute and chronic out,

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00:16:15,440 --> 00:16:18,120
and if they mention an adverse drug
reaction with culture Scene, it's going

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00:16:18,159 --> 00:16:22,000
to be a diarrhea. Culture Scene
is notorious for causing this, and they,

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00:16:22,159 --> 00:16:26,720
for some reason often like to ask
about it. On Apocrates, it

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00:16:26,720 --> 00:16:32,000
actually says in the comments quote diarrhea
will likely proceed pain relief, which I

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00:16:32,039 --> 00:16:33,799
just thought was funny. You can
tell your patients once a diarrhea starts,

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00:16:34,000 --> 00:16:38,000
you know we're getting close. Just
start working soon. So anyways, remember

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00:16:38,039 --> 00:16:41,919
colch scene is another option for acute
flares as well as chronic management. Most

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00:16:41,919 --> 00:16:47,080
common ADR is diarrhea. All right, let's talk about our chronic treatment.

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00:16:47,159 --> 00:16:51,279
So for chronic treatment, there is
one drug that absolutely runs the show,

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00:16:51,360 --> 00:16:53,840
and that is lapieran al. It's
part of your x anti inoxidase inhibitors.

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00:16:55,080 --> 00:16:59,240
If you remember only one medication for
chronic gout management, let it be lapper

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00:16:59,320 --> 00:17:03,440
at all. So it is your
first line prophylactic treatment for gout. Like

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00:17:03,480 --> 00:17:07,160
I said before, is a xanthe
and oxidase inhibitor. What the heck does

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00:17:07,200 --> 00:17:11,039
that mean? So? Xanthe and
oxidase is a enzyme that helps puring breakdown

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00:17:11,079 --> 00:17:15,440
into uric acid. So if we
inhibit this enzyme, we stop the process

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00:17:15,559 --> 00:17:19,559
and therefore we decrease the amount of
uric acid that can be produced. And

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00:17:19,680 --> 00:17:25,359
this works obviously very well. Adverse
drug reactions for alla purnal. The one

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00:17:25,400 --> 00:17:29,279
that I would remember is Steven's Johnson
syndrome. So this one always seems to

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00:17:29,319 --> 00:17:33,000
come up. Alpurnals one of the
medications, one of the menu medications that

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00:17:33,039 --> 00:17:37,079
can cause Stephen Johnson syndrome. And
I went over thisnemonic before in the seizure

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00:17:37,160 --> 00:17:41,079
lecture. But if you can remember
this demonic, it will help you remember

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00:17:41,160 --> 00:17:45,359
the common meds that can cause Stephen
Johnson syndrome. So the sentence that I

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00:17:45,400 --> 00:17:48,920
remember as soon as I see Steven's
Johnson syndrome, I think of the first

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00:17:48,960 --> 00:17:52,160
few letters in Stephen Johnson and the
first few letters of Steven Johnson are also

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00:17:52,319 --> 00:17:57,160
in Steve Jobs, And that helps
them remember Steve Jobs created Apple PCs,

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00:17:57,240 --> 00:18:02,240
and then Steve Jobs created Apple.
Piece sees Apple PC stands for the main

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00:18:02,319 --> 00:18:06,240
meds that can cause Stevens Johnson syndrome. Aliperan al, there's your alipianol,

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00:18:06,680 --> 00:18:11,599
fennetin, pheno, barbital, lemotorgene, ethosuxomie, penicillans, cover mazipine and

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00:18:11,680 --> 00:18:15,759
sulfonamides, so those are the main
ones. Alipianil is obviously in the a

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00:18:15,960 --> 00:18:19,359
there, so you remember as soon
as you see Steven's Johnson syndrome, think

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00:18:19,400 --> 00:18:23,240
of Steve Jobs and Steve Jobs created
Apple PCs. Those are the main meds

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00:18:23,720 --> 00:18:29,640
for Stevens Johnson syndrome. And one
of the men I wanted to mention the

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00:18:29,720 --> 00:18:34,440
anthienoxidase inhibitors is one called Fabucks's stat
so this is another X anthienoxidase inhibitor.

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00:18:34,519 --> 00:18:37,720
There's really nothing high yield to know
about this men except for the fact that

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00:18:38,200 --> 00:18:42,880
it's ax anthienoxidase inhibitor. We don't
use fabucks as SAD as often as aliperanol

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00:18:44,039 --> 00:18:48,920
because it has some adverse effects that
alipionol just doesn't have in particular and increased

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00:18:48,920 --> 00:18:52,960
cardiovascular risks, so be aware of
it. But remember aliperonil is going to

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00:18:52,000 --> 00:18:57,000
be the preferred agent. So there's
only two meds to know for this class.

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00:18:57,079 --> 00:19:00,079
But sometimes you're going to forget their
mechanism of action. So if you

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00:19:00,160 --> 00:19:06,079
want a way to remember there's anthienoxidase
inhibitors, because I did get a question

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00:19:06,160 --> 00:19:08,000
on this, they basically ask which
of the following is a x anthienoxidase inhibitor,

284
00:19:08,240 --> 00:19:11,240
And right away I was like,
okay, whereas all appear and all

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00:19:11,279 --> 00:19:12,960
the answer choices that wasn't there.
It would obviously be too easy. They

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00:19:14,000 --> 00:19:15,960
put fabucks is set. So the
way that I remember these two meds were

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00:19:15,960 --> 00:19:21,359
as anthienoxidase inhibitor as well was by
remembering the sentence. In February, I

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00:19:21,480 --> 00:19:25,960
get all of my exos because it's
the month of Valentine's Day. In February,

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00:19:26,000 --> 00:19:29,359
I get all of my exos like
xoxo, hogs and cases. I

290
00:19:29,440 --> 00:19:32,839
get all of my exos because it's
the month of Valentine's Day. So in

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00:19:33,039 --> 00:19:37,359
February, February is for Fabucks's stat
all is for all apperanol, and then

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00:19:37,599 --> 00:19:42,279
XO stands for xantien oxidase as an
xanthienoxidase inhibitor. So just a quick way

293
00:19:42,319 --> 00:19:45,960
to remember the two drugs and their
mechanism of action. All right, So,

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00:19:47,480 --> 00:19:52,480
ours anthienoxidase inhibitors helped decrease production of
uric acid. But what about medications

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00:19:52,519 --> 00:19:56,559
for a patients that are just under
excreening uric acid? They're building up uric

296
00:19:56,559 --> 00:19:59,839
acid they're just not peeing enough out. What do you do then that's when

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00:19:59,880 --> 00:20:04,440
you you use are uricosuric medications.
So uricosuric medications. Probenicid is really the

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00:20:04,640 --> 00:20:07,359
only one that you need to know
because it's the only drug in the US

299
00:20:07,680 --> 00:20:12,160
approved by the FDA for the specific
purpose of promoting renal uric acid clearance.

300
00:20:14,119 --> 00:20:18,480
The other two sulf in pyrozone and
lesinurad, they're no longer marketed here in

301
00:20:18,480 --> 00:20:23,799
the US, so really just focus
on probencid. Probenicid works by promoting renal

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00:20:23,880 --> 00:20:30,680
clearance of uric acid by inhibiting the
proximal tubule that mediates urid reabsorption. So

303
00:20:30,839 --> 00:20:33,880
there's not a lot to know here. Just remember probenicid is the one that

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00:20:33,960 --> 00:20:37,279
makes you pe out uric acid.
It's not used very often. One of

305
00:20:37,359 --> 00:20:40,799
the thing to know about it is
you want to avoid this drug in patience

306
00:20:40,799 --> 00:20:45,640
with the history of nephrolothiasis because it
can increase urinary calcium excretion in patients with

307
00:20:45,759 --> 00:20:48,720
gout, so it can cause a
recurrence, so just be careful in patients

308
00:20:48,759 --> 00:20:52,720
with prior kidney stones. One of
the medication to be aware of. I

309
00:20:52,759 --> 00:20:56,000
don't think there's much to know about
it, or really anything to know about

310
00:20:56,039 --> 00:21:00,759
it. Just know that it's a
treatment for chronic gout and it's called pick

311
00:21:00,799 --> 00:21:04,200
a lotic case. It's really only
a reserved for patients with severe cases of

312
00:21:04,279 --> 00:21:11,039
GAUT who have failed to previously mentioned
therapies like alipurinol. It's administered intravenously.

