Referral Guidelines

My scope of practice includes:

  • Inflammatory arthritis e.g. rheumatoid arthritis, psoriatic arthritis, seronegative spondyloarthritis (AS, reactive)
  • Crystal arthropathies
  • Connective tissue diseases
  • Local soft tissue rheumatic complaints

Where applicable please specify referral to the

  • early RA clinic - new onset inflammatory polyarthritis which needs urgent assessment
  • gout clinic - established or suspected gout especially in difficult situations eg renal failure, drug intolerance
  • injection clinic - patients with shoulder pain, OA knee, base of thumb etc where injection may help

For urgent referrals who need to be seen with 48 hours please call the office or email via one-mail.

 

Wait times

Current wait times are still less than 3 months for patients within the scope of practice, with urgent patients being seen soomer

Potential new RA should also be seen urgently within 2 weeks – please identify patients who need to be seen in the early RA clinic

In addition we are developing a rapid injection clinic for patients whom you feel need joint or soft tissue injections, e.g.trigger finger, rotator cuff disorders, OA base of thumb. Please identify these patients who should be seen in the injection clinic.

Urgent patients will be seen the same week. Other priority patients will be seen within a small number of weeks.

 

Unfortunately I am unable to offer a chronic pain service, as this requires a multiprofessional team and unique resources;  I believe there are providers in the area who are better able to help these patients.

 

The table below shows some of the considerations and investigations helpful when referring patients.

Defining the clear reason for referral is a great help e.g. is it for diagnosis, management etc?

 

Presentation

Differential diagnosis

Comments

Action

Acute Single Joint
Septic arthritis Acute hot red joint. Usually very painful. Patient generally unwell, usually with fever.Septic prosthesis may be clinically silent (ref orthopedics).Immunosuppression will mask some signs Need urgent aspiration of the joint for microscopy Urgent referral to ER within 24 hrs. Please phone if patient needs to be seen in clinic
Gout, pseudogout Difficult to distinguish from sepsis if no previous history of gout. Aspiration to show crystals is the definitive diagnostic test.The “typical” pseudogout patient would be an elderly woman with a hot red wrist or knee. After diagnosis rest, NSAIDs (if justified by GI risk) and joint injection are options. Colchicine works for gout but is poorly tolerated by many patients.Remember a normal uric acid does not exclude gout and a raised uric acid is very common.Remember that with allopurinol you aim to get the uric acid below 350, but even when you achieve this the patient may have further attacks for a year or two Urgent referral if possibility of sepsisIf you are sure this is not sepsis please all me and I will see urgently
Reactive arthritis psoriatic arthritis These patients may have a monoarthritis or oligoarthritis. Joints show clinical signs of inflammation, but redness is uncommon.Ask about inflammatory bowel disease, iritis, psoriasis and sexual history. Semi urgent referral for actively inflamed joints Investigations prior to referral;CBC, creatinine, LFT, CRP, ESR
Rarely;haemarthrosis, avascular necrosis sarcoidosis Sarcoid may be associated with erythema nodosum Ix as above: CXR if sarcoid suspected
Sub-Acute Single/Few Joints Osteoarthritis; This is a clinical diagnosis which is based on the history and examination.Generally these patients need education and encouragement towards self management.Referral is rarely useful in terms of improving patient outcome, though physiotherapy and occupational therapy assessment can help greatly. Refer patients where there is diagnostic doubt, or where intra articular injection might help.
Gout Acute gout is discussed above. Chronic gout e.g. recurrent acute attacks, tophaceous gout may be an indication for allopurinol.Patients will continue to get attacks of acute gout for several months after starting allopurinol and may abandon therapy if not warned.There is evidence that close support results in better outcomes, and we are offering nurse led support clinics for chronic gout Refer patients where there is difficulty controlling the disease or diagnostic uncertainty. Patients with renal disease may be difficult to manage and I am happy to see this group
CBC, ESR, CRP, creatinine, LFTs, uric acid

 

 

 

Inflammatory Polyarthritis
Rheumatoid arthritis This is a predominantly clinical diagnosis based on the present of persistent (i.e. >6 weeks) symmetrical synovitis , morning stiffness, malaise.Rheumatoid factor is not a helpful diagnostic test and should only be used to assess prognosis. False positives are common.Anti CCP antibodies are highly specific (95-98%) for RA.We will be reserving clinic slots every week for assessment of patients with possible early RA and if the referral is clearly marked they will be seen quickly. It is generally helpful not to start steroids before discussion with the rheumatologist All potential new RA cases should be referred urgently for assessment Investigations helpful prior to referral include;CBC, creatinine, LFTCRP, ESR, lfts, creatinine
Anti CCP, Rh f
CXRXR hands and feet 
Flare of RA Patients with active RA may flare following infections or without an obvious trigger. Generally it is reasonable to wait a few weeks to see if thing return to normal rather than rushing to change the DMARD dose etc. For persistent flares depomedrol 80 mg im may settle things down prior to referral for urgent review Please phone or fax specifying urgent review
Reactive arthritis See comments above Investigations as for inflammatory polyarthritis (see above)
May be worth having a low threshold for suspecting Chlamydia and appropriate referral
SLE / CT diseases Please contact me for patients with CT diseases for advice on where they are best referred, and investigations which would guide triage and diagnosis Contact me if you need to discuss.
ANA, ENA, CBC, renal, lfts, ESR, CRP, Urinalysis  CXR
Post viral A history of infection is not always obvious, and distinguishing from rheumatoid arthritis is notoriously unreliable.It is reasonable to treat a patient with an inflammatory arthritis symptomatically with NSAIDs for a few weeks to see if it is self-limiting. Steroids can confuse the diagnostic picture and are usually best avoided. Phone to discuss this group if worried, or refer to EARLY RA clinic for us to decide