Author:  Katrina Pavic

Editor:  Elizabeth Campbell

 

My Monday starts at 8am. I make my way to the ward to meet with my Resident. We work our way through the inpatient notes to update ourselves on what has happened over the weekend, before proceeding to discuss each case in the multi-disciplinary team meeting. Once this is finished, I make my way to the Rheumatology Clinic, where I will be seeing patients for the next few hours. During this time, I will see both new and follow-up patients, with a multitude of issues.  I chose to work in Rheumatology as it encompasses a wide spectrum of conditions of varying complexity, ensuring that each day is not only interesting, but challenging.

The first patient I see is a young woman who has recently moved to Australia from India. She tells me that she was diagnosed with some form of arthritis in India, and that she had previously managed her condition with herbal supplements. Whilst taking a detailed history, I start to think that she probably has rheumatoid arthritis. I tell her that I suspect she has an inflammatory arthritis and that we will have to do more investigations as soon as possible, before likely commencing her on disease-modifying therapy. Fortunately, she is very receptive to this advice and overall appears quite relieved that someone is willing to follow through with her case. The best aspect of working in Rheumatology is positively impacting the lives of patients, particularly when it comes to managing conditions such as inflammatory arthritis, which can be quite debilitating. In these situations, it is gratifying to watch patients so drastically improve with the treatments we offer.

Another patient I see is a middle-aged woman who has had a recently confirmed diagnosis of rheumatoid arthritis. She reports that she is feeling relatively well and as such is very anxious about commencing on any disease-modifying therapy. I explain that her symptoms may progress in the near future, in which case a more aggressive approach to her management may be warranted, so as to avoid any long-term complications. She seems understanding of this, but remains quite anxious. I give her some information on Methotrexate to read prior to her next appointment.

Whilst seeing patients in the Rheumatology Clinic, I receive multiple calls from the Emergency Department and ward teams requesting advice. In the Emergency Department, three patients are waiting to be seen. The first is a patient with a presumed flare of ankylosing spondylitis. The second is a patient with a presumed flare of reactive arthritis. The third is a patient who is unable to mobilise due to severe pain in both of her hips. I mentally schedule the rest of my day, realising that I still need to round on the inpatients. Before I set out to complete my various tasks, I grab a quick lunch and liaise with my Resident, who updates me on the status of the inpatients.

I make my way to the Emergency Department. The first patient I see is an elderly woman with a history of ankylosing spondylitis. She tells me that she has had terrible pain for multiple days, with widespread stiffness and swelling in both of her knees. She is unable to look after herself at home in her current state. I admit her for further investigation and management, and plan to aspirate both of her knees later in the day. The next patient I see is a young man who has had a recent admission with reactive arthritis. He tells me that he stopped taking his medications after his initial supplies ran out, as he didn’t realise how important they were. His ankles are swollen and he is unable to bear any weight on his feet. I admit him, recommence him on his previous medication regime and emphasise the importance of adhering to the prescribed management plan. He seems understanding of this. The final patient I see is a middle-aged woman who has no known history of any rheumatological issues. She tells me that she recently travelled to Fiji. Since returning to Australia, she has been feeling unwell with flu-like symptoms. In the past few days, she has developed severe pain in both of her hips and is unable to mobilise. I admit her for further investigation and management.

I make my way to the ward to commence rounding on the inpatients, who have an array of issues. I see a young woman who is recovering from severe lupus with cerebral vasculitis, an elderly man who is being worked-up for suspected giant cell arteritis, a young woman with severe lupus and immune thrombocytopaenia whose platelet count drops to critically low levels on a regular basis, a young man with severe and disabling tophaceous gout who has lost his independence to carry out activities of daily living, a middle-aged woman with diffuse scleroderma and ischaemic toes requiring an Iloprost infusion and an angiogram, and an elderly woman with a flare of oligoarticular pseudogout who is unable to look after herself at home in her current state.

Whilst rounding on the inpatients, I receive further calls for consults. There are two patients waiting to be reviewed with suspected giant cell arteritis – one in the Eye Clinic and the other in the Emergency Department. It’s late in the afternoon, I still have two knees to aspirate, and I need to be at a Department Meeting by 5:30pm!

I make my way to see the newly admitted patient with a presumed flare of ankylosing spondylitis. I aspirate a reasonable volume of synovial fluid from both of her knees and in turn provide her with some symptomatic relief. Fortunately, the synovial fluid doesn’t look too sinister. Once I have finished, I make my way to the Eye Clinic to review the first patient with suspected giant cell arteritis, an elderly gentleman. He tells me that he has had generalised headaches with some associated visual blurring of a few days duration. The Ophthalmologists are quite suspicious of underlying giant cell arteritis. We admit him for further investigation and management. Next, I make my way to the Emergency Department to see the final patient of the day, another elderly gentleman. He tells me that he has had a right temporal region headache with associated diplopia. We admit him for further investigation and management.

Finally, I head to the Department Meeting. The meeting centres on a case presentation, where the patient himself has arrived to be part of the discussion. He has a longstanding history of deforming rheumatoid arthritis with a relatively recent diagnosis of interstitial lung disease. We discuss in detail his management to date and the various challenges going forward, in view of his various comorbidities.

My Monday ends at 7pm. I leave work and prepare to do it all again tomorrow!