313
00:21:11,640 --> 00:21:12,599
I'm not really going to go any
further into this, man, because I

314
00:21:12,680 --> 00:21:15,839
really don't feel like it's important enough. And then, of course, remember

315
00:21:17,319 --> 00:21:19,640
another chronic med like I mentioned before, is culture scene because remember culture sting

316
00:21:19,680 --> 00:21:22,920
can be used for acute and chronic
management of GAUT. All right, So

317
00:21:23,039 --> 00:21:26,640
to wrap up treatment, I would
know your acute treatments, your acute meds,

318
00:21:26,839 --> 00:21:30,319
your acute med's well and said steroids, culture scene, if your chronic

319
00:21:30,400 --> 00:21:34,440
meds, just really focus in on
alipurinol, and that is your treatment for

320
00:21:34,680 --> 00:21:38,720
gout. All right. Next we're
going to talk about gout's cousin. That

321
00:21:38,799 --> 00:21:47,720
would be calcium pyrophosphate crystal deposition disease
aka pseudo gout pseudogaut. The name isn't

322
00:21:47,720 --> 00:21:51,880
really used that much anymore, and
more acutely, more accurately describes the acute

323
00:21:51,920 --> 00:21:56,000
attacks which clinically resemble acute attacks of
gout. But I'm going to call it

324
00:21:56,079 --> 00:22:00,160
pseudogaut the whole time because calcium pyrophosphate
crystal deposition disease is just too long to

325
00:22:00,240 --> 00:22:03,599
say, so there's way less to
know here compared to gout. I've broken

326
00:22:03,640 --> 00:22:07,839
it down into just about five things
that you need to know. First,

327
00:22:07,920 --> 00:22:11,720
it is a deposition of calcium pyro
phosphate dihydrate. So in GAUT we had

328
00:22:11,720 --> 00:22:15,960
accumulation of uric acid. In this
case, we have an accumulation of calcium

329
00:22:17,240 --> 00:22:21,559
pyrophosphate depositing in the joints and the
soft tissue. The knee is going to

330
00:22:21,559 --> 00:22:25,119
be the most common joint to be
affected. The knees affected in over fifty

331
00:22:25,160 --> 00:22:27,200
percent of all acute attacks. So
in gaut, who is all about the

332
00:22:27,240 --> 00:22:33,000
first toe, podagra pseudo gut,
It's all about the knee. So about

333
00:22:33,039 --> 00:22:34,400
half of the cases are going to
involve the knee. I used to have

334
00:22:34,480 --> 00:22:38,640
this weird way of remembering this,
you know, but weird demonics are sometimes

335
00:22:38,680 --> 00:22:42,200
the best. So instead of remembering
pseudo gout, I used to remember sumo

336
00:22:42,279 --> 00:22:45,720
gout, as in sumo wrestlers and
anytime you see a sumo wrestler, they're

337
00:22:45,720 --> 00:22:48,519
always bent over with their hands on
their knees. If you google it,

338
00:22:48,559 --> 00:22:52,000
you'll see what I'm talking about,
Like the sumo wrestler stands apparently. So

339
00:22:52,079 --> 00:22:56,000
anyways, as soon as I see
pseudogaut, I think of sumo gout and

340
00:22:56,119 --> 00:22:57,799
the picture of the sumo wrestler bent
over with his hands on his knees,

341
00:22:59,000 --> 00:23:02,480
and that just kind of triggered my
memory to remember. This disease most commonly

342
00:23:02,519 --> 00:23:04,960
affects the need, all right,
so the needs most common. Other areas,

343
00:23:04,960 --> 00:23:07,519
of course, can be affected to
the risk the MCP joints, the

344
00:23:07,599 --> 00:23:11,200
hip, shoulders, elbow, spine, all fair game. Just an fyi

345
00:23:11,440 --> 00:23:15,799
and acute attack of pseudogaut. While
it can be very similar to gout,

346
00:23:15,839 --> 00:23:18,759
and that's why they initially came up
with the name pseudo gaut because the close

347
00:23:18,839 --> 00:23:22,759
resemblance to gout attacks, the intense
pain, redness, warmth, swelling.

348
00:23:23,240 --> 00:23:29,240
But the thing about it is that
in pseudogauts, these acute attacks, they're

349
00:23:29,480 --> 00:23:33,799
much less common. Majority of patients
with its disease with the calcium deposition in

350
00:23:33,880 --> 00:23:37,759
their joints, more often than not, are going to be completely asymptomatic,

351
00:23:37,799 --> 00:23:41,359
So just kind of be aware of
that. All right now, this is

352
00:23:41,400 --> 00:23:47,799
really important. Positively biofringent calcium pyrophosphate
crystals. This is the thing to know

353
00:23:47,880 --> 00:23:52,920
about pseudogaut. If you forget everything
else, remember this, positively biofringent crystals

354
00:23:52,200 --> 00:23:56,720
on synovial fluid analysis. Oftentimes they're
going to be rhomboid shaped. This is

355
00:23:56,759 --> 00:24:02,799
the key difference between pseudogut and GOUT
because remember GAUT was negatively by afarringent.

356
00:24:03,440 --> 00:24:07,519
And again remember that because pseudogut has
a P GAUT does not, in as

357
00:24:07,640 --> 00:24:14,039
pseudogaut is positively biafarringent. Remember on
pseudo gaut you're looking for positively biafarringent calcium

358
00:24:14,079 --> 00:24:18,000
pyrophosphate crystals. Often they're going to
be rhomboid shaped, all right now.

359
00:24:18,119 --> 00:24:22,119
On X ray, you can use
X rays another diagnostic tool for pseudogaut.

360
00:24:22,920 --> 00:24:27,240
If they mention on X ray,
these punctate or linear radiodensities in the cartilage

361
00:24:27,279 --> 00:24:32,559
of the joint spaces, that's from
the accumulation of calcium crystals in and around

362
00:24:32,599 --> 00:24:36,319
the joints, and they look like
these little white lines on the joints.

363
00:24:36,400 --> 00:24:41,359
In the X ray and they're called
it's known as like chondrocalcinosis, which is

364
00:24:41,400 --> 00:24:45,400
like another name for pseudo gauts.
So if you see anything mentioned about punctate

365
00:24:45,480 --> 00:24:49,759
or linear radiodensities, or if they
use the word chondrocalcinosis, be thinking pseudo

366
00:24:49,839 --> 00:24:53,359
gaut all right. And then one
last thing to know. When we were

367
00:24:53,400 --> 00:24:59,440
talking about the treatment for acute attacks
of pseudo gaup, it's the same as

368
00:24:59,480 --> 00:25:03,240
in gouts. The treatments are essentially
the same. The slight difference is there's

369
00:25:03,279 --> 00:25:07,880
more of an emphasis on intra articular
steroid injections, So when two or less

370
00:25:07,920 --> 00:25:11,480
joints are involved, intra articular steroid
injections are generally going to be your first

371
00:25:11,519 --> 00:25:15,640
line of these patients. Otherwise,
treatment for a cute attacks and pseudo gaut

372
00:25:15,720 --> 00:25:19,279
it's identical to the treatment of a
Gaut flare. So just as we went

373
00:25:19,359 --> 00:25:23,839
over before in gout and says posteroids
culture. See, there's really nothing new

374
00:25:23,880 --> 00:25:29,000
to know here except for a slight
emphasis on those intraarticular glogal cortaicoid injections.

375
00:25:29,920 --> 00:25:33,039
So five things to know for pseudo
gaut. This is a calcium deposition disease

376
00:25:33,400 --> 00:25:37,160
needs going to be your most common
joint to be involved. Remember your SSEUMO

377
00:25:37,200 --> 00:25:41,440
wrestler, positively buy your fringent calcium
crystals on X ray BI looking for chondrocalcinosis

378
00:25:41,559 --> 00:25:45,640
those little white lines on X ray
and the joints and intraarticular steroid injections are

379
00:25:45,680 --> 00:25:49,359
first line when two or less joints
are involved. All right, let's move

380
00:25:49,400 --> 00:25:55,519
on to juvenile idiopathic arthritis. There's
a few different subtypes. Isstemic, oligo,

381
00:25:55,599 --> 00:26:00,319
articular, polyarticular. Wouldn't focus too
much on that. This is a

382
00:26:00,400 --> 00:26:06,759
chronic pediatric inflammatory arthritis onset before sixteen
years of age and presence of aarthritis for

383
00:26:06,880 --> 00:26:11,960
at least six weeks. So juvenile
idiopathic arthritis, it's this blanket term that

384
00:26:11,119 --> 00:26:15,519
covers a bunch of different types of
chronic pediatric authritis. Pathos really not well

385
00:26:15,599 --> 00:26:21,319
understood with this condition. It's ultimately
a diagnosis of exclusion and there's really only

386
00:26:21,359 --> 00:26:26,079
a few things to know for the
exam. So peak incidence is between one

387
00:26:26,160 --> 00:26:30,079
and five years of age, and
it's important to remember that less than sixteen

388
00:26:30,200 --> 00:26:33,519
years old is the cutoff for this
disease, so if they're any older,

389
00:26:36,599 --> 00:26:40,440
the onset is after sixteen years of
age. It's no longer called juvenile idiopathic

390
00:26:40,480 --> 00:26:44,680
authritis. It's then going to be
called adult onset stills disease or remember they're

391
00:26:44,680 --> 00:26:48,359
going to be younger than sixteen years
old. Let's talk about the clinical manifestations

392
00:26:48,440 --> 00:26:51,640
next. These are fairly unique and
you should be familiar with them. It's

393
00:26:51,680 --> 00:26:52,599
really four that you need to know, and that's going to be fever,

394
00:26:52,720 --> 00:26:56,880
authritis, rash uveitis. All right, so let's talk about them. So

395
00:26:56,000 --> 00:27:02,279
the fever, this is primarily seen
with the systemic subtype, but it's not

396
00:27:02,359 --> 00:27:04,799
just any fever. The fever is
unique and you need to remember it's unique

397
00:27:04,839 --> 00:27:10,160
characteristics for the exam. So first
it's persistent at least two weeks to make

398
00:27:10,200 --> 00:27:15,839
a definitive diagnosis of the systemic subtype. And then more importantly, it follows

399
00:27:15,880 --> 00:27:19,559
this diurnal or quotium pattern, meaning
that every day they're going to spike a

400
00:27:19,759 --> 00:27:25,880
fever, but every day the fever
is also going to dissipate. That's the

401
00:27:26,000 --> 00:27:30,319
key. The diagnosis is questionable if
the patient's temperature is not spontaneously returning to

402
00:27:30,519 --> 00:27:34,519
normal on a daily basis. So
fever during the day then return to normal

