WEBVTT 1 00:00:00.320 --> 00:00:03.399 All right, so let's go ahead and get started with rheumatology. This is 2 00:00:03.399 --> 00:00:07.719 going to be a one of two part podcasts only because rheumatology is just too 3 00:00:07.759 --> 00:00:11.400 dense to make this into one podcast, I broke it up into two before 4 00:00:11.400 --> 00:00:14.519 we get started. Thank you, as always for the really nice comments the 5 00:00:14.560 --> 00:00:17.440 support. I really do appreciate it. All right, let's go get started 6 00:00:17.440 --> 00:00:20.519 with rheumatology. We're going to start with probably one of the lowest heel topics 7 00:00:20.839 --> 00:00:25.359 for rheumatology, and that's five romyalgia. This is a chronic disorder of widespread 8 00:00:25.480 --> 00:00:30.480 muscular skeletal pain accompanied by other somatic symptoms. So you're looking for fatigued cognitive 9 00:00:30.480 --> 00:00:36.280 disturbances, psychiatric symptoms. Etiology is unknown, and the patho phiz is uncertain, 10 00:00:36.320 --> 00:00:38.679 so there's really not a lot to know here. Just know that they're 11 00:00:38.679 --> 00:00:43.280 going to have some kind of chronic, widespread MSK pain combined with other somatic 12 00:00:43.320 --> 00:00:46.200 symptoms. So who you're going to be looking for in the vignette is going 13 00:00:46.240 --> 00:00:49.960 to be women twenty to fifty five years of age. It's much more common 14 00:00:50.000 --> 00:00:52.719 in women, and like I said, generally in the age range of twenty 15 00:00:52.719 --> 00:00:55.840 to fifty five, So the vignette be looking for a young or middle aged 16 00:00:55.920 --> 00:01:00.079 woman on physical exam eleven of eighteen to fine tender points. Let's talk about 17 00:01:00.079 --> 00:01:04.480 that because there's a little fyi for that. So on physical exam person with 18 00:01:04.519 --> 00:01:07.920 fibromiologia, they're very often going to have tenderness. This is going to be 19 00:01:07.920 --> 00:01:11.599 a multiple soft tissue sites throughout the body. But with that being said, 20 00:01:11.879 --> 00:01:15.840 you likely have heard of this criteria. That's eleven of eighteen to fine tender 21 00:01:15.840 --> 00:01:21.840 points. This was from nineteen ninety diagnostic criteria for fibromylogist, so it's been 22 00:01:21.879 --> 00:01:25.680 around a while. Basically stated that if a patient had symptoms of widespread pain, 23 00:01:25.840 --> 00:01:29.120 was tender and at least eleven of eighteen different areas when you poked them, 24 00:01:29.599 --> 00:01:33.159 essentially they had fibromylogia. This is what I was taught when I was 25 00:01:33.200 --> 00:01:34.959 in school. It's still in a lot of the literature, but if you 26 00:01:36.000 --> 00:01:38.760 got up to date and you look at their latest information, their latest quote 27 00:01:38.760 --> 00:01:44.000 from up to date, they state quote, we no longer recommend palpating specific 28 00:01:44.040 --> 00:01:48.439 tender point locations or enumerating the number of tender points. The presence of such 29 00:01:48.480 --> 00:01:53.400 tender points was part of the nineteen ninety ACR Classification criteria. Performing such a 30 00:01:53.439 --> 00:01:57.920 tender point examination has proven to be impractical and clinical practice, So in reality 31 00:01:59.079 --> 00:02:01.120 still around may honestly still get tested on it. And that's why I bring 32 00:02:01.159 --> 00:02:04.400 it up. It's an easy thing to make an exam question out of. 33 00:02:04.439 --> 00:02:08.759 But there's newer criteria, the twenty ten American College of Rheumatology Diagnostic Criteria, 34 00:02:08.879 --> 00:02:12.159 which you don't need to memorize. I just wanted to make you aware of 35 00:02:12.199 --> 00:02:15.599 that, and then just kind of I had to bring up the eleven of 36 00:02:15.599 --> 00:02:17.439 eighteen ten or points just in case you're testing on it, but just be 37 00:02:17.479 --> 00:02:21.199 aware of the more up to date info as well. All right, moving 38 