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You are a junior doctor working in a GP practice. Ms Ignant is a 36-year old woman who has come in complaining of severe joint pain, which has worsened over the past 2 months. She is normally fit and active, and she feels that the pain has impacted profoundly on her daily life. Please take a history from Ms Ignant, ensuring it is relevant to the presenting complaint and addresses her concerns.

You are Molly Ignant, a 36-year old woman who works as an interior designer. You live with your husband, Tom, and two sons, James and Frank, who are 6 and 8. You live in London, where your interior design business is booming.

HPC: Over the past 2 months you have noticed that your hands have started to become very painful, particularly around your knuckles. You have had increasing difficulty doing buttons up whilst getting dressed and also with writing. Recently you have also struggled to open your daily can of Diet Coke at lunch. This morning, whilst making breakfast, you were unable to open the jar of peanut butter, which seemed like a little thing, but was very distressing. You have also noticed that your feet have been feeling sore this week too, particularly when you wake up in the morning. Come to think of it, your hands also seem to be more difficult to move in the morning compared to the evening. It’s been harder to get going at the start of work with your hands – things are a lot stiffer.

You have also been feeling generally run down recently. Work has been very stressful so you have been attributing it to this. You have been feeling tired and a bit feverish and think you might be coming down with something. Yesterday, Tom mentioned that you had lost some weight, but you’ve been too busy to notice. You have been working long hours, and might have skipped a lunch or two, but haven’t been trying to lose weight or anything. You haven’t had time to go to the gym, something you used to love to do. Thinking about it, you did put that off a few times because of the pain…

You have not noticed a rash or experienced dry eyes or mouth.

PMH: You have had no significant medical problems in the past. Both pregnancies and births were normal of your sons.

DH: You are not taking any medications at the moment.

FH: When questioned, you remember that your auntie suffers from a joint problem. There is no family history of psoriasis.

SH: You do not smoke and drink approximately a bottle of wine a week. You are normally a keen runner, however you haven’t felt up to exercising lately. You live in a town house with multiple flights of stairs. Your husband has been extremely helpful this week and encouraged you to go see the doctor.

ICE: You are extremely concerned that this problem may not go away. It has already had such a big impact on your daily life and you don’t know how you would cope with your job and looking after your boys if it were to persist.

Please ask the student to: • Summarise their history • Give a differential diagnosis – an example may be:

‘My differential diagnosis would mainly consist of rheumatological problems. Firstly, I would consider rheumatoid arthritis, as we have evidence of joint pain and stiffness, with impact upon function. This sounds like an inflammatory polyarthropathy mostly affecting the small joints. There is no evidence of psoriasis from the history but one may wish to consider psoriatic arthritis if a scaly plaque were to be noted. Other multi-system diseases can present with polyarthropathy, including SLE and Sjogren’s syndrome. However the lack of systemic symptoms make these less likely’.

• Explain the clinical findings found on examination in Rheumatoid Arthritis • Explain what investigations you would perform in this case • Explain how you differentiate between Rheumatoid Arthritis and Osteoarthritis • Explain the management pathway for Rheumatoid Arthritis, including the different types of medication that are available.