rheumatoid arthritis
Doctor Information
Patricia McLennon, age 48
PMH: nil
Last consultation, seen by Dr Jones 1 week ago
Complaining of painful swollen hands, says been going on for over a year but was afraid to come in. No other joints affected, hair, nails and skin ok. Mum has hypothyroidism.
On examination synovitis present bilaterally in the MCP joints.
Plan: for bloods then review
Blood tests:
Hb 12.9
Wcc 5.9
Plt 200
Na 136
K 3.6
Urea 9
Creatinine 98
CRP 41
Rheumatoid factor positive
PMH: nil
Last consultation, seen by Dr Jones 1 week ago
Complaining of painful swollen hands, says been going on for over a year but was afraid to come in. No other joints affected, hair, nails and skin ok. Mum has hypothyroidism.
On examination synovitis present bilaterally in the MCP joints.
Plan: for bloods then review
Blood tests:
Hb 12.9
Wcc 5.9
Plt 200
Na 136
K 3.6
Urea 9
Creatinine 98
CRP 41
Rheumatoid factor positive
Patient Information
Patricia McLennon, age 48
History: You came last week with swollen hands and the doctor said you needed some bloods. He didn't really tell you much and you have been worrying about the results all week.
Your hands have been painful and swollen for over a year. You hate coming to the surgery because you had a bad experience as a child, but your husband forced your to come and get checked out. There were times when the swelling was ok, but other times you had trouble holding things in your hands. You wondered whether you were allergic to something but you haven’t changed your cream or washing powder recently. What was strange was that you noticed your hands were very stiff in the morning, which lasts for around for at least 50 minutes. No other joints are swollen or painful. Your skin is fine, as is your hair and nails. You have no eye problems
You live with your husband and son, and work at Barker and Stonehouse furniture store.
You are a non smoker, and you never drink alcohol. Your mum has hypothyroidism, no one in your family has had any form of arthritis.
Life is good at the moment, no problems with low mood, and you have lots of hobbies you enjoy,
You have no rash if asked.
Ideas: you really hope it is just an allergy to something and will go away
Concerns: the doctor didn't tell you much last time but now you have called back in and that must mean it is something serious. You have done some reading online and someone on a forum mentioned rheumatoid arthritis, and you googled photos that showed gross deformity. You really don't want this to be rheumatoid arthritis!
Expectation: some tablets for the symptoms
You are generally very anxious about everything, and will easily get upset. When you are told the likely diagnosis of rheumatoid arthritis you burst into tears - isn't that the condition that makes your hands deformed so you can’t use them anymore. You need a lot of consoling and reassuring that medication is available to reduce the chance of this happening, and at the moment we need to confirm whether this is the right diagnosis. You will be reassured if the doctor is understanding and explains the diagnosis well. If they mention complications you start to cry again. You are very happy to referred on to Rheumatology.
History: You came last week with swollen hands and the doctor said you needed some bloods. He didn't really tell you much and you have been worrying about the results all week.
Your hands have been painful and swollen for over a year. You hate coming to the surgery because you had a bad experience as a child, but your husband forced your to come and get checked out. There were times when the swelling was ok, but other times you had trouble holding things in your hands. You wondered whether you were allergic to something but you haven’t changed your cream or washing powder recently. What was strange was that you noticed your hands were very stiff in the morning, which lasts for around for at least 50 minutes. No other joints are swollen or painful. Your skin is fine, as is your hair and nails. You have no eye problems
You live with your husband and son, and work at Barker and Stonehouse furniture store.
You are a non smoker, and you never drink alcohol. Your mum has hypothyroidism, no one in your family has had any form of arthritis.
Life is good at the moment, no problems with low mood, and you have lots of hobbies you enjoy,
You have no rash if asked.
Ideas: you really hope it is just an allergy to something and will go away
Concerns: the doctor didn't tell you much last time but now you have called back in and that must mean it is something serious. You have done some reading online and someone on a forum mentioned rheumatoid arthritis, and you googled photos that showed gross deformity. You really don't want this to be rheumatoid arthritis!
Expectation: some tablets for the symptoms
You are generally very anxious about everything, and will easily get upset. When you are told the likely diagnosis of rheumatoid arthritis you burst into tears - isn't that the condition that makes your hands deformed so you can’t use them anymore. You need a lot of consoling and reassuring that medication is available to reduce the chance of this happening, and at the moment we need to confirm whether this is the right diagnosis. You will be reassured if the doctor is understanding and explains the diagnosis well. If they mention complications you start to cry again. You are very happy to referred on to Rheumatology.
Examination Findings
Both hands show swelling of the MCP joints, particularly over the first and second MCP joints. They are tender to palpate.
No nodules or deformity seen.
Normal grip (but painful for the patient).
Normal sensation and radial pulse.
MCP squeeze positive
No areas of psoriasis
No nodules or deformity seen.
Normal grip (but painful for the patient).
Normal sensation and radial pulse.