403
00:27:34,640 --> 00:27:38,279
each day. That's the diurnal or
quotium pattern to the fever, and it's

404
00:27:38,319 --> 00:27:42,400
how they're going to describe it in
the vignette. So remember that arthritis arthritis

405
00:27:42,519 --> 00:27:48,240
has to be present for at least
six weeks. The polyarticular subtype just means

406
00:27:48,359 --> 00:27:52,319
that specifically five or more joints is
involved, and fewer than five joints would

407
00:27:52,319 --> 00:27:59,000
be the ollegal articular subtype rash,
the salmon colored rash we see in the

408
00:27:59,079 --> 00:28:03,000
systemic subtype. It's another thing that
they love to mention. It's this evanescent,

409
00:28:03,160 --> 00:28:06,680
macular salmon pink rash. So look
out for that too, because,

410
00:28:06,759 --> 00:28:08,480
like I said, oftentimes that comes
up in the vignette as well. And

411
00:28:08,599 --> 00:28:14,440
then uveitis, this is really only
seen in the oligo articular and poly articular

412
00:28:14,480 --> 00:28:19,039
subtypes. It's most prevalent in patients
that are ANA positive. So children who

413
00:28:19,079 --> 00:28:23,480
are positive for anti nuclear antibodies their
screen more often than those who are ANA

414
00:28:23,680 --> 00:28:29,559
negative since they're at a higher risks. Remember, uveitis really oligo articular and

415
00:28:29,640 --> 00:28:33,920
poly articular subtypes that you'll see it
in treatment. Mild to moderate symptoms and

416
00:28:34,119 --> 00:28:38,000
sets are going to be your initial
treatment option. More severe disease, you'll

417
00:28:38,000 --> 00:28:41,759
start them on a biologic like a
temera, even glucocorticoids, but for the

418
00:28:41,799 --> 00:28:45,640
exam, focus on your end says
that will likely be the answer. And

419
00:28:45,720 --> 00:28:51,000
that's really it. For juvenile dowpathic
authritis. Remember your daily spiking and remitting

420
00:28:51,039 --> 00:28:53,920
fever, your salmon colored rash,
some uveitis, and the oligo and poly

421
00:28:55,039 --> 00:28:57,799
articular subtypes and end sets for your
treatment and you're done. Let's move on

422
00:28:57,880 --> 00:29:03,079
to osteoporosis. Like gaut this is
another very dense topic. Let's just focus

423
00:29:03,160 --> 00:29:07,480
on your need to know stuff.
So. Osteoporosis is a metabolic bone disease

424
00:29:07,599 --> 00:29:14,039
characterized by deterioration of bone tissue,
leading to low bone mass and increased skeletal

425
00:29:14,119 --> 00:29:17,720
fragility. I don't want to dive
too deep into the patheo because the pathos

426
00:29:17,799 --> 00:29:22,799
multifactorial, but basically, your osteoclasts
are breaking down the bone faster than osteoblasts

427
00:29:22,880 --> 00:29:27,079
can rebuild them, so we get
osteoporosis leading to these porous, brittle bones

428
00:29:27,160 --> 00:29:32,279
that are susceptible to fractures. Just
an fyi if you ever forget which breaks

429
00:29:32,319 --> 00:29:34,839
down bone and which builds new bone
when it comes to osteoclast and osteoblasts.

430
00:29:36,119 --> 00:29:40,359
Just remember, osteoclast has a C, and that C in my mind stands

431
00:29:40,400 --> 00:29:44,960
for consume bone because osteoclasts are involved
in the breakdown and resorption of bone.

432
00:29:45,160 --> 00:29:48,160
And then osteoblasts has a B,
and the B in your mind should stands

433
00:29:48,240 --> 00:29:52,079
for build, as in build bone, because osteoblasts are involved in rebuilding and

434
00:29:52,160 --> 00:29:56,440
remodeling bone. Let's talk about the
risk factors next. Advanced age is obviously

435
00:29:56,599 --> 00:30:03,359
a really big risk fact Probably one
of your biggest females are more at risk

436
00:30:03,799 --> 00:30:07,279
glucocorticoid therapy long term. One of
the main reasons steroids put you at a

437
00:30:07,319 --> 00:30:12,759
higher risk for osteoporosis is that they
actually decrease calcium absorption from the GI tract.

438
00:30:14,119 --> 00:30:18,599
They also cause osteoclast activation. They
inhibit osteoblasts a lot of different reasons.

439
00:30:19,000 --> 00:30:23,839
Just remember steroids are another big risk
factor for development of osteoporosis. Cigarette

440
00:30:23,880 --> 00:30:29,359
smoking and alcohol consumptions, some other
ones, and physical inactivity just to name

441
00:30:29,400 --> 00:30:33,400
a few. There's a ton more. Some secondary causes like ciliac disease,

442
00:30:33,480 --> 00:30:37,160
Cushing's diabetes. It's more common in
Caucasians worth other ethnicities. It's really a

443
00:30:37,240 --> 00:30:41,359
lot of difference factors, and I
encourage you to look them all up if

444
00:30:41,400 --> 00:30:44,559
you're interested. But the ones I
went over the more common ones to see,

445
00:30:44,599 --> 00:30:49,319
so keep those in mind. Clinical
manifestations, so osteoporosis really has no

446
00:30:49,400 --> 00:30:55,400
clinical manifestations until the patient has a
fracture. So there's no weakness or other

447
00:30:55,519 --> 00:30:59,119
symptoms. There's really nothing, and
that's why it's sometimes referred to as the

448
00:30:59,240 --> 00:31:03,000
silent disease. So let's talk about
the fractures, because that's what you're going

449
00:31:03,079 --> 00:31:07,319
to talk about. You know,
when we're talking about the clinical manifestations is

450
00:31:07,359 --> 00:31:11,319
the actual fracture. So the big
one that is associated the type of fracture,

451
00:31:11,440 --> 00:31:15,440
the main one that's associated with osteoporosis. Most common type of fracture you'll

452
00:31:15,480 --> 00:31:19,400
see in a patient with osteoporosis,
by far, is going to be vertebral

453
00:31:19,480 --> 00:31:25,200
compression fractures. So these are your
most common type of osteoprodict fractures. This

454
00:31:25,400 --> 00:31:27,400
is the one that you need to
focus on. What's really interesting about the

455
00:31:27,480 --> 00:31:33,680
type of fracture is that two thirds
of vertebral fractures and patients with osteoporosis are

456
00:31:33,759 --> 00:31:37,200
painless. That's just crazy to me. And this is actually one of the

457
00:31:37,279 --> 00:31:41,880
many reasons why we assess for loss
of height in patients at risk for osteoporosis,

458
00:31:41,960 --> 00:31:45,759
because the only indicator that in some
patients that they've had a vertebral compression

459
00:31:45,759 --> 00:31:49,400
fracture is the pact. That is
the fact that they've shrunk in the past

460
00:31:49,480 --> 00:31:53,440
few months from the fracture and the
result in disk space narrowing. So remember

461
00:31:55,480 --> 00:32:00,839
vertebral fractures are the most common type
of osteoproduct fracture. And just be aware

462
00:32:00,000 --> 00:32:04,519
they may not be complaining of any
paint and they vignette be looking for them

463
00:32:04,640 --> 00:32:07,559
just to mention maybe a patient complaining
of shrinking, or maybe you'll notice some

464
00:32:07,680 --> 00:32:12,200
chyphosis on the exam, that hunchback
appearance, which can also come from this.

465
00:32:13,079 --> 00:32:15,559
Another common one it would be hip
fractures. Fifteen percent of women five

466
00:32:15,599 --> 00:32:20,000
percent of men by the age of
eighty will have an osteoproduct hip fracture.

467
00:32:20,440 --> 00:32:24,240
And then distal radius fractures your colleagues
fractures, But again really focus in on

468
00:32:24,319 --> 00:32:30,720
those vertebral fractures. Now, diagnosis, there's two main ways to diagnose osteoporosis.

469
00:32:30,240 --> 00:32:32,960
It's going to be with a fragility, fracture, and then the other

470
00:32:34,039 --> 00:32:36,680
one. The main one you should
focus on is with your DEXAS scan.

471
00:32:36,839 --> 00:32:39,359
So let's start with a dexas scan
because this is your best test, your

472
00:32:39,400 --> 00:32:44,079
gold standard for osteoporosis. It's what
you really need to focus on for your

473
00:32:44,119 --> 00:32:49,079
exam. So DEXAS scan or dual
energy X ray absorbed geometry is how you

474
00:32:49,200 --> 00:32:52,880
check the bone density of a patient. Uses low dose X ray to measure

475
00:32:52,920 --> 00:32:55,720
the bone density at different sites in
the body, usually the spine, hip,

476
00:32:55,839 --> 00:33:00,480
forearm, and then we measure those
areas we come up with this T

477
00:33:00,720 --> 00:33:04,640
score. So the T score measures
how far away this person's bone density is

478
00:33:05,119 --> 00:33:08,720
from that of a young, healthy
individual with normal bone density. And that's

479
00:33:08,759 --> 00:33:14,759
why osteopenia and osteoporosis are represented with
negative numbers. So that's how far they

480
00:33:14,839 --> 00:33:17,759
deviate from a normal healthy adult.
So osteoporosis, for instance, is defined

481
00:33:17,799 --> 00:33:22,000
at a negative two point five or
less, so that means there are two

482
00:33:22,039 --> 00:33:25,599
point five standard deviations below the average
healthy adult with normal bone density. All

483
00:33:25,680 --> 00:33:29,279
right, So now that we have
an understanding of the test, let's talk

484
00:33:29,279 --> 00:33:30,599
about the numbers you need to know
for the exam. So the one.