00:02:21.240 --> 00:02:23.879 on diagnosis, this is very much a clinical diagnosis. You're going to have 39 00:02:23.919 --> 00:02:29.479 normal lab tests. So that's the hard part about fibromyalgia is there's no confirmatory 40 00:02:29.520 --> 00:02:34.639 tests or biomarkers. It's a clinical diagnosis. You suspect fibromylogien patients with three 41 00:02:34.680 --> 00:02:39.199 months of widespread or multisite pain without another identifiable cause, so you get lab 42 00:02:39.240 --> 00:02:43.039 tests, but this is just to rule out your differentials. You mainly want 43 00:02:43.080 --> 00:02:47.639 to exclude systemic inflammatory diseases, so get a CBC and esr C reactive protein. 44 00:02:49.240 --> 00:02:53.280 This is really just to rule out another underlying inflammatory cause. Key thing 45 00:02:53.319 --> 00:02:55.680 to remember here is that all of the labs and imaging are generally going to 46 00:02:55.719 --> 00:03:00.680 be normal and fibromyalgia treatment you start with. Your servative measure is patient education 47 00:03:00.840 --> 00:03:07.080 including cognitive behavioral therapy. Exercise. Low impact aerobic exercise actually has been shown 48 00:03:07.120 --> 00:03:10.840 to improve not only the pain, but improves the sleep disturbances these patients may 49 00:03:10.879 --> 00:03:16.439 have. You also want to address any comorbidities, so these things aren't always 50 00:03:16.439 --> 00:03:21.280 often tested on. What they're likely going to ask you is the pharmacologic treatment. 51 00:03:21.520 --> 00:03:23.360 So if they ask you which medication you're going to give a patient with 52 00:03:23.400 --> 00:03:28.800 fibromylogya, it's going to be your TCA. So tricyclic antidepressants AM a trip 53 00:03:28.840 --> 00:03:32.560 DeLine So when most patients, you're going to initiate therapy with a low dose 54 00:03:32.960 --> 00:03:37.879 of a tricyclic antidepressant and a trip delane is the main one. There's some 55 00:03:37.960 --> 00:03:42.280 other options cyclobenzoprene a cent arise for your exam, though I'd really focus on 56 00:03:42.280 --> 00:03:46.240 your TCAs in particular am a trip DeLine. So in conclusion, little no 57 00:03:46.319 --> 00:03:51.240 for fibromyology. Just know the diagnosis should be considered in any patient with greater 58 00:03:51.280 --> 00:03:54.520 than three months of wide spread or multi site pain companied by other somatic symptoms, 59 00:03:54.759 --> 00:03:59.599 no evidence of another condition accounting for the pain. Patient very likely it 60 00:03:59.639 --> 00:04:02.879 is going to be female normal labs. Treatment's going to be conservative initially, 61 00:04:03.080 --> 00:04:06.759 exercise, patient education, cognitive behavioral therapy, and if you're going to give 62 00:04:06.759 --> 00:04:10.280 them meds most of the time, it's going to be your TCAs. That 63 00:04:10.439 --> 00:04:14.000 is fibromyalgia, all right, Moving on to gout. So gout it's a 64 00:04:14.080 --> 00:04:16.480 very dense topic. I honestly could have made a whole podcast just on gout, 65 00:04:16.519 --> 00:04:19.079 but I try my best to condense this and focus just on the high 66 00:04:19.120 --> 00:04:24.680 yield stuff. So there we go. Gout is a condition characterized by hyperurasemia 67 00:04:24.720 --> 00:04:30.519 and deposition of monosodium ura crystals, causing attacks of acute inflammatory authoritis. So 68 00:04:30.560 --> 00:04:33.759 I'm sure most of you are already somewhat familiar with gout. It's a common 69 00:04:33.759 --> 00:04:36.839 condition, but essentially, you have too much uric acid and the blood from 70 00:04:36.839 --> 00:04:41.240 a number of causes will go over and this results in the formation of these 71 00:04:41.240 --> 00:04:45.519 sharp needle shaped crystals that can deposit in the joints, leading to severe pains, 72 00:04:45.560 --> 00:04:49.040 swelling, effusion, And just so you know, hyper eurasemia. While 73 00:04:49.079 --> 00:04:55.199 it's a necessary predisposing factor for gout, majority of