CRP RAPID TEST AS REAL SUPPORT IN CLINICAL DECISION

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CRP RAPID TEST AS REAL SUPPORT IN CLINICAL
DECISION
QuikRead Sales Meeting12-15 June 2005
HelsinkiFINLAND
Madis Veskimägi FAMILY PHYSICIANS CENTRE OF
TÕSTAMAA, ESTONIA
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AIM OF PRESENTATION

• Short discussion of primary care pain and charm
• How looks like an ideal test in context of
  primary care speciality
• Work arrangement with QuikRead

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• Patients general condition in reception, CRP
  level and later course of illness. Is there any
  correlation. Overview of study.
• Some illustrative examples of real life
• Discussion and conclusion

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PAIN AND CHARM OF PRIMARY CARE

• Wide spectrum of patients and problems from
  infant to elderly
• Need for a quick assesment of patients
  condition
• Making proper plan for later management during
  10-15 min in reception or in patients home

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• Lack of time both doctor and patient
• A lot of talk and serious complaints
• Sometimes patients do not talk absolutely
  (infants, patients with dementia or stroke)
• Pressure from patient for getting a useless
  prescription of antibiotics or admission to
  hospital

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• Lack of objective data
• Need for assesment course of illnes and proper
  intervention
• Danger missing of serious condition which need a
  quik admission to hospital

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AND FINALLY AS MOST IMPORTANT....
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NEED FOR REDUCING ANXIETY OF PATIENT AND
DOUBTFULLNESS OF DOCTOR
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IDEAL TEST IN PRIMARY CARE

• Accuracy
• Quickness
• Answer for main question
• Severity of infection or tissue damage
• Distinguishing viral or bacterial infection
• Monitoring the course of illness
• Objective data in doubt of serious illnes in
  well-looking patient

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ONE AND IDEAL TEST ABSENT, BUT TEST WHICH IS
NEARLY PROPER OF PREVIOUS CRITERION IS C
REACTIVE PROTEIN RAPID TEST
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WORK ARRANGEMENT WITH QuikRead CRP

• 2-5 CRP QuikRead tests daily
• Answer during reception
• Equipment in examinations room with all
  diagnostical equipment of rural healthcare centre

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DIAGNOSTICAL ORCHESTRA
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• Test is usually done by doctor on the need. So we
  can save time and win patients pressure for
  getting any prescription etc.
• QuikRead equipment is carried in homevisits when
  indicated

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PATIENTS GENERAL CONDITION IN RECEPTION. CRP
LEVEL AND LATER COURSE OF ILLNESS. OVERVIEW OF
STUDY
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• In primary care is common a mixture of somatic
  and light-degree of psychiatric compliants
• In patients with serious complaints may have a
  light, self-limiting dissease

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• Contrarily may have a well-looking patient a
  serious condition which need an urgent
  intervention
• Is there any correlation-it is the subject for
  following study

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REVIEW OF STUDY

• The aim of the present study was to estimate the
  connections between the results of CRP rapid
  test, performed by rural family doctor during
  the ambulatory or home visit and clinical
  statement and later course of disease

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METHODOLOGY

• The study material is from the time period of
  01.01.2003-07.03.2004
• Performed 188 CRP rapid tests
• Comparison of the quantitative results, got by
  Quik-Read CRP methodology and picture of disease
  and difficulty of situation, determined during
  the visit and further course of disease

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• The ten-point scale has been used 1 light...10
  complicated
• Comparing these data the following correlative
  relations have been calculated
• The difficulty of the common statement during the
  visit and level of CRP.
• The level of CRP and difficulty of the course of
  disease

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RESULTS

• 188 rapid tests have been performed
• Mean age of studied patients 36,6 y, the youngest
  ½ y and the oldest 94 y
• 79 male and 109 female patients
• The average CRP level 43,5 mg/l

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Indication of test depending on main problem
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Results grouped by CRP value and further
management
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Comparision CRP and common statement in reception

