conference – te papa. friday 8 – saturday 9 july 2016 · conference – te papa. friday 8 –...
TRANSCRIPT
Conference–TePapa.Friday8–Saturday9July2016Thisyear,PodiatryNZispresentinganinformativeofferingforthisyear’sconference.Weanticipatethattheprogrammewillbebothstimulatingandchallenging.Youhavebeenidentifiedasaspeakerwhowillofferinnovativeandinspirationalcontentthroughin-depthsubjectknowledge.Thisyear,PodiatryNZisthemingtheconferenceonthePatientJourney.Viathepatient,wewillwalkthroughallaspectsofpodiatry,followingthejourneyofthepatient(s)andtheircomplexmedicalissue.Wewillfocusontheircomplexconditionwhichwillemphasiseonmanyaspectsofclinicalmanagementrelatedtothecomplexcase.Asaspeakerattheconference,youwillhopefullybeabletoaddressmanyaspectsofyourpresentationtothepatientandtheconditionaspresented.TheconferencewillbeheldonFriday8–Saturday9July2016attheiconicTePapaMuseuminWellington,NewZealand.
Apatienthasbeentoseeaspecialistwhohassuggestedthatshecontactsapodiatristregardinghercondition.Thefollowinginformationhasbeenprovided:
A48-yearoldEuropeanfemalewithaBMIof20diagnosedwithseropositiverheumatoidarthritisin2004
Diseasemarkers,functionsandactivitiesusedtoestablishdiagnosis
• AssessedDiseaseActivityScore28(DAS28)was7.22(22tenderjoints,13swollenjoints,patientglobal
assessmentVAS-80,CRP15).Shehadelevatedrheumatoidfactor-681IU/ml,highlypositivelevelofanti-citrullinatedprotein/peptideantibodies(anti-CCP)–263U/ml.HealthAssessmentQuestionnaire(HAQ)scorewas1.2indicatingmoderatedisability.
Medicationhistory
• Since2004thepatienthasbeentreatedwith:prednisone,atthehighestdoseof15mg/day.Shehasalso
receivednonsteroidalanti-inflammatorydrugs(NSAIDs)-paracetamol,ibuprofen,naproxenanddiclofenac.
• Methotrexateandsulfasalazinewereprescribedatdiagnosisbutthepatientdiscontinuedthemin2005
againsttheadviceoftherheumatologist.Sincethistimeshehasself-managed.Thishasincludedtheuseofnaturalanti-inflammatorytherapies,meditation,physiotherapyandmassage
• Recentlythepatientwasprescribedmethotrexate(25mgperweek)orallywithfolicacid,twiceaweek,
withintramuscularmethylprednisolone120mgadministered,whileoralprednisonewasreducedto7.5mgdaily.Diclofenacdosewasreducedto150mgdaily.Additionalmedicationsincludeomeprazole20mgdaily,Accupril20mgdaily,Fosamax70mgonceaweekandCitalopram20mgdaily.
Physicalexaminationreportedbyrheumatologist:
• Numerous rheumatoid nodules, with diameter range from 2 to 3cm. The nodules were located on the
extensorpartsoftheproximalinterphalangealandmetacarpophalangealjointsandaroundwristsandanklesandelbows.
Radiography
• Radiographsdemonstratedsevereerosivediseaseandstructuraldeformitytothehandsandfeet• Totalkneereplacementtotheleftkneein2014
Yourexaminationrevealsthefollowing:1. Footpain(inthepastweek)
• VisualAnalogueScale80/100(100beingworstpain,0beingnopain)
2. Structure• Splayedforefootwithbilateralhalluxvalgusdeformity(grade3)• SubluxedMPJs2-5bilaterally• Bilateralretractedlesserdigits2-5withseconddigitover-ridingthirddigitonrightfoot• Distalshiftplanterfatpadbilaterally• Prominentmetatarsalheads2-4withoverlyingadventitiousbursaebilaterally• Foot-type-pesplanus(L),rectus(R)
3. Skin
• HelomadurumdorsumseconddigitRfootandlateralaspectof5thdigitbilaterally• Extensiveinterdigitalmaceration(possiblefungalinfection)• Plantarcallusoverlyingmetatarsalheads2-4bilaterally• Dry,fragileskinlowerlimbs• Lacerationonanteriorleg(L)coveredwithdressing
4. Functionnon-weightbearing
• Restrictedrangeofmotionankle,subtalar,midtarsaland1stMTPjointsbilaterally• Generalisedweaknessoffootinvertors,evertors,plantarflexorsanddorsiflexorsbilaterally
5. Functionweightbearing
• Functionalleglengthdiscrepancyapproximately15mm(leftshorterthanright)• Limitedrangeofmotionankle• PositiveRomberg’stest-indicatinglossofproprioceptionanddecreasedposturalstability
6. Gait
• Ashufflinggaitwithdecreasedwalkingspeed
7. Footwear• Crocsworntoappointment-reportedasusualfootwear• AdditionalfootweardescribedbypatientincludesPedorsissuedbyorthoticcentre,walkingsandals,
sketchersslip-on,runningshoesandjandals
8. Orthotics• Anaccommodativeinsolemouldedtothefoot.Inaddition,shereportedhavingpurchasedvarious
‘shoeinserts’overtheyearsbutusuallyfoundthemtobeuncomfortable
9. PROMs• LeedsFootImpactScale,Impairment/Footwearsubscalescore9,Activities/Participationrestriction
subscalescore15indicatingmoderatefoot-relateddisabilityandimpairment