Continue our discussion of Rheumatology.
We'll take a look at rheumatic diseases.
Under rheumatic disease,
our category include
Now, the first example
that we're going to walk you through
is going to be osteoarthritis. But,
very importantly, you need to be
able to compare this with
So, how do we approach arthritis in general?
With joint pain is going to be
a common symptom,
except that doesn't tell you much.
Apart from the fact that, "Oh, yeah,
I have issues in the knee,"
Most likely, I'm going to go
with what most likely.
Also, we're going to pay
attention to those joints
that most likely will lead you into
the proper diagnosis.
What's the difference between
arthritis versus arthralgia?
Algia refers to pain,
whereas itis refers to well, inflammatory,
but even that
can be a little tricky, you shall see. But
technically speaking, there is a difference
in definition between the two.
Arthralgia, sensation of pain,
but understand that the pain oftentimes
is accompanied by
the arthritis, perhaps, maybe around
the joint or periarticular.
Next, we'll be defining what's meant
by acute and chronic,
especially, for example, we talk
about crystalline arthritis,
for example, gout.
We'll talk about acute and chronic gout
or talk about issues even with pseudo
gout, what that means.
Now, in general, 6 weeks, we'll define
or delineate between acute and chronic.
Also, we'll take a look at
a particular arthritis.
Is it's presentation symmetric in
nature, or is it asymmetric?
That tells us a lot,
and also tells us as to well,
if it's long standing,
maybe went from asymmetric to symmetric,
right, or acute to chronic.
Or, was it 1 joint to be affected,
was it monoarticular,
or was it many joints to be
Inflammatory versus non inflammatory,
and that's a little tricky, huh?
Well, let me start off by
telling you immediately
that one would think that
as the name implies come under
inflammatory, but it really doesn't.
And the reason for that is
we're going to check…
together, we're going to
check the synovial fluid.
Synovial fluid, picture that for me, please?
Want you to picture the knee,
the most common…
that's the joint that I'm going to
be using most commonly.
And then I'll tell you other joints that
might be involved in other types,
but picture the knee for me.
From anatomy and histology,
think about the joint capsule.
Think about the synovial lining
responsible for secreting or
making synovial fluid.
Now, we're going to take the synovial
fluid and we'll go and check for WBCs.
And if you find that WBC count to
be quite low, or let's say < 2000,
that technically refers to as being non-
inflammatory, as we shall see.
Even though in osteoarthritis, we…
the name implies that it's inflammatory,
but it's not, as we shall see.
This then forms the basis of what's
meant by acute versus chronic.
Now, the timeline, approximately 6 weeks.
Something also very important.
You're going to read or you're
going to have a patient
comes in and says…or you're going
to ask this question of the patient,
"So, tell me about this pain when you
woke up in the morning, AM,
and tell me about, well, how long did it take
before you could actually feel better
in your joints, for example, the knee?"
And if your patient says,
"Well, Doc, it took me
greater than 1 hour."
I repeat, it took the patient
greater than 1 hour
before the patient started to feel better,
then this puts you into what's
known as your inflammatory
autoimmune type of arthritis.
Now, the most common type of
arthritis has nothing to do with
immune osteoarthritis as we get older.
In that patient, the stiffness only
lasts for about 30 minutes.
Osteoarthritis has nothing
to do with immune
and it comes under what category?
Non-inflammatory. Are you
getting a better grasp
of how to approach arthritis
If not, not to worry.
All this will be repeated as I go through.
As I go about osteoarthritis, let's
start with the presentation.
The common joints to be affected,
no doubt, the knee.
The patient may have been obese,
may have been a female, maybe there's trauma.
As we get older, wear and tear, our knee.
I need you to really know the histology.
If you don't, make sure you
go back and review it.
What may then happen is the joint
space may become narrow.
Think about the cartilage.
The cartilage covers
the articular surface of your knee,
doesn't it? The bone and such.
But what may then happen
there is ulcerations,
and I'll talk about this, moving forward.
But what I'm saying is,
as there's mechanical wear and tear,
chronic, over a period of time,
the patient is going to start feeling pain.
It is non-inflammatory. How do we know?
Because the synovial fluid, if you
expect it to be inflammatory,
you would expect the WBC count to be maybe
What's the normal WBC count?
4,500 to 11,000, isn't it?
So, if you find the WBC count
in your synovial fluid
to be < 2000, please know
that this is then defined as being
non-inflammatory. Is that understood?
"But Dr. Raj, I know for a fact
that with osteoarthritis
that we give the patients…"
What kind of management?
Well, we give to patients, obviously, Tylenol.
Maybe give the patient NSAIDs, right?
So you give them non-inflammatory. I get it.
But, by definition, you can't call
it as such in medicine.
What's degenerating? Oh, the cartilage.
Where is the cartilage located?
In between the joints. Can you
think of the knee, please?
I want you to think of the femur
and understand that it should
be covered by cartilage,
protecting the articular surface,
but that cartilage may undergo ulcerations.
In addition, over a period of time,
with stress occurring on your knee
that the bone may then react,
and when it reacts, it becomes thicker.
We call this sclerosis.
So, there might be subchondral
cysts or subchondral…what's
known as sclerosis.
And then this made them give rise
to what's known as osteophytes.
Yeah, those are to come.
So osteoarthritis going to be a collection
of these type of issues that
we'll take a look at.
I want you to, once again, use
as an example, the knee.
Once you understand the knee, I
will tell you other common joints
that also will be affected,
undergoing the same type
of process, wear and tear.
Know thy patient well.
So what are the common joints
that are to be affected?
Well, the small joints. That's a
big, big, big, big deal.
Small joints. What do you mean small
joints? Oh, maybe the fingers.
Those are really tiny, huh? I want you
to put out your hand for me.
Can you reach out? There you are.
Now, what I'm reaching out
for is going to be the DIP.
Picture that for me.
Distal interphalangeal joint. Huh.
So if in osteoarthritis DIP is affected,
technically, do you remember
what the name of that is?
If you've never seen it before,
then you have no idea,
but it's called Heberden nodes.
Heberden, DIP. Picture that.
What's a little bit proximal to it?
How about we call that PIP?
Ha ha. That's brilliant.
Proximal interphalangeal joint.
Those are called Bouchard's nodes, okay?
So those are 2 joints. Quite specific.
Usually going to be asymmetrical.
What else might be affected? Can you…thumb up?
Give me a thumbs up because you're
doing well. You're getting this down.
No. Seriously speaking,
that is your first digit.
Can you picture the carpometacarpal?
CMC stand for carpal.
What are your carpal bones?
Think, for example, the trapezium.
Can you picture the trapezium for me?
Now, that, plus your metacarpal is your joint.
Interesting enough, the thumb joint,
carpometacarpal phalangeal joint
be affected by osteoarthritis.
So what I'm trying to give to you
is the foundation of comparing
rheumatoid arthritis that we'll
discuss, moving forward.
Small joints: DIP, PIP, carpal metacarpal.
You're focusing upon the thumb,
the knees, as I told you. Obviously,
over a period of time, let's say the
patient is 45, 50, 55, whatnot.
As I stand here, I know I'm developing
I'm putting a lot of strain on my knees.
Hips, and maybe the spine.
At this point, give yourself a good example.
I told you the knee can be affected,
there are other joints as well.