people with hyper eurasemia actually 74 00:04:55.279 --> 00:04:58.519 never developed gouts. It's just a little extra knowledge. You don't need one 75 00:04:58.560 --> 00:05:01.759 for the other and etc. Whatever, So you can have hyper euraseemia never 76 00:05:01.800 --> 00:05:05.600 developed GAUT. All right, let's talk about risk factors. So there's a 77 00:05:05.600 --> 00:05:09.319 few different things that can trigger a GOUT attack. There's certain people that are 78 00:05:09.319 --> 00:05:13.839 more susceptible to gaup male sex. GAUT has a male predominant, so very 79 00:05:13.879 --> 00:05:15.839 likely in the vignette it's going to be a man. Part of the reason 80 00:05:15.879 --> 00:05:21.399 it's more common in men compared to women is estrogen actually has a mild euricosuric 81 00:05:21.399 --> 00:05:26.720 effect, so it actually promotes the excretion of uric acid. So GAUT is 82 00:05:26.959 --> 00:05:32.199 very unusual in premenopausal women. So male sex is a big non non modifiable 83 00:05:32.279 --> 00:05:38.240 risk factor. Another one is advanced age, so that's another nonmodified I can't 84 00:05:38.240 --> 00:05:42.839 say that word nonmodifiable risk factor. So you're generally looking for an older man 85 00:05:42.839 --> 00:05:46.439 in them. Yet, and then we have our modifiable risk factors for GAUT. 86 00:05:46.480 --> 00:05:48.639 So these are the ones you should be familiar with because this is more 87 00:05:48.680 --> 00:05:54.319 often tested on. The two important ones to be familiar with is diet and 88 00:05:54.439 --> 00:05:57.959 medication. So let's start with your diet. So puring rich foods is what 89 00:05:57.959 --> 00:06:02.240 you're looking for. So diet be a triggering factor for gaut increase consumption. 90 00:06:02.519 --> 00:06:08.279 Consumption of purings which are found in seafood, red meat, oregon meat like 91 00:06:08.360 --> 00:06:12.480 liver. Alcohol is another big one. They can all increase the formation of 92 00:06:12.560 --> 00:06:16.000 monosodium urate crystals, so be aware of these foods. And the reason why 93 00:06:16.000 --> 00:06:20.600 it happens with puring rich foods is because when puring that's founding these foods is 94 00:06:20.600 --> 00:06:25.439 broken down when it's metabolized in the body, it's actually broken down into uric 95 00:06:25.480 --> 00:06:30.000 acid. So you can see why the problem happens with these types of foods. 96 00:06:30.000 --> 00:06:32.600 So once the patients are actually on urate lowering meds like gallopurinol, diet 97 00:06:32.639 --> 00:06:35.720 really doesn't play such a big role anymore since these meds do such a good 98 00:06:35.800 --> 00:06:40.800 job of keeping muric acid levels under control. But prior to diagnosis and proper 99 00:06:40.800 --> 00:06:44.439 treatment, diets definitely a key factor to be aware of. And then there's 100 00:06:44.439 --> 00:06:48.160 medications they can increase cerum urate levels and can increase the risk of a Gaut 101 00:06:48.199 --> 00:06:51.560 flare. And it's important to know these meds because you may get a question 102 00:06:51.600 --> 00:06:55.160 like I did it describes a patient with GAUT and they list of buns of 103 00:06:55.199 --> 00:06:58.519 meds and basically say which med should you just continue in this patient? So 104 00:06:59.199 --> 00:07:01.920 should know your meds that can lead to hyperurosemia and a potential gout attack. 105 00:07:02.720 --> 00:07:05.959 The ones that you need to know, the ones that get tested on are 106 00:07:06.079 --> 00:07:12.720 piazenamide that's a tuberculosis med, loop diuretics like ferosamide aspirin, but low dose 107 00:07:12.839 --> 00:07:16.800 aspirin's odd one because it really only triggers GAUT when it's taken in low doses 108 00:07:16.839 --> 00:07:19.839 like less than three hundred and twenty five milligrams, like a lot of people 109 00:07:19.839 --> 00:07:25.480 take for cardiovascular prophylaxis. Higher doses of aspirin actually have the opposite effect and 110 00:07:25.560 --> 00:07:30.639 decrease urate levels. Another one is thiazides like hydrochlorothiside, and then a fambuta, 111 00:07:30.720 --> 00:07:34.439 which is another tuberculosis med So those are the main meds to be aware 112 00:07:34.480 --> 00:07:38.639 of the ones that are commonly tested on. The way that you're going to 113 00:07:38.680 --> 00:07:42.879 remember those meds is by remembering this sentence. If you put too much seafood 114 00:07:42.920 --> 00:07:46.240 on your plate, you'll get gout. If you put too much seafood on 115 00:07:46.279 --> 00:07:49.920 your plate plat, you'll get gaut. So plate is the word that you 116 00:07:49.959 --> 00:07:54.959 need to remember. And plate stands for the P stands for piazenamide, the 117 00:07:55.319 --> 00:07:59.120 L and plate stands for loop diuretics, the A and plate stands for aspirin, 118 00:07:59.199 --> 00:08:03.120 The T stands athisides, and then the E a Thambutall. So remember 119 00:08:03.560 --> 00:08:05.240 that sentence, You remember the common medas you need to know. If you 120 00:08:05.279 --> 00:08:09.439 put too much seafood on your plate, you'll get gallup, pure zenemie, 121 00:08:09.439 --> 00:08:15.000 loop diuretics, aspiranthisides, and a thambutall all right. Clinical manifestations, they 122 00:08:15.079 --> 00:08:18.360 are going to have severe pain, redness, warmth, swelling. That's very 123 00:08:18.360 --> 00:08:24.360 common. Usually this is going to be isolated into one joint. Around eighty 124 00:08:24.360 --> 00:08:30.600 percent of initial flares involved just a single joint. And then it's most common 125 00:08:30.720 --> 00:08:33.840 for its involve the lower extremities. In particular, the most common area is 126 00:08:33.840 --> 00:08:37.480 going to be your first metatar sophalangial joints, so the base of the great 127 00:08:37.480 --> 00:08:41.320 toe, and this is known as podagra. So if you hear podagram mentioned 128 00:08:41.519 --> 00:08:45.519 it's gout of the big toe, so remember that term. It's of course 129 00:08:45.559 --> 00:08:48.240 possible to have it in other areas the knees and other common area ankles, 130 00:08:48.279 --> 00:08:52.320 but focus on that first toe podagraph. That's a really important one, all 131 00:08:52.399 --> 00:08:56.639 right. So as a recap clinical manifestations of a gaut flare, be looking 132 00:08:56.639 --> 00:09:01.519 for a description of severe pain, redness, warm swelling, likely going to 133 00:09:01.519 --> 00:09:05.720 be the lower extremities most often the base of the first toe podagra. All 134 00:09:05.799 --> 00:09:09.559 right, So for diagnosis, there's two things that I would be familiar with 135 00:09:09.600 --> 00:09:13.440 for diagnosis, Arthur a centesis that's the main one, and then you have 136 00:09:13.480 --> 00:09:16.799 your imaging. So Arthur a sentesis. This is your best test. Definitive 137 00:09:16.840 --> 00:09:20.759 diagnosis can be made with Arthur sentesis in real life. How many patients are 138 00:09:20.799 --> 00:09:24.240 actually going to let you stick a needle in the toe that's hurting them so 139 00:09:24.279 --> 00:09:28.000 bad? Even a vet she makes them scream, It's questionable, But if 140 00:09:28.000 --> 00:09:31.679 they ask you. The best diagnosis tests on the exam, Arthur sentesis is 141 00:09:31.720 --> 00:09:35.600 eighty five percent sensitive and one hundred percent specific for gaut and what you're looking 142 00:09:35.639 --> 00:09:43.279 for under microscopy when you perform an Arthur sentesis is negatively biofarringent needle shaped crystals, 143 00:09:43.320 --> 00:09:46.600 which is a characteristic finding of monosodium urate. So again I'll repeat that 144 00:09:46.720 --> 00:09:50.840 because it's very very important to know this. You have to know this. 145 00:09:50.320 --> 00:09:54.879 They're going to ask it. So aspiration of the synovial fluid of the joint 146 00:09:54.919 --> 00:09:58.240 and a patient with gout is going to show negatively by your farringent. It's 147 00:09:58.279 --> 00:10:03.759 really important. It's negatively bierfarringent because it differentiates it from pseudo Gaut, which 148 00:10:03.759 --> 00:10:07.559 will go over next. And Pseudogaut is positively buy a furringent. So again 149 00:10:07.639 --> 00:10:11.799 negatively buyerfarringent needle shaped crystals. You have to know that, all right, 150 00:10:11.879 --> 00:10:18.200 So I mentioned that Gaut is negatively by a farringent and Pseudogaut is positively by 151 00:10:18.200 --> 00:10:20.279 afringent. I do have a trick, not really a trick, but just 152 00:10:20.320 --> 00:10:24.639 an easy way to remember. One is positive, one is negatively buy a 153 00:10:24.639 --> 00:10:30.000 furringent. So Pseudogaut has a P. Gaut does not. So Pseudogaut is 154 00:10:30.039 --> 00:10:33.120 positively buyer farringent positive with a P. Pseudo Gaut with a P. Gaut 155 00:10:33.240 --> 00:10:37.159 was negative buyer furringent. So if you can't remember which one is negative or 156 00:10:37.200 --> 00:10:39.440 positive. Just remember which one has a P in the name only pseudo gaut. 157 00:10:39.919 --> 00:10:43.879 Therefore it's the one with positive with a P buyer furringeent. Just an 158 00:10:43.879 --> 00:10:48.320 easy way to remember that, all right. So what about X ray? 159 00:10:48.399 --> 00:10:54.360 So I mentioned before imaging does play a role. Imaging isn't really super high 160 00:10:54.480 --> 00:10:58.000 yield except for the fact that if you see an a vignette they mention anything 161 00:10:58.039 --> 00:11:03.960 about overhanging edges or margins with a punched out appearance. These are characteristic findings 162 00:11:03.960 --> 00:11:07.399 of the erosive appearance scene and it joint with the patient with gout. Normally, 163 00:11:07.399 --> 00:11:11.399 this is long standing gout. So if you see that the back of 164 00:11:11.440 --> 00:11:16.399 your mind, just kind of remember that overhanging edges or this erosive appearance on 165 00:11:16.600 --> 00:11:20.279 x ray that can be long standing in a patient, long standing finding sent 166 00:11:20.320 --> 00:11:24.679 a patient with gout on imaging. So really I would just focus on your 167 00:11:24.720 --> 00:11:26.879 author of sentesis, but just kind of have that in the back of your 168 00:11:26.879 --> 00:11:30.000 mind, all right. So those are the things I think you should know 169 00:11:30.080 --> 00:11:33.120 for the diagnosis for the exam. In real life when you're practicing, very 170 00:11:33.159 --> 00:11:37.519 often the diagnosis of gout is just going to be a clinical diagnosis made upon 171 00:11:37.600 --> 00:11:39.679 the history of the exam. There's even a diagnostic rule chart if you want 172 00:11:39.679 --> 00:11:43.600 to look that up. Not important enough for the exam, but just basically 173 00:11:43.639 --> 00:11:46.879 a point system that helps make the diagnosis in the absence of an Arthur sentesis. 174 00:11:48.600 --> 00:11:50.720 All right, So one last thing that you might be saying to yourself, 175 00:11:52.360 --> 00:11:54.879 what about measuring uric acid to help make the diagnosis. We're talking about 176 00:11:54.919 --> 00:11:58.679 diagnosis. We know, you know increased uric acid hyper eursemia. Why aren't 177 00:11:58.720 --> 00:12:03.080 we the uric acid levels? So it turns out that up to forty three 178 00:12:03.120 --> 00:12:07.600 percent of patients with acute gaut flares they're actually gonna have normal or even low 179 00:12:07.720 --> 00:12:11.240 serum urate levels. And part of the reason is because the cytokinds that are 180 00:12:11.240 --> 00:12:16.519 released during an acute attack, they can actually lower the urate levels. So 181 00:12:16.679 --> 00:12:20.039 measuring uric acid levels not a good idea during an acute attack. So when 182 00:12:20.080 --> 00:12:24.679 are you going to measure uric acid? Best time is two or more weeks 183 00:12:24.759 --> 00:12:28.919 after the flare has completely resolved, and measuring uric acid levels it's a good 184 00:12:28.919 --> 00:12:33.000 tool to measure the response to treatment once you have them on a prophylactic agent 185 00:12:33.039 --> 00:12:37.480 like alipurinol. Obtain uric acid levels to make sure the treatment is working at 186 00:12:37.480 --> 00:12:39.960 suppressing the uric acid levels in the body. So to reiterate, don't measure 187 00:12:41.080 --> 00:12:43.759 uric acid levels during an acute attack. All right, let's talk about our 188 00:12:43.840 --> 00:12:48.000 treatment. Let's start with acute first and then we'll talk about chronic treatment. 