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You are a Foundation doctor who has just started a placement in General Practice. You are looking forward to finishing for the weekend and your final patient is Miss O’Cin, a 32-year-old female who has come in for a follow up appointment for some wrist and finger pain. She currently takes lymecycline 408mg BD and had an intra-articular steroid injection from your GP supervisor two weeks ago for wrist pain. Please take a history and perform an appropriate examination.

You are Miss O’Cin, a 32-year-old primary school teacher. You are Caucasian and live with your girlfriend, Sarah who works as a stewardess on an international airline.

HPC: You have come in because you have been getting persistent pain in your right wrist. You first noticed some discomfort around six months ago, however the pain appeared to settle down by itself. At this time, you didn’t fall or injure your wrist. Around two months ago, you feel that the pain became severe again. At the moment it is located in the centre of your right wrist. You also have a swollen and tender right 1st digit, which has only come on over the past week or so.

You have also experienced some stiffness in your wrists and fingers. This is starting to affect you every day. You haven’t noticed any wrist swelling, however your finger is markedly swollen and tender. You would describe the pain as a 5/10 ‘throbbing’ pain. If asked, you think that you may have had some lower back and buttock pain in the past, but you have put up with this and managed it at home.

You are starting to feel frustrated. You have been to the doctors about this problem multiple times. You were initially told to try some paracetamol, but that has no effect on the pain at all! You received an injection to your wrist a few weeks ago, and this initially helped the pain significantly. Since then however you have notice a swollen finger and the wrist pain is returning.

Apart from your joint and skin problems you feel fit and well.

ICE: You have recently been marking lots of exercise books and papers as your class have had exams. You wonder if this has contributed to the worsening pain. You are hoping that you can get something else to take for the pain as it is now stopping you from going to your weekly yoga class. You’re worried that there might be something else going on, such as rheumatoid arthritis as your grandmother had an arthritic condition.

PMH: You rarely went to the doctors as a child but over the past few years you have attended more frequently. You have noticed some dry skin over the past few years and you were started on an acne medication by a locum GP you saw last year. You were surprised you were told you have acne as you very rarely get spots and it is usually patches of dry skin that cause you to feel self-conscious.

DH: Lymecycline 408mg BD. No known allergies.

FH: Your father has high blood pressure. Your grandmother had a type of arthritis but you’re not sure which kind. Your mother left home when you were very young so you’re unsure of any family history on her side.

SH: You live in a rented flat with your girlfriend. You only smoke socially when you are on a night out. You tend to drink 1 bottle of wine per week and every pay day you go out with your friends and tend to drink excessively. You feel like your diet is ok. You went through a phase at university where you were vegetarian but this is no longer the case.

Please observe the student taking a history from this patient. Ideally, they should perform a hand and wrist examination. You should ask them to present their findings to you, with a list of possible differentials. An ideal list of differentials would look something like: “My primary differential diagnosis would be an oligoarticular arthropathy, specifically, psoriatic arthritis, due to the inflammatory pattern associated with this patient’s wrist pain. She also has a family history of joint disease. I would also consider a polyarticular arthropathy such as rheumatoid arthritis, however this patient has signs and symptoms of dactylitis – a fusiform swelling of an entire digit and a history of what sounds like sacroiliac pain, both of which are not associated with rheumatoid arthritis. Finally, it sounds like she has been misdiagnosed with acne vulgaris and has actually been developing skin features of psoriasis, which would also be in keeping with my diagnosis.

Topics for discussion may include: - ‘What blood tests can you use to diagnose inflammatory arthropathies?– What are the x-ray features of psoriatic arthritis? - What are the risk factors for psoriatic arthritis? – How would you manage this patient in primary care? –Is it appropriate to refer this patient or would you trial some medications first?’