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Take care. So, what's the difference
between rheumatoid arthritis and osteoarthritis?
Think about this, the presentation?
Yeah, there is some similarities, the joint pain, of
course, the female predominance age, things of that nature.
So there's a lot of overlap that can happen.
So great way for the board to ask you questions.
However, One happens as wear and tear.
While the other one is an autoimmune disease.
Let's learn about the disease process first, so it's
autoimmune. Meaning what our own immune
system is causing this damage. We've got elevated inflammatory
markers. What are some risk factors that
are going to lead. To rheumatoid arthritis is what
do I say? Risk factors and signs and
symptoms are your select all that apply questions.
Okay? Those are going to be a good
makeup of reselect other place. So what are some risk factors,
gender, family, history, or genetics?
Smoking positive rheumatoid Factor.
Anti cyclic to try, new lated, antibody ABS antibody.
And this is going to be your most specific test that you can
do. So this is the one that we're
going to want to do and then obviously an elevated ESR, you
see these different things. So what we can test for, as we
test for a positive rheumatoid Factor, Great that will, that
will help us diagnose it, but right off the bat, we don't
necessarily want to go right into rheumatoid factor or the
anti cyclic Citron elated antibody.
When a person presents, they're going to present with these
signs and symptoms of joint pain, maybe fatigue, maybe
fever. And I'll go through those signs
and symptoms, but we want to do an easier test a cheaper test.
So what we want to do is we want to do an ESR, what is that?
That's an erythrocyte sedimentation rate with the
erythrocyte sedimentation rate, what is saying is you're saying
erythrocytes so that's your red blood cell.
Sedimentation is how fast it falls to the bottom of Of your
tube. And the rate is actually how
fast it falls, right? So why do we do this test?
We do this testing inflammatory processes so it's not specific.
It's not specific to rheumatoid arthritis but in any
inflammatory process we can do this test because it is cheap.
It's fast because what happens is when we have an inflammatory
process in our body, Release. Fibrinogen, which is
inflammatory marker and that fibrinogen.
It binds to the art, be season to your red blood cells.
So now that red blood cell that was floating around has its
inflammatory marker attached to it.
It's made it heavier, It's Made It.
Heavier when you have this inflammatory process in your
body, any inflammatory process in your body, You go for an ESR
because that erythrocyte sedimentation rate is going to
be higher. So that fibrinogen that's
released from inflammation, binds to the red blood cell,
makes it thicker, makes it heavier so that red blood cell.
Drops faster. ESR, it's not a specific test,
but it definitely can let us know.
That we have an inflammatory process in our body.
Real life, right? For those of you that are in the
course. So I say, when I break down labs
and you look at them, you don't want to look at and say, oh
elevated ESR. Oh, they've elevated, limb
lymphocytes, or neutrophils? You know what it means, right?
That's why I'm just come out and do so.
Well, in real life, what are some signs and symptoms that
we're going to see. We got to risk factors great, so
I called applied question right there.
Understanding what we're going to do or what we would expect in
lab values. What are some signs and symptoms
that we're going to see? Well obviously I'm going to see
joint pain but more specifically.
When are we going to see in this joint pain?
In the morning or upon wakening. I do.
I do like that. As a better term.
So upon Awakening, and it lasts more than an hour.
It lasts more than an hour. So you've got this pain morning,
stiffness. And it will improve.
With use, it will improve with use.
It's an inflammatory process. I said osteoarthritis is wear
and tear. Do you think that rheumatoid
arthritis is going to be in one specific joint?
Or do you think it's going to be symmetrical?
That inflammatory process is not going to just attack one of
those joints? It's going after all of them and
it likes to go after certain specific areas in the hand.
And what you'll see is that Ulnar deviation ulnar deviation.
So their hands. Will actually go out words yet.
I'm a horrible jar. This is my.
These are my hands. They're going out like this.
Alright, so you'll see this in this is called ulnar deviation.
We'll also see it's an autoimmune disease.
So we're also going to see systemic issues, right?
And systemic issues that you're going to encounter.