• The coefficient of correlation between the
  difficulty of the common statement, estimated
  during the visit and the CRP level is 0,23
• The correlative relation is very weak

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• The coefficient of correlation between the CRP
  level, determined during the visit and the
  difficulty of the further course of disease is
  0,79
• The correlative relation is strong

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SUMMARY OF STUDY

• The correlation between clinical picture and
  severity of dissease found during examination and
  CRP level is weak (0,23)
• Well looking patient may have severe condition
  and vice versa
• The correlation between CRP level and complicated
  latter course of dissease is strong ( 0,79)

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ILLUSTRATIVE CASES.HOW MEDICAL THOUGHT IS
CHANGED AFTER CRP RAPID TEST
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ACUTE PHARYNGITIS

• 13 y old girl, history for a 3 days of painful
  swallowing, weakness and temperature 38-39 C
• The case is complicated by a exessive anxiety
  from mother and pressure for getting at least
  antibiotic or admission to hospital
• General condition good, medium degree rednes of
  throat, local tenderness of noduli

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INITIAL DIAGNOSIS BEFORE TESTS ACUTE
PHARYNGITIS, UNKNOWN ETIOLOGY
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TESTS

• Strep A neg.
• CRP lt 8 mg

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DIAGNOSIS AFTER TESTSVIRAL PHARYNGITIS
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LATER COURSE OF ILLNESS

• Prescribed painkillers and warm tea
• In 2 days there absent fever and complaints

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TUBERCULOSIS OF LUNGS

• 45 y old man, history 2 days of pain in right
  side of chest, temperature 37,2 C and cough
• General condition is good, findings of
  ausculation and percussion completely normal
• There was a doubt of malingering. Patient has a
  history of hyposocial life. He was send from city
  to farm as unskilled worker

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INITIAL DIAGNOSIS BEFORE CRP TESTCOMMON COLD
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CRP 127 mg/l
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DIAGNOSIS AFTER CRP TESTSTRONG SUSPICION OF
SERIOUS CONDITION PROBABLY PULMONARY ORIGIN.
IDEA FOR CHEST X-RAY
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NEW DIAGNOSISPNEUMONIA OR STRONG SUSPICION OF
PULMONARY TUBERCULOSIS. THERE WAS PRESCRIBED
COURSE OF ANTIBIOTIC (AMOXICILLIN-CLAVULANIC
ACID). AFTER 4 DAYS OF TREATMENT...
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...CRP 154 mg/l
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FINAL DIAGNOSIS BEFORE REFERRAL PULMONARY
TUBERCULOSISPATIENT WAS TREATED IN DEPARTAMENT
OF TUBERCULOSIS UNIVERSITY CLINIC FOR A 2 MONTH
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ACUTE PYELONEPHRITIS

• 37 y man, history of 2-3 days for pain in lumbar
  region, fever 38 C
• Patient work as forestman, a lot of carring heavy
  trees, exposition of wet and cold
• General condition was satisfactory, there
  revealed pain on palpation right side of lumbar
  back

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INITIAL DIAGNOSIS BEFORE CRP TESTCOMMON COLD,
LUMBALGIA DUE TO A HEAVY LIFTING
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CRP 117 mg/l
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NEW WORKING DIAGNOSISACUTE PYELONEPHRITIS. IDEA
FOR DIP-STICK TEST OF URINE REVEAL OF POSITIVE
NITROGEN AND LEUCOCYTE
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FOLLOWING COURSETHERE WAS PRESCRIBED NORFLOXACIN
0,4 x3, PROPER REGIMENIN 9 DAYS LATER THERE
ABSENT COMPLAINTS AND THE LEVEL OF CRP WAS...
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...lt 8 mg/l
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ACUTE MYOCARDIAL INFARCTION