485
00:33:30,640 --> 00:33:36,279
We just went over t score negative
two point five or less that is diagnostic

486
00:33:36,359 --> 00:33:40,160
of osteoporosis, and then negative one
point zero to negative two point five would

487
00:33:40,160 --> 00:33:45,160
be osteopenia or low bone masses,
the new term that they're using more often.

488
00:33:46,160 --> 00:33:50,079
Now, how do you remember those
two key numbers for the exam?

489
00:33:50,440 --> 00:33:53,759
How do you remember which one classifies
osteopenia, which one classifies osteoporosis. What

490
00:33:53,880 --> 00:33:58,880
I want you to remember is pen
is ten poor is less than two point

491
00:33:58,960 --> 00:34:01,359
four. Pen Is ten poor is
less than two point four, So a

492
00:34:01,440 --> 00:34:07,920
little rhyme there. So what does
that mean? So osteopenia like PN is

493
00:34:07,039 --> 00:34:12,119
negative one point zero or less aka
pen is ten ten being one point zero,

494
00:34:12,400 --> 00:34:17,000
and then osteoporosis poor is less than
two point four because remember osteoporosis is

495
00:34:17,000 --> 00:34:21,199
a negative two point five or less
another way of saying, negative two point

496
00:34:21,239 --> 00:34:24,599
five or less is less than negative
two point four. So remember pen is

497
00:34:24,679 --> 00:34:29,960
ten as an osteopenia is negative one
point zero or less, and then poor

498
00:34:30,199 --> 00:34:34,440
is less than two point four as
an osteoporosis is less than negative two point

499
00:34:34,480 --> 00:34:37,280
four. All right, So I
talked about this before. Bone density isn't

500
00:34:37,320 --> 00:34:43,079
the only way to make the diagnosis
of osteoporosis. Another way is from fragility

501
00:34:43,159 --> 00:34:46,760
fracture. So a fragility fracture is
just it's another way to make a diagnosis

502
00:34:46,760 --> 00:34:52,559
of osteoporosis independent of the T score. So a fragility fracture is a fracture

503
00:34:52,599 --> 00:34:55,800
that occurs from minor trauma like a
fall from standing height, something that wouldn't

504
00:34:55,880 --> 00:35:00,039
normally lead to fracture unless the patient
is an osteoproduct. So if a patient

505
00:35:00,079 --> 00:35:04,280
tells they were casually walking down the
street they had a trip in a fall,

506
00:35:04,719 --> 00:35:08,840
now they have multiple vertebral compression fractures. That's a fragility fracture, and

507
00:35:08,920 --> 00:35:14,760
you've made a clinical diagnosis of asti
process in that patient. Most common site

508
00:35:14,800 --> 00:35:17,599
of fragility fractures are going to be
the spine, so your vertebral compression fractures

509
00:35:19,119 --> 00:35:22,719
the hip the risk. They can
also occur the humorous ribs, pelvis.

510
00:35:22,519 --> 00:35:27,599
So again for diagnosis, really just
two things they have to remember negative two

511
00:35:27,639 --> 00:35:30,800
point five or less for the T
score or a fragility fracture. That's really

512
00:35:30,840 --> 00:35:35,159
all you need to focus on for
diagnosis. Technically, there also is the

513
00:35:35,400 --> 00:35:38,000
fracts tenure probability that can be used
for diagnosis, but for the exam,

514
00:35:38,360 --> 00:35:42,679
focus on your DEXA in your fragility
fractures and you're done. All right,

515
00:35:42,760 --> 00:35:45,679
let's move on to treatment. M
start with your lifestyle. I won't go

516
00:35:45,760 --> 00:35:50,760
too depth into that because the book
of your questions are going to come from

517
00:35:50,760 --> 00:35:53,719
your pharmacologic agents. But just make
sure your patients have adequate vitamin D and

518
00:35:53,800 --> 00:35:59,679
calcium intake. Encourage weight bearing,
exercise, smoking cessation, counseling on fall

519
00:35:59,679 --> 00:36:01,639
prevent mention, etc. All right, let's talk about men's which is where

520
00:36:01,639 --> 00:36:06,239
the high yield stuff is at.
So let's start with your bis phosphonates alendronate,

521
00:36:06,320 --> 00:36:09,039
recindronate. Those are your first lines. Bis Phosphonates are going to be

522
00:36:09,079 --> 00:36:15,880
your first line treatment for most patients. They're very effective, inexpensive in comparison

523
00:36:15,920 --> 00:36:17,360
to some of the other classes,
and they've been around a long time,

524
00:36:17,400 --> 00:36:22,199
so there's long term safety data available. So lendronate, which is fospimax,

525
00:36:22,760 --> 00:36:25,719
recindronate, which is actin. Now, these are the ones that you're going

526
00:36:25,800 --> 00:36:30,559
to hear about the most. There's
also zolodronic acid abandronate. These both come

527
00:36:30,559 --> 00:36:34,719
in IV forms. So a few
different agents in this class, a lot

528
00:36:34,760 --> 00:36:37,199
of different weird names, and how
are you going to remember the drugs in

529
00:36:37,280 --> 00:36:42,119
this class? Well, luckily,
all of the men's in this class have

530
00:36:42,239 --> 00:36:46,039
the word drone in them alendronate,
zoladronic acid. So as soon as you

531
00:36:46,119 --> 00:36:50,079
see a med that has the word
drone in it, I want you to

532
00:36:50,239 --> 00:36:54,800
think of this sentence. Phone in
your drones to build strong bones. Phone

533
00:36:54,960 --> 00:36:58,840
in your drones, to build strong
bones. So what does that mean?

534
00:36:59,199 --> 00:37:00,719
Well, drones, we just went
over all the meds have the word drone

535
00:37:00,760 --> 00:37:06,800
in them. Phone is because bisphosphonate
has the word phone in it. So

536
00:37:06,880 --> 00:37:09,039
if you can remember the sentence,
you can associate the two together. So

537
00:37:09,280 --> 00:37:15,960
phone as in bisphosphonates, drones as
in allen dronate to build strong bones.

538
00:37:15,000 --> 00:37:19,519
So when they give you a vignette
clear cutost your process patient that lists a

539
00:37:19,559 --> 00:37:22,159
bunch of meds, ask you which
is the first line men for this patient?

540
00:37:22,480 --> 00:37:23,920
You know it's a bisphosphonate, but
you can't remember any of the drugs

541
00:37:23,960 --> 00:37:28,360
in the class. Remember, look
for your drones. Phone in your drones

542
00:37:28,400 --> 00:37:31,079
to build strong bones. All right, Now, the mechanism of action if

543
00:37:31,119 --> 00:37:37,719
your bisphosphonates, they inhibit osteoclastic bone
resorption. So bis phosphonates are what are

544
00:37:37,800 --> 00:37:40,760
known as anti resorptive agents. It's
a little more complicated than this, but

545
00:37:40,840 --> 00:37:45,960
the general ideas that patient takes bisphosphonate. Bisphosphonates plant themselves onto the bone,

546
00:37:46,000 --> 00:37:52,800
onto something called hydroxy appetite. Osteoclasts
begin to resorb that bone that's impregnated with

547
00:37:52,840 --> 00:37:57,800
bisphosphonates at these binding sites. Once
they do, this leads to a couple

548
00:37:57,920 --> 00:38:05,199
different things that ultimately leads to the
destruction of the osteoclast. What happens,

549
00:38:05,360 --> 00:38:09,199
the first one is that it disrupts
the osteoclass ability to resorb bone, and

550
00:38:09,280 --> 00:38:15,920
then the second thing is it leads
to osteoclast apoptosis. Once the osteoclast absorbs

551
00:38:15,960 --> 00:38:19,719
these bisphosphonates, so the cell dies. So in the end we have less

552
00:38:19,760 --> 00:38:22,360
bone breakdown or resorption, which is
pretty nice and simple if you just think

553
00:38:22,360 --> 00:38:24,800
about it that way. Like I
said, it's a little bit more involved

554
00:38:24,840 --> 00:38:29,920
than that, but that's just the
general idea. Now adverse drug reactions,

555
00:38:30,360 --> 00:38:35,719
this is probably the most important thing
about bisphosphonates that they always test on always,

556
00:38:35,840 --> 00:38:37,800
I mean, there's always gonna be
a question on this, whether it's

557
00:38:37,840 --> 00:38:39,840
in your clinical medicine class on your
pants. You need to remember this about

558
00:38:39,920 --> 00:38:45,480
this class. They can cause pill
induced esophagitis. So in patients that take

559
00:38:45,519 --> 00:38:50,800
bisphosphonates, you have to tell them
to remain upright for at least thirty minutes

560
00:38:51,039 --> 00:38:54,360
and take with six to eight ounces
of water to avoid esophagitis. You have

561
00:38:54,480 --> 00:38:59,280
to remember to tell all of your
patients that stay upright for at least thirty

562
00:38:59,320 --> 00:39:01,920
minutes them take it with six state
ounces of water. If you take one

563
00:39:01,920 --> 00:39:05,119
of these meds and you lay down
to bed right after, you don't drink

564
00:39:05,159 --> 00:39:07,199
enough water, they remain in the
esophagus and they can lead to esophagitis.