With rheumatoid arthritis. If their bodies becoming
inflamed, their body's under stress, they're going to see
that low grade fever under that 100.4.
If their body is constantly inflamed and that is autoimmune
disease, they're going to be fatigued.
They may even experience weight loss.
So when they wake up, we want to be careful and educate them
because when they wake up they're going to be extremely
stiff. And at night time we want them
laying down straight, don't have their joints bent.
It's going to make the process worse.
So make sure that they are flat. And if they need an immobilizer,
Let them use one at night time because we don't want those
joints to get dysmorphia. That inflammatory process is
going to also cause tissue swelling.
So, all this that's going on. In their body.
Now they wake up and for about our they've got this joint pain,
this stiffness, this fatigue, this swelling Tell them to take
a warm shower in the morning. Or warm bath because we want
those joints to get loose and we want Mobility because it's going
to take them an hour. And we know that if we are able
to have that blood circulation and that Mobility that it will
start to get better and better as time progresses throughout
the day. so, the problem with this is it affects their there,
daily Life right there, active activities of daily living.
What's all this right here are signs and symptoms, perfect,
select all that. Apply question joint pain joint
pain upon Awakening for the first hour morning stiffness
improves with use warm shower or more showers going to be more so
education. They're going to experience
tissue swelling, weight loss, fatigue, fever, under 100.4.
It's going to be symmetric and you'll see that ulnar deviation.
Owner deviation. Now that hand, if you guys have
not seen a picture of somebody rheumatoid arthritis, I want you
to Google it. So with the joints that it's
going to affect. So this is your wrist.
So it's going to affect your wrist.
And then it's going to affect your proximal interphalangeal
joints, which are over here. These are your proximal
interphalangeal joints. These are your distal.
It does not affect your distal and also affects your meta.
Carpal phalangeal joint. Why is that so important?
Because if you just think about this, those joints are going to
now become the tissue around. It's going to be sold in those
joints are to become deformed and their hands are going to go
like this, so their activities of daily living.
It's going to be tough. It's gonna be tough.
And that deformity is also going to affect the mentally, because
now, their body image is changing and that's, it's
something that you're going to see all the time, you can't just
hide it under clothes. So people are going to start to
become self-conscious of it, right?
So very important to understand what's going on here because it
affects a lot of different things moving forward.
So what are we going to do about this?
How are we going to treat this patient?
Got to give them medications. Hey, what's up everyone?
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discount. Start with NSAIDs.
But what do we know about NSAIDs?
Well, we can't chronically take them, we've talked about that,
right? I talked about that a lot with
NSAIDs. We can't chronically, give it
because it decreases that prostaglandin production, which
coats our stomach. and when it decreases that, Prostaglandin,
that lining goes away. And when that lining goes away
acid will eat at the lining and it will create an ulcer.
So we can't clinically take NSAIDs.
And it also causes constriction of the efferent arterioles in
the kidney. So the blood supply in the
kidney is going to be decreased. So now we're going to have Renal
issues. So, watch out for that person,
that's on a chronic NSAIDs because if this person has
rheumatoid arthritis and this is exactly how I would word.
This question person comes in with the history of rheumatoid
arthritis and is that says that I don't need medication, I take
Ibuprofen over-the-counter four times a day.
You're gonna be like wait a minute, which of the following
statements is further teaching for the intervention moment.
100%, you're going to be looking at that because you don't want
them chronically on NSAIDs. it will lead to ulcers or one of
ask graph, which is what Hemorrhage.
Right? You'll see that black tardy
story will start to see that pain so we want to educate them
that NSAIDs are great, temporary relief but ultimately we want to
get them on disease-modifying agents, right?
Or rheumatoid? Yeah, disease.
So, The one that comes up the most in my opinion on the boards
is going to be Methotrexate. So let's get into some pain.
So with Methotrexate it is a folic acid synthesis inhibitor.
That's the reason why I can cause neural tube defects.
Definitely want to educate your patient.
Whoever is on it, that it is a teratogen the lack of folic
acid. Or the production of folic acid
or the conversion of folic acid, that, that, that is decreased.
