Borders Ref Help Toolkit
Who to refer:
Rheumatology Emergencies -
- The acute hot joint - assessment on its merits but septic arthritis and gout are both in the differential diagnosis. In the otherwise well patient who is afebrile consider joint aspiration (if you are able) and send fluid for MCS and also polarised microscopy for crystals, or discuss with the on-call orthopaedic surgeon or rheumatology during routine hours. For the febrile patient, or patients who are immunocompromised discuss with orthopaedics with a view to assessment and admission if necessary.
- Sepsis/suspected sepsis in immunosuppressed patients - if the patient appears to have serious infection consider medical admission to hospital - particularly for those patients on biologic therapies or those who are neutropenic and septic
- Methotrexate pneumonitis - consider this diagnosis in the patient with fever, shortness of breath and dry (usually) cough. Stopping methotrexate may be sufficient, but patients with hypoxia or severe shortness of breath may require medical admission for investigation and treatment.
Urgent Rheumatology OPD
- New inflammatory arthritis - we do like to see these patients early in the course of their disease - but not so early that we cannot give a diagnosis or when the condition may prove to be self limiting or viral. In general if an episode of true inflammatory arthritis is not settling by 6 weeks you should refer for an urgent appointment. In the interim treat with NSAIDs (unless contraindicated) and rest. If you are considering using im depomedrone please discuss first with rheumatology - it can actually result in a delay in achieving a diagnosis and a long term management plan. Please do not use oral steroids without discussing. Do ask about other systemic features and check a urinalysis - serious multisystem disease presenting arthritis is not common but is serious and if there is significant blood and protein in the urine may need more urgent investigation.
- Suspected serious connective tissue disease/vasculitis - new onset of systemic symptoms, often with rash and/or arthralgia or arthritis, with dipstick haematuria and proteinuria, impaired renal function, and usually raised inflammatory markers. A long standing non-specific rash, non-specific aches and pains and a low grade positive ANA is not an emergency
Routine Rheumatology OPD - approximately half of new referral to NHS Borders rheumatology clinics are considered non-urgent. They encompass problems such as:
- Long standing arthritis which is felt to be probably non-inflammatory but where there is genuine diagnostic doubt
- Suspected inflammatory back pain - treatment is initially with NSAIDs and unless there is also peripheral arthritis is not considered an urgent problem
- Difficult to manage polymyalgia rheumatica
- Non-specific widespread aches and pains
- Difficult to manage gout - or suspected gout where there is diagnostic uncertainty
- Suspected connective tissue disease without evidence of major organ involvement
- Joint hypermobility
Who not to refer:
All referrals are reviewed by the consultant along with any relevant investigations. Patients with clear cut soft tissue problems, non-inflammatory back pain, clear cut osteoarthritis should not be referred and will not be offered appointments. Examples include:
- Shoulder impingement pain - treat with pain relief, physiotherapy, local steroid injection and consider orthopaedic referral if all of these have failed
- Lateral and medial epicondylitis - analgesia, physio, consider local steroid injection or refer to the musculoskeletal clinic via orthopaedics
- Dupuytren's contracture - rheumatology has nothing to offer for this
- Clear cut osteoarthritis of a single joint where the disease has not yet advanced far enough to consider surgery or where the patient is not fit for surgery - consider local steroid injection or referral to the musculoskeletal clinic if it is a joint that nobody in your own practice can inject
- Cervical spondylosis, chronic low back pain with no inflammatory features and no neurological features. Management consists of analgesia, exercise and physiotherapy.
- Primary Raynaud's phenomenon - if no other features of a connective tissue disease (no arthritis, rash, hypertension, abnormal urinalysis) try calcium channel blockers. If this is not successful and there is severe Raynauds associated with digital ulceration we are happy to provide advice on other therapeutic options.
- Confirmation of fibromyalgia - where patients have multiple symptoms that have been present for months with normal clinical examination and normal investigations the diagnosis can be made in primary care. A specialist opinion is not required to confirm such a diagnosis. We do not offer appointments to confirm the diagnosis for the benefit of the Department of Work and Pensions.
A link to Royal College of Physicians guidelines on diagnosis and treatment of fibromyalgia is attached.
The diagnosis of fibromyalgia syndrome | RCP
It is enormously helpful if you can ensure that patients understand that where a referral is made for a rheumatology opinion that a potential outcome may be the provision of advice and that an appointment may not be issued. It is also helpful if you indicate in the referral letter that you would be happy to receive advice alone.
How to refer:
Rheumatology OPD Referrals
Electronic referral for outpatient appointments, via Sci Gateway, to Medical Records Department. All referrals are graded appropriately by the Consultant.
Please include in your letter:
- The history and objective findings on examination
Re: examination findings, please provide some comments on which joints are involved, whether the joint is swollen/hot/red, and whether the joints are stiff/have restricted movement. It is not necessary to record degree of restriction. Please also record anything else found on examination that may be relevant e.g. rash, weakness.
- The results of relevant investigations
- Current and relevant previous drug history/sensitivity
- Record of previous illness or surgery
- Psychosocial history
- Specific questions that you would like addressed
- X-rays - state where and when performed - this is particularly important when patients have had films taken in Berwick, as these are not accessible from NHS Borders, and access to these films needs to be requested
- Copies of relevant correspondence from other hospitals/specialists
Please remember that the priority assigned to your patient and the speed with which they are seen will depend on the quality of the information you provide in your referral letter
Suspected giant cell arteritis – please see relevant page
Alternatives to referral:
If the problem can be easily encapsulated in an e-mail the consultant is happy to provide advice by this route. Please provide CHI number to allow retrieval of any relevant results, and allow us and you, where relevant, to print and file the correspondence in the patient's case notes.
Rheumatology specialist nurses
The nurse helpline is not for emergency problems. It is an answerphone service and calls will be returned within 5 working days.
The rheumatology nurses can help to provide advice on managing disease flares in inflammatory arthritis, and management of suspected adverse reactions to disease modifying drugs. They are not, however, trained in the diagnosis of rheumatological conditions, or the evaluation of unusual symptoms that are unlikely to be related to the patient's arthritis or therapy. If you have seen the patient with a problem that you are uncertain about, please do not ask the patient to contact the nurses, but do so yourself. The additional information that you provide is almost always important and invaluable. Our nurses are more than happy to respond to emails using the contact details at the top if that is most convenient for you.
Triage of referrals
All referrals are read by the consultant rheumatologist, and may be offered one of the following:
- An urgent appointment
- Strong probability of early inflammatory arthritis
- Strong probability of a connective tissue disease with concerns about major organ involvement (eg lupus with proteinuria/haematuria)
- A routine appointment
- Difficult to manage polymyalgia rheumatica (please give as much information as possible about the symptoms prior to therapy, subsequent course of symptoms in relation to steroid reduction, dose of steroid at which symptoms relapsed)
- Some symptoms compatible with inflammatory arthritis but either long standing, or low overall probability on the basis of the clinical content of the letter
- Advice only
- Insufficient clinical information to allow triage - in which case more information will be requested
- History and examination, plus investigations suggestive of degenerate disease - where the service has no specific therapeutic interventions to offer
- Gout - where the diagnosis is not in doubt, but treatment has proved difficult
- Requests for advice on analgesia - rheumatology has no drugs that are not available to all medical practitioners
- Joint hypermobility with features of hypermobile EDS only
- Longstanding fibromyalgia/ME/chronic fatigue