565
00:39:07,599 --> 00:39:12,159
You have to remember that in these
patients you have to tell them those instructions,

566
00:39:13,199 --> 00:39:15,880
and then you also want to try
to avoid these medications and patients with

567
00:39:15,960 --> 00:39:20,960
a history of echalasia, esophageal strictures, barretts esophagus, or really any of

568
00:39:21,000 --> 00:39:25,719
the esophageal problems, particularly with allandronate. That's really important to remember that about

569
00:39:25,719 --> 00:39:29,719
this class. They're going to ask
you a question on it. Most commonly

570
00:39:29,760 --> 00:39:31,719
the list a bunch of meds.
They'll say which one of these medications should

571
00:39:31,760 --> 00:39:36,360
the patient avoid recumbency for least thirty
minutes, and then of course one of

572
00:39:36,400 --> 00:39:39,159
them will be a bisphosphonates. Remember, bisphosphonates can destroy your esophagus, so

573
00:39:39,239 --> 00:39:43,360
stay upright thirty to sixty minutes,
take with six state ounces of water,

574
00:39:44,119 --> 00:39:45,599
and just a heads up. If
you really need a patient to be on

575
00:39:45,639 --> 00:39:49,920
a bisphosphonate and you know they're not
going to follow the rules and stay upright

576
00:39:49,960 --> 00:39:52,079
for thirty minutes, or they have
esophageal disorders, you can actually give them

577
00:39:52,119 --> 00:39:58,320
an IV bisphosphonate like solodronic acid as
opposed to PO to circumvent this issue.

578
00:40:00,079 --> 00:40:05,280
Other adverse strug reaction is osteoocrosis of
the jaw and atypical femur fractures. I

579
00:40:05,440 --> 00:40:07,840
list these not because they're common,
it's quite the opposite. They're actually quite

580
00:40:07,920 --> 00:40:12,320
rare, but just because they do
come up in questions from time to time.

581
00:40:12,400 --> 00:40:15,159
So austegnocrosis of the jaw, the
incidence is anywhere from one in ten

582
00:40:15,239 --> 00:40:19,840
thousand to one and one hundred thousand, and it was really only seen in

583
00:40:19,960 --> 00:40:23,239
cancer patience or in patience with a
compromise immune system that were treated with high

584
00:40:23,280 --> 00:40:29,679
doses of ibiv bisposphonates, but it
can still happen, so encouraged dental hygiene.

585
00:40:30,000 --> 00:40:32,880
And then the atypical femur fractures is
another rare complication, so just be

586
00:40:32,920 --> 00:40:37,800
aware of those in real life,
very uncommon. Really, just focus in

587
00:40:37,920 --> 00:40:40,639
on your esophagitis. So those are
the main adverse strug reactions to focus on.

588
00:40:40,840 --> 00:40:44,239
Of course, there's a laundry list
of others, but again, focus

589
00:40:44,320 --> 00:40:46,199
on what's likely going to be tested, which is burning a hole in your

590
00:40:46,280 --> 00:40:51,320
esophagus, austeinocrosis of the jaw,
and you'r atypical fema fractures. All right,

591
00:40:51,440 --> 00:40:53,920
let's move on. There's some other
classes of men's to treat osteoporosis.

592
00:40:54,239 --> 00:40:57,840
I'm going to mention them, but
I'm not going to go really that into

593
00:40:57,920 --> 00:41:00,079
depth because if you're going to get
an exam question nine of the time,

594
00:41:00,320 --> 00:41:04,039
it's going to be on bisphosphonates.
So focus on those, but at least

595
00:41:04,239 --> 00:41:07,320
let's mention the other classes. So
first let's talk about your antibolic agents.

596
00:41:08,000 --> 00:41:13,679
These are used more frequently, they're
really reserved for patients with severe osteoporosis,

597
00:41:13,840 --> 00:41:17,039
like a T score of negative three
point five or less. The reason that

598
00:41:17,079 --> 00:41:22,519
you reserve these meds for your more
severe cases is because these meds, unlike

599
00:41:22,599 --> 00:41:27,679
bis phosphonates that really only preserve existing
bone, these antibolic agents actually have the

600
00:41:27,719 --> 00:41:31,360
ability to rebuild new bone. The
meds in this class are terraparatide, a

601
00:41:31,440 --> 00:41:37,920
belloparatide, and then romo suzumab.
These are your antibolics, and teraparatide and

602
00:41:38,079 --> 00:41:44,639
a belloparatide are synthetic forms of PT
and PTRP, respectively. And then when

603
00:41:44,679 --> 00:41:50,199
you take these drugs, these agents
stimulate osteoblasts which help rebuild bone. And

604
00:41:50,400 --> 00:41:52,960
like I said before, this is
different than your bis phosphonates, which were

605
00:41:52,960 --> 00:41:59,239
antiresorptive agents that prevented bone resorption.
These antibolics are actually rebuilding new bone.

606
00:42:00,559 --> 00:42:02,039
What you do is you take these
meds for a year or two, you

607
00:42:02,159 --> 00:42:06,159
build your new bone, and then
you discontinue these meds. They can really

608
00:42:06,199 --> 00:42:07,559
only be used for a max of
one to two years, and then you

609
00:42:07,679 --> 00:42:12,679
start them on a bisphosphonate or another
anti resorptive just to preserve that new bone

610
00:42:12,719 --> 00:42:15,679
that was built. The last one
that I mentioned Romo suzumb it's a fairly

611
00:42:15,760 --> 00:42:20,079
new med It just got after you
approval in twenty nineteen. Same idea,

612
00:42:20,159 --> 00:42:22,920
though it builds bone. Just does
it a little bit differently. It's actually

613
00:42:22,039 --> 00:42:29,360
a monoclonal antibody that inhibits something called
sclerostin. Don't worry too much about that.

614
00:42:29,519 --> 00:42:31,039
So those are your antibolic agents.
I gave you a little bit of

615
00:42:31,079 --> 00:42:34,599
extra inflo there. I don't think
you should memorize all of that. Just

616
00:42:34,800 --> 00:42:37,400
be aware when it comes to your
antibolic agents. Have some familiarity with the

617
00:42:37,519 --> 00:42:42,239
names of the meds that are involved, and know they're generally reserved for your

618
00:42:42,320 --> 00:42:45,039
more severe osteoporosis and that they can
build bone. And that's really it,

619
00:42:45,760 --> 00:42:52,400
right. So another medication for osteoporosis
is another antiresorptive drug like our bisphosphonates,

620
00:42:52,679 --> 00:42:55,320
and it's known as dinasim mAbs.
So it's not as potent as the antibolic

621
00:42:55,400 --> 00:42:59,320
agents I just went over, But
the nice thing about it is it's only

622
00:42:59,320 --> 00:43:02,880
administered every six months. It's basically
reserved for people who are not good candidates

623
00:43:02,960 --> 00:43:07,960
for bis phosphonates, and it's particularly
useful in patients with impaired renal function as

624
00:43:08,000 --> 00:43:10,880
it can be safe in these patients. And then one final men to be

625
00:43:10,960 --> 00:43:16,960
aware of is reloxophene. So reloxophene
is a selective estrogen receptor modulator or SERM

626
00:43:17,119 --> 00:43:22,320
for short. It's another anti reservative
agent. Does not work as well as

627
00:43:22,360 --> 00:43:25,719
bis phosphonates. But the unique thing
about this drug in addition to treating osteoporosis

628
00:43:27,079 --> 00:43:30,679
is that it also reduces the risk
of breast cancer, so it's usually reserved

629
00:43:30,960 --> 00:43:35,639
for osteoprosis patients when there's also a
need for breast cancer prophylaxis. And the

630
00:43:35,719 --> 00:43:42,960
way that you can remember that is
reloxophene also sounds similar to another breast cancer

631
00:43:43,039 --> 00:43:46,039
prophylaxis treatment met that you've probably heard
of, and that's tamoxifen. So it

632
00:43:46,079 --> 00:43:52,599
sounds very similar, right, reloxofen
or reloxophene or sounds similar to tamoxifen.

633
00:43:52,880 --> 00:43:57,280
So remember this is the one that
you use when breast breast cancer prophylaxis is

634
00:43:57,320 --> 00:44:00,559
also indicated. That's the unique thing
to focus on here. So those are

635
00:44:00,599 --> 00:44:06,079
some additional options outside of your bis
phosphonates for treatment of osteoporosis. I'll reiterate

636
00:44:06,360 --> 00:44:09,360
focus should be on your bis phosphonates, your drones, the other ones I

637
00:44:09,400 --> 00:44:12,920
went over. Just be familiar with
them. But I wouldn't waste any more

638
00:44:12,960 --> 00:44:16,239
than a minute because you're likely going
to get a question about your bis phosphonates

639
00:44:16,280 --> 00:44:21,400
if they give you a farm question
about osteoporosis. So remember phoning your drones

640
00:44:21,440 --> 00:44:24,360
to build strong bones, willindronate residronate. Those are the ones you need to

641
00:44:24,480 --> 00:44:28,360
know, all right, So there's
a lot to know frosteoporosis. If I

642
00:44:28,440 --> 00:44:30,360
had to give you a few top
things to remember, it would be one.

643
00:44:30,800 --> 00:44:34,800
Remember your DEXIS scan as your gold
standard test, and a negative two

644
00:44:34,840 --> 00:44:38,800
point five or less it's diagnostic of
osteoporosis. Remember vertebral fracture is your most

645
00:44:38,880 --> 00:44:44,920
common Remember bis phosphonates are first line
treatment. And remember esophagitis is an adverse

646
00:44:45,000 --> 00:44:49,280
drug reaction of bis phosphonates, so
avoid recumbency for at least thirty minutes after

647
00:44:49,400 --> 00:44:52,320
taking them. Those are the high
sealed things to remember about osteoporosis. All

648
00:44:52,360 --> 00:44:55,239
right, we're almost there. We
just have two small topics to go over.

