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