Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year Doctor working at General Practice. You have a 51-year-old female (Emma Waterstone) presenting with joint pain in her upper limbs. Please take a history and perform a relevant examination.
Patient History:
Emma Waterstone - a 51-year-old female - receptionist.
You have noticed joint pain in your fingers + knuckles + wrists of both hands. The pain started gradually and has been getting worse since 12 months ago. You only bothered to see a doctor as you recently started a job as a receptionist, and you received pain typing the keyboard. You have longed to have a job as you have been unemployed for over a year. The pain started gradually and has been getting worse since 12 months ago. You rate the pain as 5/10 and describe the pain as aching. You have also noticed swelling + stiffness in these joints. Symptoms affecting your hands tend to worsen in the morning when you wake up and get better throughout the day. They usually last for 50-60 minutes before settling down.
You also sometimes have mild muscle aches affecting your shoulders. You noticed that you also feel tired all the time with some weight loss – 2kg over the past few weeks. No malar rash/ weight loss/ fever/ night sweats.
Ideas, Concerns, Expectations:
You think it may be lupus, as your mother suffers from similar symptoms. You are worried that because of this condition, you can't work – you have only started working! You would like to have some painkillers and control the symptoms if possible.
Past Medical History:
Hypertension, previous eczema/gout affecting the big toe
Drug History:
Ramipril
NKDA
Family History:
Mum has SLE and arthritis affecting his hands and hips, but you don't know which type.
Social History:
Ex-smoker – used to smoke 10 cigarettes a day for 10 years.
Alcohol – drink about 2 bottles of Vodka every week – split evenly throughout the week.
IVDU - you do not want to say what drug you use because you don't want to get into trouble.
Work as a receptionist.
Managing well at home except having difficulties buttoning your clothes/ opening cans. Lives alone.
Examination Findings:
Joint swelling/tenderness affecting PIP/MCP/ wrist joints
Swan neck deformity
Z thumb deformity
Ulnar deviation
Differentials:
Rheumatoid Arthritis (RA)
Polymyalgia Rheumatica- due to bilateral shoulder pain + stuffiness lasting >45 mins in the morning
SLE – due to family history + symptoms
Important to rule out septic arthritis
Osteoarthritis
Investigations:
Bedside:
Basic Observation
Calculate DAS28 score
Bloods:
Baseline bloods – FBC/U&E/LFT
B12/folate due to high alcohol intake
CRP/ESR – raised in RA
Rheumatoid Factor (RF) – may be positive in RA
Anti-CCP antibodies – may be positive in RA
Imaging/Special Test:
Hand XRay – may show loss of joint space, bony erosion, subluxation, and soft tissue swelling in RA
CXR to look for rheumatoid pulmonary nodules + before starting methotrexate treatment
Might involve joint aspiration if suspicious of septic arthritis – culture/microscopy/sensitivity
Other Investigations:
Calcium (raised in hyperparathyroidism/cancer, reduced in osteomalacia)
Serum protein electrophoresis/ urine Bence jones protein (myeloma)
Creatine Kinase (myositis)
Urinary dipstick
ANA/ Anti-smith/ Anti-dsDNA (lupus)
C3/C4 (reduced in active lupus)
Management: