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Hello and welcome back to the rheumatoid arthritis clinically simple series so this will be part two i wasn’t planning on there being two parts but this will be part two and we were discussing about how on x-ray how we are supposed to identify the osteopenia so make sure to watch part one if you miss that and we will simplify all of the x-ray findings everything that

Is to do with rheumatoid arthritis now what is osteopenia this is a reduction so this is kind of like a reduction in the bone and it typically occurs with a couple of the bone and connective tissue diseases but how are we supposed to identify the osteopenia on the x-ray normally bone appears solid white on the x-ray when it’s osteopenia there will be a reduction

In the light around the joint and you will now be seeing some areas of black so where typically there is a solid area of white obviously the joint doesn’t look like this but you will now i see more and more black in between and here’s an x-ray just to demonstrate now what about the blood tests the blood tests in rheumatoid arthritis are key and they are very very

Important especially when it comes to the auto antibodies as well so you have esr which is a wreath recite sedimentation rate you also have crp you also have platelets and b’s get risen these get increased so along with the x-ray you also have plus that’s what i meant by plus you also have these characteristic blood test findings so the esr crp and platelets are

Increased hemoglobin and white blood cell count is reduced okay what exactly is esr crp what does that stand for now this is what i mean by simplified this is gonna be honest this stuff means something and we will just simplify it so it makes a lot more sense now esr crp are simply a markers of inflammation okay and when you have these infection or inflammation esr

Trp will be characteristically risen so they will be characteristically risen now you will then have rheumatoid factor positive auto antibodies which are positive in 70% of the cases so you will not always get a positive rheumatoid factor in fact sometimes sometimes once sometimes the rheumatoid factor can be initially negative and and then positive afterwards and

This occurs in 70% of the patients you can also get anti-nuclear antibodies and these are positive in 30% of the case and then you can also get anti-ccp antibodies anti-ccp antibodies are anti cyclic anti cyclic situated protein okay remember i talked about the socialization process in the last video but when you get these anti cyclic citroen amazed protein antibodies

This firstly it’s not that common to get but when it is when it when it does show up as positive that is almost certain that this is rheumatoid arthritis anti cyclic citrulline ancient peptide okay anti cyclic such eliminated peptide now if you’re not aware of what an auto antibody is our immune system has something called self detection or self antigen this is

All to do with mhc class 1 which molecules represent mhc class 1 in which molecules don’t now when it comes to the rheumatoid factor also antibody when it comes positive when it’s positive in 70% of the cases what is happening is a human body is producing a self antibody an auto antibody and it will go and target target various antigens especially around the joint

Areas areas of the joints in the body now this is all to do with the immune system not realizing that these are our own guys if this was if this was a criminal nice race the immune system things that we are the criminals our own cells are the criminals because the immune system is kind of blind to the self antigen because there is a lack of self tolerance and when

You get that that is the cause of the arginine being replaced by citrulline and the citral ination peptide process all it’s happening is our immune system is making antibodies to ourselves they the immune system things that our own cells are the criminals okay and that’s what happens remember that here the anti double-stranded dna this is the anti double-stranded

Dna antibody and this is the most specific this is most specific for rheumatoid arthritis now let’s move on and go to treatment okay treatment now you are there’s anything else here no so you are giving the patient suggestions for physical exercise and physiotherapy but in the case of rheumatoid arthritis suspection it’s a suspicion then you will refer the patient

To a rheumatologist so they can then administer the medications now you will advise regular exercise and physiotherapy but the rheumatologist can then narrow down if there is needs to be a differential diagnosis actually you already know all of these things anyway if there is a differential diagnosis there to be done what about the medications now this is where it

Gets interesting and this is where we can simplify things even more so so because this is an autoimmune disease an autoimmune inflammatory disease you will be using steroids which are anti-inflammatory you will be using anti-inflammatory medication steroids either oral or intra-articular and that’s because you have such a big immune inflammation process going on

In charak you know just means directly going into the joys directly going into the joints and this is typically used for acute flare ups when the patient has any kind of acute flare up and severe symmetrical pain now you have to avoid nsaids in warfarin taking patients because of drug interaction and finally surgery is a potential surgery is a potential treatment

Now what is common what is common about all of these initial medications this one this one here these are all kind of symptomatic treatments so symptomatic i want to write symptomatic but i have a lag in the system so these are all symptomatic treatments when it comes to actually modifying the progress of the disease because remember if you get this consecutive

Signs of inflammation consecutive over and over persistent inflammation persists in autoimmune you will get damage of the joins and eventual loss of function as well you won’t just get stiffness you will get damage and the damage in the joints so we want to do use disease-modifying agents of rheumatoid disease and dmards are your treatment of choice these include

Sulfasalazine methotrexate and hydroxychloroquine okay now before i talk about the demars i forgot to mention that whenever this is very clinically important whenever you use any kind of steroids you use something that i like to call ste pack well where is that going you use something that i like to call ste pack what is t pack well it’s a pack o it’s a pack of

Medication so you don’t give steroids on their own you always give steroids with either a gut protectant or with a gut pretended and a burn protectant so a case steroids have minimal side effects well they have side effects but the long-term side effects of steroids can cause damage to the guts and also to the bones especially to the bones gastric side effects can

Occur with short-term use of steroids but the bone steroids are known also to cause have research has shown to cause osteoporosis and so you administer something i like to call steep steep a steroid pack so you’re going to administer gastric protection and bone protection with the steroids and the medication you are going to use there is if a gastric protection

You’re just protecting your gastric lining gastric area so you’re gonna give ppi or omeprazole which includes a map rizal and for bowing protection you’re going to be using bisphosphonates so this includes alendronate okay alendronate when it comes to the d-man so remember ste park okay when it comes to the dmards you have also these are the ones that are actually

Going to be immunosuppressive so these guys are all immunosuppressive these are disease modifying agents we’re actually now slowing the progression of the disease while we’re trying to with immunosuppression sulfasalazine methotrexate and hydroxychloroquine sulfasalazine has known has been known to cause as oh spur mia matta tricks it is known to cause oral ulcers and

You are also supposed to always do liver function test when you are administering methotrexate okay because it can cause liver toxicity it causes liver toxicity and the other very important thing about methotrexate is that you always give it with folic acid supplements okay you always give it a small like acid because it often causes a folic acid deficiency finally

Hydroxychloroquine oh this one has a big one this one has a big side effect a long-term irreversible retinopathy it can cause irreversible retinopathy so you always do i test in this case okay so remember most social immune diseases use anti-inflammatory medication which is the steroids and this was all symptomatic treatment the disease modifying agents of rheumatoid

Disease arthritis are the most important ones now i have a quick recap of the clinical case of these pictures of what it means to have rheumatoid arthritis and what the different lab values might show okay thank you so much if you like this video please leave a like or a comment and subscribe to my channel i will be making more videos for the perfectly simple series thank you antica

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