FY1 Teaching 20221122 131038 Meeting Recording

[00:00:02]so good afternoon everyone um today we are going to discuss out of which a case of temporal arthritis um or another name is Ryan still arthritis or GCE which is very important case actually um and yet e or AMU or simply Emergency Care Unit or even and um primary care if you are going to work at GP how to recognize and double check case of giantale arthritis or temporal arthritis actually as a medical rule um you have to build your mind this medical rule you have to exclude the worries until otherwise is proved so in the case of chest pain for example you have to exclude and think about PE um ACS alloortic dissection pneumothorax which are the most serious symptoms or the most serious diagnosis of chest pain in the case of headache for example you have to think firstly and rule out or to exclude the more serious Life 3d condition like intracellular Hemorrhage subarachnoid hemorrhage and tubular arthrites which is a vision threatening you know condition so always bear your mind to rule out the worst until otherwise is proved um so jump rather arthritis or uh tries or Timber arthritis is a vision or uh eyesight threatening condition so it is not diagnosed I'm not giving the treatment properly in the proper time it may lead to visualness that's why you have to decrease your threshold for a diagnose of Johnson cell arthritis so jealous arthritis is a systemic vasculitis and it affects you know the large and medium-sized bezels especially the gastrocranial branches of the Carotid artery as we mentioned about twice is a medical emergency which require prompt treatment and action as soon as possible to save vision because it may lead to and may be Complicated by visual loss what our tribes is a common more in women with age more than 50 years old but doesn't mean that it doesn't come with other uh you know six it can come with uh men as well and middle aged men but it's more common in female more than 50 years old and most commonly is associated with umatica patient 50 of the vision of polymergeometrica may present with a joint cell arthritis what the Theology of GCE they told you is could be multifactual there is no specific cause actually to identify cause of Johnson arthritis but it is thought to be autoimmune in nature or maybe uh environmental and or genetic perposition could be a culprit as well but overall it is a kind of vasculitis you know and vasculitis is um an autoimmune disease it's because of an auto antibodies so it is a characterized by girl lumita's inflammation of the medium or large blood thistles arteries as we mentioned it is Orchestra cranial carotid branches especially the temporal you know branches and opthalamic artery are most common included in such condition what are the risk factors for dry cell arthritis or Timber arthritis as we mentioned before the age is very important so more than 50 years old are most common you know age group which are affected by such condition female sex but doesn't you know rule out Middlesex can be affected as well but it's more common in female patients and also it's highly associated with body my nausea body large aromatic ambition approximately 50 percent of patients with tumble arthritis have aromatica that's why in your history you have to ask about symptoms of body manager aromatica and a history of body imagica BMR including frozen shoulder back pain chest pain difficulty of moving especially the morning difficult stiffness in the morning nickel Fisher of uh Timber arthritis number one with the history the history is very important to have of course the bottomic symptom of of a case of General choice is headache and the character of the headache of Timber arthritis is unilateral headache and sub-acute in nature so that could mean that it started gradually within a couple of weeks and getting worse or on and off so uh but of course General headache doesn't rule our Timber arthritis so in most of the cases it says your natural headache and some acute started within couple of weeks coming on and off or getting worse with time this is one of the orthogonomic features actually of chamber of choice as well you'll find the vision has um gludication of Joe and tongue and during talking or showing and this is because of the ischemia of the mercy term muscle still between Journeys this is Rich flag actually in the case of headache any patient coming with lateral headache and scalp tenderness the first thing to think about is chamber arthritis and this kelbet Engineers will be by touching the uh the scalp of the vision or when he's getting to the bed and touching the pillow he'll he will find that he has tenderness of the side of the scale laws of vision in one or both eyes because this is one of the life-threatening you know conditional or eye the historic not life that I think it's I side-threatening condition now if there's individual disturbance including martial laws of vision leaders of vision you have to act at once because the species are at high risk of permanent irreversible loss of vision uh developer also is one of the manifestation or clinical picture or in the history of the visual still brought writers other important areas to cover in the history also uh constitutional symptoms constitutional symptoms include fatigue malaise uh fever weight loss anorexia depression which are manifestation of polymer energy aromatica actually which is highly associated with dry cell arthritis in the past medical history you have to ask about history of PMR polymerase aromatica as we mentioned before 50 percent of chamber arthritis patients are associated with PMR so constitutional symptoms are very important including malaise fatigue headache loss of weight and of course muscle pain shoulder pain frozen shoulder and more negativeness which are manifestation of PMR clinical examination and clinical examination you'll find palpation sculptation phantoscopy and blood pressure four elements or four points in clinical examination are is are very important in the case of tubular tries and palpation of the Temple of the site of the headacheal find that there is tenderness and there is it used or absent chamber artery pulse so there's two signs genderness on the temple and absent reduced temporal artery Bots and brachial sorry anti-carotid carotid artery for per week the presence of prairie is highly suggesting chamber or choice but the