Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are currently a foundation year 2 doctor working in a GP practice. Your next patient is called Yvonne Hiddleston, a 54-year-old caucasian lady complaining of shoulder pain. Please take a history and perform an appropriate examination.
Patient History:
Yvonne Hiddleston, 54-year-old, Occupation: cleaner.
You have noticed increasing shoulder pain. The pain is located on both shoulders and gradually worsens over the past week. You describe the pain as aching, radiating to the elbows. It is associated with morning stiffness, usually lasting over 45 minutes to settle. Pain is worse in the morning and is triggered by movement (sometimes, you find it hard to lift your arms up to crush your hair). Pain score 5/10.
You also are having poor sleep because of pain – feeling really tired each day, and this is affecting your work during the daytime. Because of the pain and poor sleep, you have been feeling down lately.
You do notice you have been feeling a little warmer than usual. Your appetite is poor. Unsure about weight loss. You just feel really unwell. You are tired all the time.
If asked specifically: you also notice similar pain in the neck and hip on both sides.
No headache. No jaw claudication/visual disturbance. No flu-like symptoms. No fever / abnormal shakes. No rashes. No temporal pain or skin changes. No previous trauma to shoulders.
Ideas, Concerns, Expectations:
You think you might have arthritis as your mother has it as well. You are concerned about being started on biologics which your mother did. You heard that there are lots of side effects associated with those medications. You hope to have something to help control the pain.
Past Medical History:
Temporal arteritis previously, thyroidectomy, carpal tunnel syndrome
Drug History:
Levothyroxine
NKDA
Family History:
Mother has Rheumatoid Arthritis.
Social History:
You have been fairly healthy most of your life.
You do not smoke or drink.
You work as a cleaner in a busy hospital.
You live with your partner at home in a flat.
You are independent at home.
Examination Findings:
Bilateral upper limb and hip tenderness on palpitation and movement. Appeared low in mood. No evidence of temperoral arteritis.
Differentials:
Polymyalgia Rheumatica
Rheumatoid arthritis
Polymyositis
Fibromyalgia
Osteoarthritis
Hypothyroidism
SLE
Investigations:
Bedside:
Observations (low-grade fever)
Urine Dip (proteinuria in lupus nephritis)
Bloods:
Inflammatory markers ( ESR, plasma viscosity, CRP)
FBC
U&E
Liver Function
Bone Profile – Ca
TSH (raised in hypothyroidism – patient has low mood)
Serum protein electrophoresis – (myeloproliferative diseases present similarly to PMR e.g. fatigue/ bony pain/ raised ESR)
CK – myositis
Rheumatoid factor – Rheumatoid arthritis
ANA (SLE)
Anti-CCP / rheumatoid factor (RA)
Imaging/Special Test:
Consider Chest XR for lung / mediastinal abnormalities
Consider US shoulder / MRI if the diagnosis is unclear (subdeltoid bursitis/ glenohumeral synovitis/ biceps tendon tenosynovitis/ trochanteric bursitis)
Management (PMR):