649
00:44:55,360 --> 00:45:01,639
So polyardorized night polyardoritis no dosa wich
is also known as PAN to keep

650
00:45:01,679 --> 00:45:07,360
it short. So this is a
systemic vasculitis characterized by necrotizing inflammatory lesions that

651
00:45:07,519 --> 00:45:13,639
primarily affect medium sized arteries, with
occasional involvement of small arteries. So in

652
00:45:13,679 --> 00:45:19,079
this condition, the immune cells attack
the endothelium. This causes transmural inflammation of

653
00:45:19,119 --> 00:45:22,320
these arteries. Transmural meaning all of
the layers of the vessel are inflamed.

654
00:45:22,679 --> 00:45:28,039
Eventually this causes the wall of the
vessel to die. And then where we're

655
00:45:28,079 --> 00:45:30,599
left with these fibrotic changes, and
due to all the fibrosis and inflammation,

656
00:45:30,920 --> 00:45:36,280
we have these blood flow disturbances,
so a schemia infarction, which causes a

657
00:45:36,360 --> 00:45:38,639
lot of the clinical manifestations will go
over in a minute. Basically, this

658
00:45:38,800 --> 00:45:43,519
disease screws up your arteries, which
screws up your blood flow, and whichever

659
00:45:43,679 --> 00:45:46,039
organ is supplied by the artery that's
affected is going to lead to your clinical

660
00:45:46,119 --> 00:45:50,719
manifestation so kidney, heart, intestine, etc. Then Remember, mainly is

661
00:45:50,719 --> 00:45:53,440
going to be affecting your medium sized
arteries, but occasionally can involve the small

662
00:45:53,519 --> 00:45:59,960
ones as well. Hepatitis, So
what about hepatitis. The etiology of most

663
00:46:00,280 --> 00:46:06,119
cases of PAN is going to be
idiopathic, but hepatitis B and hepatitis C

664
00:46:06,280 --> 00:46:10,079
infection are important in the pathogenesis of
some cases, and one study from France

665
00:46:10,119 --> 00:46:15,039
they found that hepatitis B virus accounted
for one third of all the cases,

666
00:46:15,440 --> 00:46:17,320
so look out for that in the
vignette. It can be HAPPY or C,

667
00:46:17,519 --> 00:46:21,800
but it's mainly hepatitis B that they'll
talk about, which is more common.

668
00:46:22,280 --> 00:46:27,000
Talk about our clinical manifestations next.
So renal disease. Renal disease causing

669
00:46:27,119 --> 00:46:31,159
hypertension, So the kidneys are going
to be very commonly affected. In autopsy

670
00:46:31,199 --> 00:46:36,039
studies, they actually found the kidneys
to be the most commonly involved organ And

671
00:46:36,159 --> 00:46:40,239
I mentioned hypertension as a clinical manifestation
under renal disease because remember the kidneys control

672
00:46:40,280 --> 00:46:45,039
blood volume and in turn are blood
pressure. So when the renal arteries are

673
00:46:45,039 --> 00:46:47,320
affected, we have renal eschemia,
which you can lead to hypertension. So

674
00:46:47,480 --> 00:46:52,679
they may mention hypertension because of the
renal arteries being affected. So let's talk

675
00:46:52,679 --> 00:46:57,800
about our dermatologic findings next. So
there are some skin manifestations of PAN that

676
00:46:57,920 --> 00:47:01,599
can include purpora, levid or articularius
ulcers. It's even possible to get these

677
00:47:01,679 --> 00:47:06,840
tender nodules on the skin levito articularius. If this is the first time you're

678
00:47:06,880 --> 00:47:10,119
hearing this term, it's just this
blue purple discoloration of the skin. It

679
00:47:10,199 --> 00:47:15,000
almost has this netli or web like
pattern, which is just due to vessel

680
00:47:15,159 --> 00:47:19,159
eschemia. If you've ever gotten really
cold and you notice your skin was kind

681
00:47:19,199 --> 00:47:22,159
of turning blue, that's what this
is. It's just when your blood vessels

682
00:47:22,159 --> 00:47:24,719
constrict in response to the cold,
which leads to a schemia. But in

683
00:47:24,800 --> 00:47:29,199
this case, the eschemia isn't from
the cold temperature, it's from the fibrodict

684
00:47:29,280 --> 00:47:34,679
changes we talked about before. Something
else with your neurologic findings is known as

685
00:47:34,840 --> 00:47:43,039
monneuropathy multiplex. SO monneuropathy multiplex or
asymmetric polyeuropathy is another common finding and patients

686
00:47:43,079 --> 00:47:45,960
with PAN. It's in up to
seventy percent of patients. The neuropathy is

687
00:47:46,079 --> 00:47:50,920
usually asymptomatic at the start, but
later on, as it involves additional nerve

688
00:47:51,000 --> 00:47:53,679
branches, it can lead to a
more systemic neuropathy. So just kind of

689
00:47:53,719 --> 00:48:00,599
remember that term mono neeuropathy multiplex,
So those are the main clinical benifestations I

690
00:48:00,639 --> 00:48:04,039
feel like you should try to focus
on. In reality, though virtually any

691
00:48:04,159 --> 00:48:07,159
organ of the body can be affected
in patients with PAN, then you can

692
00:48:07,239 --> 00:48:10,559
have a wide number of clinical manifestations, so I'm obviously not going to go

693
00:48:10,599 --> 00:48:14,519
over all of them. But you
can also have breast and uterine involvement,

694
00:48:14,639 --> 00:48:20,519
splenic infarction, orchitis, abdominal pain
from esenteric arteritis. But the ones I

695
00:48:20,639 --> 00:48:22,519
listened above are the most common ones
and the ones that you should try to

696
00:48:22,559 --> 00:48:25,760
remember. But I said, it
can involve almost anything, but there is

697
00:48:25,880 --> 00:48:30,159
one really important exception that you need
to know. So it has this tendency

698
00:48:30,679 --> 00:48:35,480
to spare the lungs. So I
said that PAN can affect almost any organ.

699
00:48:35,800 --> 00:48:38,599
But what's unique about this form of
vasculitis compared to the others is that

700
00:48:38,719 --> 00:48:43,400
it has this tendency to spare the
lungs. That's really unique. It could

701
00:48:43,480 --> 00:48:47,079
absolutely be mentioned in the vignette.
So if you see lung perinchomal involvement by

702
00:48:47,159 --> 00:48:52,880
vasculitis, this strongly suggests a different
disease, not PAN, because PAN has

703
00:48:52,920 --> 00:48:55,880
the striking tendency to spare the lungs
for whatever reason, which is quite different

704
00:48:55,920 --> 00:49:00,519
than the other forms of vasculitis.
To remember that if it mentions long involvement,

705
00:49:00,639 --> 00:49:06,400
be looking for something other than PAN
diagnosis. Most important thing to remember

706
00:49:06,440 --> 00:49:10,440
about diagnosis is that this condition will
generally be ANCHA negative. So nothing's one

707
00:49:10,519 --> 00:49:14,920
hundred percent medicine, but most of
the time PAN is not going to be

708
00:49:14,960 --> 00:49:20,840
associated with the presence of antineutrophil cytoplasmic
antibodies or ank UP for short. So

709
00:49:20,920 --> 00:49:23,480
if you see the patient as anchor
positive, generally you should be thinking of

710
00:49:23,639 --> 00:49:30,360
some of the other vascular tides like
microscopic polygitis, et So remember that you

711
00:49:30,440 --> 00:49:34,360
also need to know for diagnosis.
If you do an androgram of these patients,

712
00:49:34,400 --> 00:49:37,360
you're likely going to see numerous aneurysms
of the vessels. The reason this

713
00:49:37,480 --> 00:49:43,119
happens is from the fibrotic changes we
talked about before. Those fibronic changes weaken

714
00:49:43,199 --> 00:49:45,960
the vessels, which make them more
susceptible to aneurysm. So just kind of

715
00:49:45,960 --> 00:49:50,320
be aware of that as well,
but really focus on that ANCHA negative.

716
00:49:50,360 --> 00:49:52,960
That's the important takeaway here. Now
for treatment, it's pretty easy. It's

717
00:49:53,000 --> 00:49:57,960
going to be glucocorticoids pretty much all
patients with PAN are going to be treated

718
00:49:57,960 --> 00:50:01,800
with glucocorticoids. You're more severe cases, you can add on your immuno suppressive

719
00:50:01,840 --> 00:50:06,679
man's like cyclophospha mind, but in
general, gluca corticoids is going to be

720
00:50:06,800 --> 00:50:08,280
what you need to remember for your
treatment of PAN. All right, So

721
00:50:08,400 --> 00:50:14,079
the most important thing to remember about
PAN is not what it does have,

722
00:50:14,360 --> 00:50:16,079
but what it doesn't have, and
that's really the best way to differentiate it

723
00:50:16,639 --> 00:50:22,239
from the other forms of vasculitis.
And what it doesn't have is lung involvement

724
00:50:22,320 --> 00:50:24,559
in ANKA, so no lung involvement, negative anchor. And the way that

725
00:50:24,599 --> 00:50:30,239
you're going to remember that is PAN
is the only vasculitis that has the word

726
00:50:30,440 --> 00:50:34,639
no at the start of its name, polyardoritis no dosa. So when you

727
00:50:34,719 --> 00:50:38,800
see polyardoritis no dosa, I want
you to remember the no in its name

728
00:50:38,920 --> 00:50:44,159
and think, this is the one
doesn't involve the lungs no no dosa.

729
00:50:44,639 --> 00:50:47,519
Is this the one that's anchor positive? No no dosa. So if they

730
00:50:47,599 --> 00:50:52,199
mentioned the lungs or positive ANCA,
it's very unluckly to polyardoritis no dosa.

731
00:50:52,239 --> 00:50:55,840
So be thinking of some of the
other vasculitides that don't have no in their

732
00:50:55,920 --> 00:51:00,760
name, like microscopa, polyangitis,
shirt strauss ease, which are generally anchor

733
00:51:00,880 --> 00:51:05,679
positive and do involve the lungs.
To remember, if you see no and

734
00:51:05,760 --> 00:51:09,320
no dosa, be remembering no lung
involvement, no anchor, as this will

735
00:51:09,400 --> 00:51:13,199
likely be the only thing to differentiate
from the other causes. All right,

736
00:51:13,239 --> 00:51:15,760
So let's move on to polymyalgia rheumatica. It's not allow to know for this,

737
00:51:15,880 --> 00:51:19,360
but there's a few high old things
I've picked out for you to focus

738
00:51:19,440 --> 00:51:23,480
on. So this is a chronic
inflammatory condition of unknown etiology leading to pain

739
00:51:23,599 --> 00:51:27,719
and stiffness in the shoulders, hip, girdle, and neck. So the

740
00:51:27,880 --> 00:51:32,159
name may throw you off because polymyalgia
rheumatica polymyalgia basically, when you break it

741
00:51:32,239 --> 00:51:37,159
down, means pain and multiple muscles. So you would assume that this involves

742
00:51:37,239 --> 00:51:42,119
the muscles. But the muscle in
PMR is histopathologically normal, and that's why

743
00:51:42,199 --> 00:51:46,239
in physical exam you'll normally find normal
muscle strength. PMAR really involves the joints

744
00:51:46,280 --> 00:51:52,320
and the periarticular structures like the bursa
and the tendons. PMR is almost exclusively

745
00:51:52,400 --> 00:51:55,960
a disease of adults, over the
age of fifty. The older the patient,

746
00:51:57,039 --> 00:52:00,079
the higher the prevalence. Peak incidence
is going to be between seventy eighty

747
00:52:00,159 --> 00:52:05,039
years old, and women are affected
two to three times more common than men.

748
00:52:05,320 --> 00:52:07,199
So the vignette be looking for an
older patient, likely a woman.

749
00:52:07,480 --> 00:52:10,239
If you see a twenty year old
NA vignette, you know it ain't PMR,

750
00:52:10,360 --> 00:52:14,800
so move on, look for something
else. Next thing, giant cell

751
00:52:15,000 --> 00:52:17,920
ardoritis ring the alarms. This is
the most important thing to know about PMR,

752
00:52:19,440 --> 00:52:22,000
probably the top five things to know
in all of rheumatology. You're going

753
00:52:22,079 --> 00:52:27,079
to be asked about this at some
point. Giant cell arduritis is associated with

754
00:52:27,280 --> 00:52:30,519
polymyalgia rheumatica. You have to know
that anywhere from five to thirty percent of

755
00:52:30,519 --> 00:52:35,320
patients with PMR are going to have
giant cell So why is that so important

756
00:52:35,320 --> 00:52:37,559
to know? Well, giant cell
ardoritis can lead to blindness if it's not

757
00:52:37,639 --> 00:52:40,920
treated. So if you make the
diagnosis of PMR and a patient, make

758
00:52:40,960 --> 00:52:45,039
sure you're asking the patient about headaches, jaw claudication, transient vision loss,

759
00:52:45,079 --> 00:52:50,800
which can all be found in a
patient with giant cell So you want to

760
00:52:50,840 --> 00:52:53,480
make sure that they don't also need
a workup for giant cell ardoritis. You

761
00:52:53,519 --> 00:52:58,199
don't want to miss that diagnosis.
It's really important. It's so important that

762
00:52:58,320 --> 00:53:00,840
I had this ridiculous way to remembered
in school, and so to this day

763
00:53:00,840 --> 00:53:04,360
I remember the two are associated with
each other. So I want you to

764
00:53:04,440 --> 00:53:08,199
remember instead of the name Paul E. Mayaljo roumatica, PAULI mayalgio romatica.

765
00:53:08,559 --> 00:53:14,199
I want you instead, instead of
remembering PAULI mayalgio romatica, remember Paul B.

766
00:53:14,480 --> 00:53:17,920
Mayalgio rumatica. Paul as in the
name Paul Paul and B as in

767
00:53:17,960 --> 00:53:22,679
the letter B, B as in
boy. So instead of Paul emyalgo romatica,

768
00:53:22,800 --> 00:53:28,320
Paul B Mayaljo rumatica. So forget
about the name Paul mayalgia forever.

769
00:53:28,480 --> 00:53:31,320
I want you to remember this as
Paul B. Mayalgio romatica. Why Paul

770
00:53:31,440 --> 00:53:36,280
B. Because Paul B is going
to help you remember Paul Bunyan. And

771
00:53:36,360 --> 00:53:39,079
if you remember those stories you read
as a kid, like in elementary school,

772
00:53:39,280 --> 00:53:43,559
Paul Bunyan was that giant who held
that big axe and then helps you

773
00:53:43,639 --> 00:53:47,800
remember giant sell artritis. So Paully
mayalgio romatica is forever going to be known

774
00:53:47,880 --> 00:53:52,000
for you as Paul B Myalgia romatica
Paul B as in Paul Bunyan the giant

775
00:53:52,239 --> 00:53:57,039
to help you remember, this is
associated with giant cell artortis. Let's talk

776
00:53:57,039 --> 00:54:00,519
about the clinical manifestations next. These
patients are gonna have aching and stiffness involving

777
00:54:00,559 --> 00:54:04,480
the shoulders, hip, girdle,
neck, and torso that's going to be

778
00:54:04,559 --> 00:54:07,119
worst in the morning. So this
is the general presentation. You're looking for

779
00:54:07,360 --> 00:54:12,679
pain in the proximal joints, with
bilateral shoulder pain being the most common presenting

780
00:54:12,760 --> 00:54:16,800
menifestations in almost all patients seventeen to
nine. You can also remember that because

781
00:54:16,800 --> 00:54:20,920
if you think back to Paul Bunyan, remember he carried that big axe over

782
00:54:21,039 --> 00:54:23,199
his shoulder all day. Definitely had
some shoulder pain, at least that's how

783
00:54:23,239 --> 00:54:27,920
I remembered it. And like I
said, these symptoms that they're going to

784
00:54:27,960 --> 00:54:31,039
be worst in the morning or after
any period of inactivity up to day.

785
00:54:31,079 --> 00:54:37,280
Goes as far as to say morning
stiffness in PMR is invariable. Its absence

786
00:54:37,480 --> 00:54:40,840
excludes a diagnosis of PMR, So
look for that in the vignette to describe

787
00:54:40,920 --> 00:54:45,000
the stiffing or acheness to aching to
be worse in the morning. They also

788
00:54:45,119 --> 00:54:49,440
may mention the patient as difficulty rising
from a chair, turning over in bed,

789
00:54:49,800 --> 00:54:52,119
raising the arms above shoulder height,
but in general be looking for stiffness

790
00:54:52,199 --> 00:54:55,960
aching in the shoulders most common,
as well as the neck hips worst in

791
00:54:57,039 --> 00:55:00,920
the morning. Let's talk about our
laboratory findings next. Increased ESR and CRP.

792
00:55:01,239 --> 00:55:06,880
So you're a cute phase reactance,
orthrocyte sedimentation rate and your c reactive

793
00:55:06,960 --> 00:55:10,039
protein, which are your inflammatory markers, they're going to be elevated and virtually

794
00:55:10,199 --> 00:55:14,199
all patients with PMR, so keep
that in mind. That's really important.

795
00:55:15,039 --> 00:55:19,599
And then really the only thing otherwise
to focus on for labs is you're going

796
00:55:19,639 --> 00:55:22,400
to order other labs, but it's
just to rule out your differentials. So

797
00:55:22,480 --> 00:55:25,480
you'll check your rheumatoid factor. You'll
check your anti CCP. This is to

798
00:55:25,599 --> 00:55:30,519
rule out late on set a rheumatoid
arthritis. You also check your muscle enzymes

799
00:55:30,599 --> 00:55:36,639
like creating kind as to rule out
polyumyocytis. So with PMR, there's really

800
00:55:36,679 --> 00:55:40,679
no path etemonic test or labs to
make a definitive diagnosis. You're essentially just

801
00:55:40,800 --> 00:55:45,519
looking for a few different factors is
a patient over fifty? Check do they

802
00:55:45,559 --> 00:55:49,480
have the classic presentation bilateral shoulder or
pelvic girdle aching horse in the morning?