Because this person is on Methotrexate, can complicate the
pregnancy because it's a teratogen, we're worried about
neural tube defects. so, if a person is on methotrexate, And
this is the way that I would ask him.
I say this all the time to my students.
I go listen, if somebody's on whatever or lets you say forget
the question, okay? If you see in the answer choice,
if you see an answer Choice, check pregnancy, ask him what
the last semesters tide cycle was do a upt doing.
HCG asking, if you're sexually active, why did they put that in
the answer Choice? Well, this is a question that I
would ask. Person wants to ask about
pregnancy and they're currently taking Methotrexate.
What are we gonna do? Well, we're going to stop it.
And what if they got pregnant, while they were on Methotrexate?
We're going to give good. We're gonna give folic acid.
In double the dose. This is not just limited to
Methotrexate. I also talked about this Insight
when we talk about Fina Towing, right?
And what is the normal level of folic acid that we give 400 to
800 micrograms. So if we're going to double
that, make sure you're giving them 800 to 1600 micrograms.
So ask them if they're pregnant, make sure they're not pregnant.
It is a teratogen and so think about this, right?
If it is a teratogen Do you think that if this is a drug
that we can use to get rid of a pregnancy on purpose?
Absolutely. Absolutely.
So now because of its nasty side effect, we can use this drug in
ectopic pregnancies. We can also use this drug to
terminate and have an abortion. Metal track.
See? You gotta tie it all together.
You can't memorize. Yeah, if it's a teratogen.
We can also use it on the flip side to write when you wanted to
eliminate. This is a safe one to learn a
not Auto driver. Genes are going to be good for
terminating pregnancy. This is actually a big one to
terminate pregnancy. This drug is also
hepatotoxicity, and I'm not talking. just like, oh, your
liver, check your liver enzymes, which are what Peyote.
AST, this is severely, I had a toxic.
So this is going to be that further teaching further
intervention moment where it's going to be, oh, you know, I'm
on Methotrexate, whatever they got prescribed.
This and like, yeah, I'm gonna, maybe I won't drink a lot.
I'll just have like one beer, no, no, or like one glass of
wine. No, no further teaching further
intervention further understanding moment because in
this situation, you are going to avoid alcohol.
There are three Drugs. That you need to know to avoid
alcohol that the board's love not decrease, alcohol.
Avoid alcohol metronidazole. So Methotrexate metronidazole.
How about you down iso-ne is it Isoniazid metronidazole and
Methotrexate. Now, these aren't the only ones
that you avoid completely stopped.
Not decrease, not have a sip, not have a glass of void.
These aren't the only ones, but these are the ones that the
board's love asking because they're severely hepatotoxicity.
These two are and metronidazole will cause what's called a die
salt from like reaction. Disulfiram, like reaction, some
other side effects that you can see is some GI distress.
Nausea vomiting, diarrhea. That's shorthand for how you
write that. The other thing with
Methotrexate is it can cause mouth ulcers.
So kind of like at the angle of the mouth to kind of look for
those mouth ulcers. So what are we going to educate
the patient on? Educate them on.
Proper oral. Hygiene propyl or Oral Care.
Exactly. So definitely an educational
point right there as well, too. ultimately, The issue with
Methotrexate or sorry, the issue that we're trying to solve is
what rheumatoid arthritis, which is what autoimmune disease.
So what we're trying to do is suppress it immune system.
So you have to educate this patient to avoid large crowds.
They themselves cannot get live, vaccines nor can they be around
somebody who just received it? Look out for signs of infection.
because this person is not going to be able to fight it off, so
that person that comes in And is on Methotrexate or any other
immunosuppressant starts complaining of that sore throat.
Or maybe they've got some GI distress, maybe they think
they've got the stomach flu or they've got UTI.
That's not just some run-of-the-mill issue that we're
going to deal with here. You got to be able to identify
it. We are freaking out about that
because in a person that is on an immunosuppressant that shows
signs of infection, which one of the eight of ask graph is it
Sepsis exactly sepsis. Hey guys, dr.
Zeeshan here. Thank you so much for joining us
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