absence of period doesn't rule it out uh blood pressure you can find a symmetrical blood pressure in both sides of armors but its absent doesn't rule it out it's presence how you suggested for the diagnosis foundoscopy is very important as um it may reveal that you have edema with blarge optic disc This is highly suggestive of the diagnosis that's why inhibition was put in with a chamber of twice you have to refer the patients horizontally to a cell majest in the case of individual disturbance there so clinical pressure again palpation of sculptation blood pressure and the fundoscopy poor elements this is a brief summary yeah how bad should the 10 minutes it's it's different from one Bishop to the other according to the severity of the broad Choice it could be mild moody or severe or even the absence of tenderness doesn't rule out Timber arthritis this is we are talking about the typical manifestation of just arthritis but absence of some of these fissures doesn't rule out chamber arthritis can come with a typical manifestation most of the time uh this is a summary of the clinical picture of history and the clinical picture of GCE history again we we can find headache which is very important there is no patient with tumor trust without headache actually you know so there is no headache you you don't have to think about chamber arthritis heading at the bottomic you know a symptom of the issue was GC and the headache will be you're natural most of the time and sub-acute within couple of weeks on and off or getting worse number two is Tank Engine this is because of my sister muscle affection a scale pain and change earnest and division himself will tell you that there is a pain on the side when I'm getting to the sleeve or touching a pillow or touching my temple a visual disturbance and a visual disturbance could be in the form of double vision the immunition of vision blade division loss of partial loss of vision or complete losing fission and if this individual disturbance at all this is a reflex sign that you have to refer the vision directly for post Rheumatology and Ophthalmology to do fundoscopy to check for the optic disk uh systemic Fishers as we mentioned like fever a loss of weight malaise fatigue and of course muscle pain stiffness which are manifestation of polymyalgia rheumatica PMR clinical examination as we mentioned including Four Points a palpation for tenderness auscultation for per week and the school fish will be on the auxiliary and carotid artery um asymmetrical blood pressure measurement in both arms and pontoscopy which is very important examination especially in cases of visual disturbance which we reveal pale disk with Bill peripheral disk you know um uh border which is edema disk a team yeah uh okay investigations more configuration Which choice in the case of suspected temporal Tracks number one is for black count so basically we are going to start with basic investigation like every patient FBC unes lfts and inflammatory markers uh in full black count you can find normalcytic normal chromic anemia um especially in cases of PMR but absence of anemia doesn't read it out yeah CRP and esar crb will will be high in the case of PMR but normal CRV doesn't rule out again uh um GCE why because uh crb can take like a couple of days 48 hours to raise up the more sensitive inflammatory marker in the case of body manager rheumatica sorry in the case of Timber arthritis is esar is our will increase you know abruptly and suddenly within short time and the presence of ESR more than 50 is highly suggested of the disease uh lfts you can find that LP and transamines might be slightly high but again normal lfts doesn't rule out through multiple price but increase or slightly high lfts May support the diagnose of uh uh agency Imaging non-invasive Imaging including Timber archery ultrasound is the most usual Imaging or scan or available scan for a case of GCA and it will reveal thickening of the wall of the affected block vessels a phenomena known case known as Hollow sign as you see here in hollistein you will find this is the the red uh color is the blood clue and this is the wall of the vessels which should be thickened here all right and this is very approachable and accessible uh available uh non-invasive scan which can highly support the diagnosis or even can confirm the diagnosis with other clinical features and lab features as well temporal artery biopsy jumper artery biopsy actually if the definitive investigation of a choice to confirm a diagnosis of Timber arthritis and it will reveal that there is multi-nucleated giant cells in the wall of the arteries but honestly and practically it's not usually used actually for many reasons number one it's invasive procedure number two it can give negative false negative results because you might have a skipped you know lesion on the artery you might take a pillows from the artery and this side of the artery is not affected as you know it's patchy thickening and patching vasculitis so not the whole artery is included or involve it and that's why we are not using actually Timber archery biopsy usually or practically in our clinical fault we depend more on our history clinical science and lab or blood investigations results management of uh GC if you are highly suspecting GCA in terms of History clinical science and lab science or sorry a lot of finding what the treatment of choice you have to urgently refer the vision to rheumatologists to be seen the same day so same day referral to remote Logistics because as we mentioned it is eyesight threatening condition that's why we have to refer division eventually to be seen parametologists number two is to refer debision originally two of them was just but this should be in the case of visual disturbance if it is associated with visual disturbance like visual reduction or blurred vision or bar Shadows of vision or complete loss of vision at that time you have to refer the vision or gently within the same date of someone just to check the back of the eye or from those copy for any signs of Babel edema of course the business of ability map in addition to characteristic headache and high inflammatory markers I think this is enough to make a diagnosis and start the treatment plan at the time number three um formation with mild visual symptoms what does it mean mild visual centers like bleeding with vision or dimensional Vision at the