803
00:55:49,599 --> 00:55:53,159
Check? Are my cute phase reactance
elevated? Your ESRCRP check? And then

804
00:55:53,280 --> 00:55:58,039
finally, one of the most important
keys to the puzzle to say whether or

805
00:55:58,039 --> 00:56:02,039
not this is indeed PMR is their
response to treatment. So first, what

806
00:56:02,199 --> 00:56:06,880
is the treatment for PMR. It's
steroids. One hundred percent steroids, So

807
00:56:07,440 --> 00:56:13,280
low dose gluco corticoids is recommended for
all patients diagnosed with polymiologial romatica anywhere from

808
00:56:13,280 --> 00:56:17,000
fifteen to twenty five milligrams daily.
The thing about PMR, unlike a lot

809
00:56:17,039 --> 00:56:20,559
of things in medicine that we treat, where most of the time it takes

810
00:56:20,559 --> 00:56:22,239
a while for the METS to make
an impact, PMR is one of the

811
00:56:22,360 --> 00:56:29,280
few diseases that responds super quick to
treatment. Some patients report dramatic symptomatic relief

812
00:56:29,320 --> 00:56:34,360
after just a single corticoid dose.
Majority of patients experienced substantial improvement within just

813
00:56:34,480 --> 00:56:37,239
a few days of starting treatment.
Now, I mentioned before when I was

814
00:56:37,280 --> 00:56:44,039
talking about diagnosis that steroids can be
part of making the diagnosis, and that's

815
00:56:44,079 --> 00:56:49,840
because the lack of response to initial
therapy with glucal corticoids strongly suggests an alternative

816
00:56:49,880 --> 00:56:52,000
diagnosis. Now, of course,
this isn't one hundred percent. Some patients

817
00:56:52,039 --> 00:56:55,360
may take longer to respond, but
in general, a rapid response to pride

818
00:56:55,480 --> 00:57:00,599
zone is very characteristic of this disease
and has actually include in some diagnostic criteria.

819
00:57:01,159 --> 00:57:06,159
All right, so that was part
one of the rheumatology section, Part

820
00:57:06,239 --> 00:57:08,559
one of two. Let's do five
quick questions and we will wrap it up.

821
00:57:08,679 --> 00:57:13,800
Question one, fifty two year old
man presents the emergency department complaining of

822
00:57:13,920 --> 00:57:17,480
severe pain in his first metatarsulphalangeal joint. He denize trauma to the area and

823
00:57:17,599 --> 00:57:22,599
states its started suddenly. Arthur synthesis
is performed, which displays negatively by a

824
00:57:22,639 --> 00:57:30,079
fringent needle shaped crystals. Medical history
includes hypertension, type two diabetes, hyperlipidemia,

825
00:57:30,119 --> 00:57:36,280
and current medications include hydrochlorothizide, metformin, glyposide, and resuva statin,

826
00:57:36,599 --> 00:57:39,880
which medication that the patient is currently
taking is the most likely culprit leading to

827
00:57:39,960 --> 00:57:44,119
his current clinical manifestations. Again,
I'll tell you the mens. Those were

828
00:57:44,159 --> 00:57:49,599
hydrochlorothiside metformin, glyposide and resuvastatin,
which men likely led to the clinical manifestations

829
00:57:49,880 --> 00:57:52,840
that would be hydrochlorothiside. So this
is about as clear cut a case of

830
00:57:52,920 --> 00:57:57,960
gout as you can get severe pain
first toe negatively by a fringine needle shape

831
00:57:57,960 --> 00:58:00,519
crystals on Arthur synthesis. Ring the
bell your answer right there. You just

832
00:58:00,599 --> 00:58:05,719
have to remember which meds can cause
Gaut flares, and in this case it's

833
00:58:05,800 --> 00:58:10,639
hydrochlorothiside, So remember your thyside.
Diuretics like hydrochlorthiside can increase urate reabsorption of

834
00:58:10,679 --> 00:58:15,639
the proxymoorhinal tubule, which can elevate
your uric acid levels and precipitate Gaut flares.

835
00:58:15,880 --> 00:58:20,079
So remember they're one of the many
meds that can cause Gaut flares.

836
00:58:20,360 --> 00:58:22,519
Remember the way that you remember that
as you remember, put too much seafood

837
00:58:22,559 --> 00:58:27,480
on your plate and you'll get gaut
played again. Stands for pierrezenamide, loop

838
00:58:27,519 --> 00:58:31,039
diuretics, aspirin, thisides like your
hydrochlorothyside, and a thambutol. That helps

839
00:58:31,079 --> 00:58:36,559
you remember the main meds that can
cause your Gaut flares. Question two seventy

840
00:58:36,559 --> 00:58:39,000
two year old female presents to the
office today for a routine checkup. Path

841
00:58:39,079 --> 00:58:45,239
medical history includes hypertension, hyperlipidemia.
She states she has concern about osteoporosis as

842
00:58:45,280 --> 00:58:49,400
her mother was diagnosed with it in
her sixties and wound up with a hip

843
00:58:49,440 --> 00:58:52,559
fracture. A dexas scan is order
which reveals a T score of negative two

844
00:58:52,599 --> 00:58:55,920
point six. It is designed that
the patient will be started on the first

845
00:58:57,000 --> 00:59:01,559
line medication class frosteoporosis. What mordant
instructions should be provided to the patient before

846
00:59:01,679 --> 00:59:06,960
taking her first dose, So that
would be to avoid recumbency for at least

847
00:59:07,000 --> 00:59:09,960
thirty minutes and take with six D
eight ounces of water. So first you

848
00:59:10,039 --> 00:59:14,519
need to know what's the first line
medication for osteoporosis. That, of course

849
00:59:14,639 --> 00:59:17,400
is bisphosphonates. And one of the
most important adverse drug reactions, like I

850
00:59:17,519 --> 00:59:22,760
went over before from bisphosphonates, that
you have to know is esophagitis, and

851
00:59:22,880 --> 00:59:25,199
that can be avoided by making sure
the patient stays upright for at least thirty

852
00:59:25,239 --> 00:59:29,119
minutes, takes the medication with at
least six D eight ounces of water.

853
00:59:29,800 --> 00:59:34,880
It's actually a contraindication if you look
at all of the bisphosphonate meds listening under

854
00:59:34,880 --> 00:59:37,840
the contraindications to give this any patient
who can't remain upright for at least thirty

855
00:59:37,880 --> 00:59:43,079
minutes, So remember that that's really
important. Question three. Sixty three year

856
00:59:43,079 --> 00:59:46,519
old female presents to her physician's office
complaining of pain and stiffness and her shoulders,

857
00:59:46,599 --> 00:59:50,960
hip and neck. She states the
symptoms are very severe in the morning,

858
00:59:51,239 --> 00:59:53,480
sometimes limiting her activity, and as
the day goes on there is moderate

859
00:59:53,559 --> 01:00:00,400
improvement. Physical exam reveals normal strength
and slightly reduced range of motion. Labs

860
01:00:00,519 --> 01:00:06,760
reveal elevated erythrocyte sedimentation rate and C
reactive protein serum rheumatoid factor as well as

861
01:00:06,840 --> 01:00:10,800
creating kinase are normal. The patient
is diagnosed with polymyodro romatica and started on

862
01:00:10,960 --> 01:00:16,519
cortico steroids. A clinical assessment for
the presence of what other associated condition should

863
01:00:16,559 --> 01:00:20,920
be considered in this patient. You
hunt one hundred percent need to know this

864
01:00:21,239 --> 01:00:24,599
and that will be giant cell ardoritis. So remember giant cell ardorius is associated

865
01:00:24,639 --> 01:00:29,440
with polymyogio romatica. You have to
know that anywhere from five to thirty percent

866
01:00:29,480 --> 01:00:32,159
of patients with PMR will have giant
cell ardorritis. Needs to remember the two

867
01:00:32,199 --> 01:00:37,480
are associated together. Always remember instead
of Paul emylgier romatica, remember Paul b

868
01:00:37,679 --> 01:00:42,920
mylgi romatica, Paul b as in
Paul Bunyan the giant. Remember this is

869
01:00:42,960 --> 01:00:46,639
associated with giant cell ardortus. Question
four, Who is the most common type

870
01:00:46,679 --> 01:00:52,320
of osteoporotic fracture? And that is
going to be your vertebral fractures, So

871
01:00:52,400 --> 01:00:57,360
your vertebral compression fractures are the most
common type of osteoporotic fracture. These type

872
01:00:57,360 --> 01:01:00,880
of fractures can sometimes be asymptomatic,
so remember assessing for loss of height and

873
01:01:01,039 --> 01:01:06,159
chyphosis. These are important because sometimes
these can be the only indicator of a

874
01:01:06,320 --> 01:01:09,639
vertebral compression fracture in an osteoporotic fracture. Question five, last one. A

875
01:01:09,760 --> 01:01:14,840
sixty three year old mail presents at
the office today complaining of diarrhea and abdominal

876
01:01:14,880 --> 01:01:17,880
cramping for the past few days.
He denies recent dietary changes, no recent

877
01:01:17,960 --> 01:01:22,920
travel, he states. The only
changes he was recently diagnosed with gout and

878
01:01:22,079 --> 01:01:27,880
started on a new medication. Which
medication did this patient likely start on for

879
01:01:27,960 --> 01:01:30,920
the treatment of gout? So that
is going to be culture scene, so

880
01:01:30,000 --> 01:01:34,480
it seems like a very simple question. But just remember that because I definitely

881
01:01:34,519 --> 01:01:37,199
got a question on this. In
school culture scene, most common adversdrug reaction

882
01:01:37,320 --> 01:01:40,760
is GI problems, specifically diarrhea.
They do like to ask about that,

883
01:01:40,840 --> 01:01:45,559
so remember it, all right.
So that was the first part of Rheumatology,

884
01:01:45,639 --> 01:01:47,599
part one of two. I really
hope that was helpful. Thank you

885
01:01:47,679 --> 01:01:51,599
so much for listening, and good
luck in PA school, your pants,

886
01:01:51,679 --> 01:01:52,280
your panory, and your ears.