• 65 a man, history for 3 days for a unpleasant
  feeling in middle of chest, irradiating to back
  and left shoulder
• Patient has a done physical activity, the pain
  begin in rest in theatre. Previous history absent
• On examination general condition was good. No
  restriction of moving. Noticeable changes of
  auscultation of heart and lungs absent. BP 150/80

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• There reveal some tender points in back, cervical
  region
• ECG reveal sinus rhythm, medium degree of RBBB.
  Certain findings of myocardial damage absent

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INITIAL DIAGNOSISBEFORE CRPMYOFASCIALGIA OF
CERVICAL REGION. UNCERTAIN ETIOLOGY OF RBBB
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CRP 55 mg/l
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NEW DIAGNOSISPROBABLY MYOCARDIAL INFARCTION IN
SHADOW OF BLOCADE
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PATIENT WAS URGENTLY REFFERRED TO HOSPITAL. THE
BIOMARKERS OF MYOCARDIAL DAMAGE WAS ELEVATED. THE
FINAL DIAGNOSIS WAS MYOCARDIAL INFARCTION.TWO
MONTH LATER THERE WAS DONE CORONARY BYPASS
OPERATION. TODAY PATIENT LIVE IN NORMAL CONDITION
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ACUTE GASTROENTERITIS

• 34 y man, history for 4-5 days of diarrhoea,
  vomiting and fever 38 C
• On examination moderately afected general
  condition, light degree of dehydration.
  Tenderness on the palpation of abdomen,
  auscultation of chest was normal
• Family history of infection was uncertain

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INITIAL DIAGNOSISBEFORE CRPACUTE
GASTROENTERITIS.INITIAL PLAN FOLLOW UP,
REHYDRATING SOLUTION ORALLY
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CRP gt 160 mg/l
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FINAL DIAGNOSISACUTE GASTROENTERITIS OF
BACTERIAL ORIGIN.PATIENT WAS URGENTLY REFFERED
TO DEPARTMENT OF INFECTIOUS DISEASES.IN HOSPITAL
THE CRP WAS 256 mg/l. CULTURAL EXAMINATION OF
COMMON ETIOLOGY WAS NEGATIVE
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PATIENT GET AN ANTIBACTERIAL THERAPY (NORFLOXACIN
400 mg x2)i/v REHYDRATING SOLUTIONCRP LEVEL AT
THE END OF HOSPITAL THERAPY WAS 28 mg/l.
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PHLEGMONE OF ARM

• 46 y old man
• History of two day of pain and swollowing in
  right elbow
• General condition quite well, revealed red and
  odematous elbow

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INITIAL DIAGNOSISSUPERFICIAL DERMAL INFECTION,
ERYSIPELAS ? INITIAL PLAN ORAL ANTIBACTERIAL
THERAPY, FOLLOW-UP
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CRP ? 160 mg/l
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NEW DIAGNOSISERYSIPELAS? PHLEGMONE?SEVERE
BACTERIAL INFECTION? SEPSIS ? PATIENT WAS
URGENTLY REFFERRED TO DEPARTMENT OF SURGERY. IN
HOSPITAL THERE WAS DONE INCISIONS WOR LAVAGE,
LATER COURSE WAS GOOD
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Et cetera, et cetera, et cetera! FOR HUNDREDS
OF INTERESTINC CASES
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CONCLUSION AND DISCUSSION

• CRP is perfect tool in ensuring a correct
  diagnosis and determining the need for further
  treatment
• It is crucial that result of CRP is available
  during minutes in reception

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• Economical aspects reducing unnecessary
  antibacterial treatment and hospitalisation
• CRP is valuable in monitoring the course of an
  illness and efficacy of antimicrobial therapy
• CRP in uncertain condition is valuable for
  detecting serious condition which need urgent
  consultation or hospitalisation

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• The CRP rapid test will increase compliance of
  both patient and doctor
• Doctor can find a right solution and patient get
  the right treatment

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THANK YOU FOR ATTENTION !!!
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AND WELCOME TO ESTONIA