time you have to start on Britney's alone at once and uh at the dose or statues or brings long between sickestly and 100 milligram before referring the mission traumatologist you don't have to wait for rheumatologist to see the patient or of someone just to see the patient of start steroid at once if you're highly suspect you know diagnosis of GCA and that those will be secrecy to 100 milligrams dead then you can refer the division and later on you can keep the vision on the news of 40 to 60 milligram for a duration of uh one year 12 months to 18 months so this iteration we stride what if the mission has visual loss uh either partial visual loss or complete loss of vision at that time you have to start Miss outbreaks how I do the result paid what 500 to 1 gram IV for three subsequent days in addition to referral to some just and apologies of course yeah so two referrals and two treatment two one referral is for Robert Logie at the same day one referral to of some just in the same day if there's individual disturbance if these minor visual disturbance we can start with bring this alone six six milligram or 100 milligram if there's any visual uh um severe visual disturbance or a bar shutter complete loss of vision at that time we can start 500 to 1 milligram sorry one gram into a venous missile bread for three subsequent days this is just you know a brief or a concise uh aggressive of treatment or management or approach of a case of GCA uh so again as we mentioned urgent referral terminal Justice the same day urgent referral two of some just in the same day if there is individual disturbance to check for any evidence of ability edema and start with the tattoos of bridges alone between 60 to 100 if there is minor visual disturbance start with the dose of 500 milligram or one gram homicide bread if there is any partial or complete loss of vision again starting brick is alone that's right it's definitely Bridges along as soon as possible might be reserved the eyesight of the Visions might keep his vision and in our delay of starting steroid May threaten the eyesight of the vision that's why uh steroid is very important to be started as soon as possible after full history full examination and uh um a blood investigation if all of these are highly suggestive of GCA you have to start your treatment at once in addition to your referrals ongoing management it means that long-term management now you started you confirmed your diagnosis of gdca and uh you are going to continue on treatment for how long we'll build the treatment and what other consideration you have to build your mind um the recent guidelines suggest suggest that if division has started in bridges alone overall it has to be continued for 12 months to 18 months with stepping dues of course and this will be done by rheumatologists by the way can be to decrease the dose of five milligram every week um as a turbine those to avoid of course Adrian sufficiency number two is to monitor the patient how what two miniature after division should be seen after two to eight weeks for the first six months gradual uh regularly um to check for the Improvement of the symptoms of the patient and also to check for other complications of a steroid lung thermostat we know that story of the long term it can cause complications like weight gain search markers hypertension hyperglycemia and osteoporosis of course you have to monitor the side effects and the complication of uh Braden is alone in the long term brain is alone for one year one and a half a year might have a lot of complication that's why it should be monitored you have to monitor uh uh glucose cpg and you have to monitor blood pressure of the patient you have also to give PPI don't forget to give PPI for your it upset um also you will have to give reflexes for for osteoporosis especially in all patients like zodronic acid or alternate because of risk of osteoporosis complication what complication can be associated with GCA if not treated properly in rubber time GCA came can be Complicated by irreversible laws of vision it also can be Complicated by aortic dissection aortic aneurysm and large uh artery stenosis in a case of if it is including arteries like allergic artery or carotid artery CPA can be one of the complications as well of chamber artery arthritis struck and myocardial infarction are more common inhibition with tubular arthritis so it's not only threatening the vision it can threaten also the heart it can be associated with CVA can be associated with Mi as well it's a kind of vasculitis of the major uh blood vessels uh and medium-sized blood vessels and of course don't forget about a complication of longer term is tried including hyperglycemia hypertension used to processity are upset weight gain stretch markers these all of these should be monitored um carefully and regularly thank you all and I've been discussion if anyone has any question at all I try to make it very concise precise and targeted to the point not to wish a lot of information on needed information in your stage or level if anyone has any question or question at all hallucinations yeah I was just wondering how you realize this Droid can be associated with many side effects hallucination and more disturbance could be one of the side effects of is Detroit but some other tweeting the risk versus the benefit actually um hallucination could be mentioned by referring to psychiatrust we cannot give anything actually you know and you cannot stop the treatment because of the importance of the treatment you know yeah of course three days this is three days treatment in a case of partial or complete loss of vision and followed by Oral for total um 12 to 18 months yeah it can happen sorry can't happen within the first Do's by the way even when it's no news yeah okay could be a but ludus at the beginning is quite difficult actually but can happen because what what's called tolerance patients are different of tolerating a treatment actually some patient can't deliver treatment farewell somebody she cannot generate treatment and can start to have such serious such effects of the first first dose of the treatment any treatment you know there's what's called adaptation or tolerance which is different from from ambition to the other yeah thank you all I appreciate your uh uh your business today I'll be grateful for your feedback and let's keep on our teaching session thank you