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 2 Doctor working in General Practice. Your next patient is Clarissa Reynolds – a 28-year-old lady presenting with fatigue. Please take a history and perform an appropriate examination.
Patient History:
Clarissa Reynolds – a 28-year-old lady - sales agent.
You started to feel more tired than usual. This started gradually four months ago, and it has been progressively getting worse. You are unsure what has happened because you always ensure you get enough sleep every night, which hasn't helped. You also have been trying to drink more water, have a balanced diet and exercise more often, which has helped a bit with the tiredness.
You have also noticed some joint pain affecting your fingers of both hands – they are always there. They look quite swollen to you, and you are not sure if they are stiff. You also sometimes have pain affecting both the hips and knees. When the pain comes on, you often will need to rest for a while, which improves the pain slightly. On some occasions, your hands will appear in two distinct colours of pink and white – especially in cold weather. Your cheeks have also gotten redder than usual – mainly affecting your nose and cheeks, which is embarrassing. You have tried to put on sun cream and moisturise your face as often as possible. You do not feel confident when seeing clients at work. You are very self-conscious that they may judge you based on your appearance, and you want to appear as professional as possible.
Only mentioned if asked specifically: You have noticed you have lost some hair from your head and you cover your head with a hat most of the time.
Normal menstrual cycle. No heavy periods. No bowel/waterwork problems. No blood in the stool. No weight loss/ fever.
Ideas, Concerns, Expectations:
You have no idea what is happening. You are very concerned about how the symptoms affect your work since you often work long hours and see many different clients. You no longer feel young as you used to be because of the joint pain. You want to sort out the symptoms as soon as possible! You also hope to get some medications to improve your appearance.
Past Medical History:
Seen a doctor for recurrent headaches in the past, epilepsy, asthma.
Drug History:
Takes paracetamol for headaches PRN, carbamazepine, salbutamol.
NKDA
Family History:
Mother has systemic sclerosis.
Social History:
You smoke 20 cigarettes a day for 10 years
You do not drink
You work as a sales agent
Currently, you are managing well at home and living with your partner who supports you whenever you need
Examination Findings:
Malar (butterfly) rash on the face over cheeks and nose
Joint tenderness (PIPs, DIPs, MCPs, Hips and Knees)
Differentials:
SLE – (symptoms e.g. malar rash/ joint pain/tiredness, smoking history, association with carbamazepine, age 15-45, female gender)
Rheumatoid Arthritis – (symmetrical joint pain affecting hands/hips/knees)
Systemic sclerosis – (Raynaud's phenomenon + FH)
Fibromyalgia – (chronic widespread joint pain)
Hypothyroidism – (fatigue)
Investigations:
Bedside:
Observations
Dipstick/urine protein: creatinine ratio (may show haematuria/proteinuria in SLE)
ECG (considered in patients with cardiopulmonary symptoms)
Bloods:
FBC (may show anaemia, leukopenia, thrombocytopenia in SLE)
U&E (lupus nephritis)
LFT (baseline)
ESR/CRP (raised in SLE)
TFT (exclude hypothyroidism)
C3 + C4 ( reduced in SLE)
Rheumatoid Factor (RA)
Autoantibody screen:
Antinuclear antibodies
Anti-dsDNA antibodies (specific to SLE)
Anti-smith antibodies (specific to SLE)
Antiphospholipid antibodies (antiphospholipid syndrome association with SLE)
Anti-Scl-70 (systemic sclerosis)
Anti-Jo-1 (dermatomyositis)
Anti-CCP (RA)
Imaging/Special Test:
CXR (may be considered for e.g. pleural effusion, infiltrates, cardiomegaly in patients with cardiopulmonary symptoms + interstitial lung disease in SLE)
Echo (is done for patients with systemic sclerosis at onset and yearly basis to look for pericardial effusion and pulmonary hypertension)
Consider renal biopsy (lupus nephritis)
Management (SLE):