189 00:12:48.639 --> 00:12:52.720 So before we start with treatment and the meds, always make sure you address 190 00:12:52.759 --> 00:12:56.559 lifestyle changes less beer, less meat, seafood, lose weight. Not so 191 00:12:56.639 --> 00:12:58.200 much test it on, but just good to know for real life. All 192 00:12:58.240 --> 00:13:01.120 right, let's talk about acute attacks first. So for an acute attack, 193 00:13:01.159 --> 00:13:05.480 there's three meds or classes that you need to know. End sets, steroids, 194 00:13:05.480 --> 00:13:09.600 and culture scene. They all work and quoted from up to date, 195 00:13:09.639 --> 00:13:13.159 we suggest oral glucocorticoids, end sets, and culture scene as equivalent first line 196 00:13:13.200 --> 00:13:16.919 options. So basically, you just have to decide which agent will be your 197 00:13:16.960 --> 00:13:22.600 best for a patient, considering the patient's comorbidities and other factors which I'll go 198 00:13:22.759 --> 00:13:26.320 over. So let's start with our end sets for US, so end sets, 199 00:13:26.519 --> 00:13:31.360 neproxin, endomethsin. Those are some commonly used ones. A potent oral 200 00:13:31.480 --> 00:13:35.919 nd set like neproxin or intomethicin. They work really well for GAUT. They're 201 00:13:35.919 --> 00:13:39.480 generally pretty cheap, so they are used very frequently, but you have to 202 00:13:39.519 --> 00:13:43.480 be careful in using these in certain patient populations. So they're going to give 203 00:13:43.519 --> 00:13:46.559 you a patient with an acute GAUT attack, They're going to list a bunch 204 00:13:46.600 --> 00:13:48.159 of meds and they're going to ask you what you'd pick. You have to 205 00:13:48.159 --> 00:13:52.200 look at the comorbidities the patient has. You don't want to use end sets 206 00:13:52.399 --> 00:13:56.120 and a patient with core renal function and active duad and ologastric ulcer. Even 207 00:13:56.159 --> 00:14:01.240 in some types of cardiovascular disease like hard fact failure, there's some other contraindications. 208 00:14:01.240 --> 00:14:05.759 Obviously, allergies and sets can combinatet use of antiquagulance. But the three 209 00:14:05.759 --> 00:14:09.240 that I focus on for the exam bad kidneys, bad heart, bad GI 210 00:14:09.360 --> 00:14:13.320 tracked. Don't get tricked in a vignette when they give you a patient with 211 00:14:13.360 --> 00:14:16.759 gout asking which meant to pick before you pick the proxy and make sure their 212 00:14:16.759 --> 00:14:20.600 GFAR isn't like twenty. So again, end sets are a first line agent 213 00:14:20.639 --> 00:14:22.519 for a cute GUT as long as the patient doesn't have chronic kidney disease. 214 00:14:22.879 --> 00:14:28.559 Generally, a gfar less than sixty and acute ulcer or certain types of cardiovascular 215 00:14:28.559 --> 00:14:31.320 disease, but really focus in on the chronic kidney disease because that's normally what 216 00:14:31.360 --> 00:14:35.240 they're going to give you in the vignette to try to trick you. Okay, 217 00:14:35.320 --> 00:14:37.639 let's talk about our glucocorticoids next. They come in a couple of varieties, 218 00:14:37.759 --> 00:14:43.480 oral, intraarticular, so like a steroid injection, all depends on how 219 00:14:43.480 --> 00:14:48.039 many joints are involved. They work really well, and what's really important, 220 00:14:48.080 --> 00:14:52.200 they can be used in patients with moderate to severe renal insufficiency. So keep 221 00:14:52.240 --> 00:14:54.240 that in mind. If they give you a patient that has chronic kidney disease 222 00:14:54.399 --> 00:14:58.519 and they have nd sets and steroids in the answer choices, make sure you're 223 00:14:58.559 --> 00:15:01.679 choosing your steroids and not end set. All right, So who should you 224 00:15:01.720 --> 00:15:05.480 be careful prescribing steroids too? Obviously you're poorly controlled diabetics. This is really 225 00:15:05.519 --> 00:15:09.519 important. Steroids can and will cause a pretty significant spike in blood sugar, 226 00:15:09.799 --> 00:15:13.320 so it'll be really careful with your brittle diabetics that work and the chronology. 227 00:15:13.360 --> 00:15:16.279 I see this all the time. Patients come in, their blood sugar is 228 00:15:16.320 --> 00:15:20.159 perfect. They get some prednicess on on their blood sugars through the roof, 229 00:15:20.240 --> 00:15:26.080 so be really careful in patients with diabetes. It's it's not an absolute contriunication. 230 00:15:26.080 --> 00:15:28.200 You just want to be careful with that. Also, be careful in 231 00:15:28.200 --> 00:15:33.960 patients that have an ongoing infection or post op patients because gluca cortochoids can increase 232 00:15:33.000 --> 00:15:37.679 the risk of impaired wound healing. So remember steroids are another great treatment option 233 00:15:37.720 --> 00:15:41.200 for acute flares. And I'll say it again because it's really important you can 234 00:15:41.600 --> 00:15:46.320 use this in patience with kidney disease, because that's likely the question you'll get. 235 00:15:46.879 --> 00:15:50.159 Let's talk about Culture Scene next. So this is probably the least used 236 00:15:50.159 --> 00:15:54.919 option of the three. Culture Scene is effective for acute flares. But what's 237 00:15:54.000 --> 00:15:56.799 unique about it that you really need to remember it can actually also be used 238 00:15:56.840 --> 00:16:00.200 for chronic management of gout. And it's the only men that can be used 239 00:16:00.240 --> 00:16:04.759 for both acute and chronic cases of gout. Although it's certainly not the preferred 240 00:16:04.840 --> 00:16:07.720 agent for chronic gout management, but you can use it for that. To 241 00:16:07.840 --> 00:16:11.159 just so just know that really just two things that would know for Culture Scene 242 00:16:11.600 --> 00:16:15.080 one, like I just remember you can use it for acute and chronic out, 243 00:16:15.440 --> 00:16:18.120 and if they mention an adverse drug reaction with culture Scene, it's going 244 00:16:18.159 --> 00:16:22.000 to be a diarrhea. Culture Scene is notorious for causing this, and they, 245 00:16:22.159 --> 00:16:26.720 for some reason often like to ask about it. On Apocrates, it 246 00:16:26.720 --> 00:16:32.000 actually says in the comments quote diarrhea will likely proceed pain relief, which I 247 00:16:32.039 --> 00:16:33.799 just thought was funny. You can tell your patients once a diarrhea starts, 248 00:16:34.000 --> 00:16:38.000 you know we're getting close. Just start working soon. So anyways, remember 249 00:16:38.039 --> 00:16:41.919 colch scene is another option for acute flares as well as chronic management. Most 250 00:16:41.919 --> 00:16:47.080 common ADR is diarrhea. All right, let's talk about our chronic treatment. 251 00:16:47.159 --> 00:16:51.279 So for chronic treatment, there is one drug that absolutely runs the show, 252 00:16:51.360 --> 00:16:53.840 and that is lapieran al. It's part of your x anti inoxidase inhibitors. 