MCP squeeze positive
No areas of psoriasis
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation interpretation Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently Uses an incremental approach using time and accepting uncertainty |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them Appears disorganised/unsystematic in the application of the instruments or the conduct of physical examinations |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions Refers appropriately & co-ordinates care with other healthcare professionals Manages risk effectively, safety netting appropriately |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Does not allow own views/values to inappropriately influence dialogue |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient Inappropriately influences patient interaction through own views/values |
Management
Explanation: Examining your hands and looking at your blood tests, I suspect you have rheumatoid arthritis. This is a type of arthritis that causes swelling and pain in the smaller joints, particular the hands, but can affect anywhere. It is not as a result of wear and tear, but as a result of your body attacking itself. If your hands are left with no treatment, there is a change the swelling can damage the joints over time, reducing their function. However there are many treatments available to reduce the chance of this happening, as well as controlling the pain.
There are several aspects to this case: it is about identifying the likely diagnosis of Rheumatoid Arthritis (RA), breaking the bad news gently, and consoling the patient whilst negotiating a management plan. Most of the work with the history has been done by the doctor, but the patient is clear that she was not told what the blood tests were for.
There is no ‘diagnostic test’ for RA, and all patients require urgent referral (within 2 weeks) to see Rheumatology. Whether this is possible appears to vary from area to area, certain trusts do have rapid access rheumatoid arthritis clinics for suspected cases. The earlier that disease modifying drugs are commenced, the better the long term prognosis. You can still offer the patient simple analgesia, but do not delay referral for any reason.
Which also brings us to what the first doctor should have done. It is now advisable that if you suspect rheumatoid arthritis, then do not do bloods first, before deciding to refer. You should refer in straight away, and get the bloods done prior to being seen at the clinic. In this case the patient had a good history for inflammatory arthritis, and the examination is consistent with inflammatory arthritis, therefore delaying referral for the sake of bloods is not the best management.
Always remember to exclude psoriasis in cases of inflammatory arthritis, so make sure you check the nails, skin and hair.
All chronic conditions are associated with an increased incidence of low mood / depression.
So best to do a quick depression screen using the NICE screening questions:
During the last month have you been feeling down, depressed or hopeless?
During the last month have you often been bothered by having little interest or pleasure in doing things?
If a patient with a chronic physical illness answers 'yes' to either question, the following three questions should be asked:
During the last month, have you often been bothered by:
Feelings of worthlessness?
Poor concentration?
Thoughts of death?
If then the case appears to take turn down towards the depression path, then follow it.
So what do you do when a patient breaks down? A few comforting words is a good start, and offering support (and a tissue). What has she heard about RA that is upsetting her so much? Maybe you can allay some of her fears, and it gives you a chance to explain RA to her. Nothing is confirmed yet, so there is no point going on about complications - at the initial diagnosis, be realistic but positive - there are lots of drugs to modify the disease, and for many people it doesn't affect their daily lives. She may have questions, but sometimes it is wise to give your patient some time to process things - maybe arrange a follow-up appointment in a few days and suggest that she write down a list of questions. Sometimes giving a patient information leaflet and asking them to come back to see you can help. Just be advised that in the CSA, simply saying you will give an information leaflet is not good enough, you need to state why you are giving the leaflet, and what information is included within the leaflet that you want them to look at.
There are several aspects to this case: it is about identifying the likely diagnosis of Rheumatoid Arthritis (RA), breaking the bad news gently, and consoling the patient whilst negotiating a management plan. Most of the work with the history has been done by the doctor, but the patient is clear that she was not told what the blood tests were for.
There is no ‘diagnostic test’ for RA, and all patients require urgent referral (within 2 weeks) to see Rheumatology. Whether this is possible appears to vary from area to area, certain trusts do have rapid access rheumatoid arthritis clinics for suspected cases. The earlier that disease modifying drugs are commenced, the better the long term prognosis. You can still offer the patient simple analgesia, but do not delay referral for any reason.
Which also brings us to what the first doctor should have done. It is now advisable that if you suspect rheumatoid arthritis, then do not do bloods first, before deciding to refer. You should refer in straight away, and get the bloods done prior to being seen at the clinic. In this case the patient had a good history for inflammatory arthritis, and the examination is consistent with inflammatory arthritis, therefore delaying referral for the sake of bloods is not the best management.
Always remember to exclude psoriasis in cases of inflammatory arthritis, so make sure you check the nails, skin and hair.
All chronic conditions are associated with an increased incidence of low mood / depression.
So best to do a quick depression screen using the NICE screening questions:
During the last month have you been feeling down, depressed or hopeless?
During the last month have you often been bothered by having little interest or pleasure in doing things?
If a patient with a chronic physical illness answers 'yes' to either question, the following three questions should be asked:
During the last month, have you often been bothered by:
Feelings of worthlessness?
Poor concentration?
Thoughts of death?
If then the case appears to take turn down towards the depression path, then follow it.
So what do you do when a patient breaks down? A few comforting words is a good start, and offering support (and a tissue). What has she heard about RA that is upsetting her so much? Maybe you can allay some of her fears, and it gives you a chance to explain RA to her. Nothing is confirmed yet, so there is no point going on about complications - at the initial diagnosis, be realistic but positive - there are lots of drugs to modify the disease, and for many people it doesn't affect their daily lives. She may have questions, but sometimes it is wise to give your patient some time to process things - maybe arrange a follow-up appointment in a few days and suggest that she write down a list of questions. Sometimes giving a patient information leaflet and asking them to come back to see you can help. Just be advised that in the CSA, simply saying you will give an information leaflet is not good enough, you need to state why you are giving the leaflet, and what information is included within the leaflet that you want them to look at.