253 00:16:55.080 --> 00:16:59.240 If you remember only one medication for chronic gout management, let it be lapper 254 00:16:59.320 --> 00:17:03.440 at all. So it is your first line prophylactic treatment for gout. Like 255 00:17:03.480 --> 00:17:07.160 I said before, is a xanthe and oxidase inhibitor. What the heck does 256 00:17:07.200 --> 00:17:11.039 that mean? So? Xanthe and oxidase is a enzyme that helps puring breakdown 257 00:17:11.079 --> 00:17:15.440 into uric acid. So if we inhibit this enzyme, we stop the process 258 00:17:15.559 --> 00:17:19.559 and therefore we decrease the amount of uric acid that can be produced. And 259 00:17:19.680 --> 00:17:25.359 this works obviously very well. Adverse drug reactions for alla purnal. The one 260 00:17:25.400 --> 00:17:29.279 that I would remember is Steven's Johnson syndrome. So this one always seems to 261 00:17:29.319 --> 00:17:33.000 come up. Alpurnals one of the medications, one of the menu medications that 262 00:17:33.039 --> 00:17:37.079 can cause Stephen Johnson syndrome. And I went over thisnemonic before in the seizure 263 00:17:37.160 --> 00:17:41.079 lecture. But if you can remember this demonic, it will help you remember 264 00:17:41.160 --> 00:17:45.359 the common meds that can cause Stephen Johnson syndrome. So the sentence that I 265 00:17:45.400 --> 00:17:48.920 remember as soon as I see Steven's Johnson syndrome, I think of the first 266 00:17:48.960 --> 00:17:52.160 few letters in Stephen Johnson and the first few letters of Steven Johnson are also 267 00:17:52.319 --> 00:17:57.160 in Steve Jobs, And that helps them remember Steve Jobs created Apple PCs, 268 00:17:57.240 --> 00:18:02.240 and then Steve Jobs created Apple. Piece sees Apple PC stands for the main 269 00:18:02.319 --> 00:18:06.240 meds that can cause Stevens Johnson syndrome. Aliperan al, there's your alipianol, 270 00:18:06.680 --> 00:18:11.599 fennetin, pheno, barbital, lemotorgene, ethosuxomie, penicillans, cover mazipine and 271 00:18:11.680 --> 00:18:15.759 sulfonamides, so those are the main ones. Alipianil is obviously in the a 272 00:18:15.960 --> 00:18:19.359 there, so you remember as soon as you see Steven's Johnson syndrome, think 273 00:18:19.400 --> 00:18:23.240 of Steve Jobs and Steve Jobs created Apple PCs. Those are the main meds 274 00:18:23.720 --> 00:18:29.640 for Stevens Johnson syndrome. And one of the men I wanted to mention the 275 00:18:29.720 --> 00:18:34.440 anthienoxidase inhibitors is one called Fabucks's stat so this is another X anthienoxidase inhibitor. 276 00:18:34.519 --> 00:18:37.720 There's really nothing high yield to know about this men except for the fact that 277 00:18:38.200 --> 00:18:42.880 it's ax anthienoxidase inhibitor. We don't use fabucks as SAD as often as aliperanol 278 00:18:44.039 --> 00:18:48.920 because it has some adverse effects that alipionol just doesn't have in particular and increased 279 00:18:48.920 --> 00:18:52.960 cardiovascular risks, so be aware of it. But remember aliperonil is going to 280 00:18:52.000 --> 00:18:57.000 be the preferred agent. So there's only two meds to know for this class. 281 00:18:57.079 --> 00:19:00.079 But sometimes you're going to forget their mechanism of action. So if you 282 00:19:00.160 --> 00:19:06.079 want a way to remember there's anthienoxidase inhibitors, because I did get a question 283 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 285 00:19:11.279 --> 00:19:12.960 the answer choices that wasn't there. It would obviously be too easy. They 286 00:19:14.000 --> 00:19:15.960 put fabucks is set. So the way that I remember these two meds were 287 00:19:15.960 --> 00:19:21.359 as anthienoxidase inhibitor as well was by remembering the sentence. In February, I 288 00:19:21.480 --> 00:19:25.960 get all of my exos because it's the month of Valentine's Day. In February, 289 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 291 00:19:33.039 --> 00:19:37.359 February, February is for Fabucks's stat all is for all apperanol, and then 292 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, 294 00:19:47.480 --> 00:19:52.480 ours anthienoxidase inhibitors helped decrease production of uric acid. But what about medications 295 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 297 00:19:59.880 --> 00:20:04.440 you you use are uricosuric medications. So uricosuric medications. Probenicid is really the 298 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 302 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 304 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.