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You are the FY1 on a GP placement, seeing a new patient at the practice. She is Tess Tickle, a 59 year old female presenting with joint pain. She has a past medical history of hypertension.

Her medications include:

Ramipril Paracetamol

You are aged 59 and hate coming to the GP but this pain has just been getting too much. For the last three weeks you’ve been waking up and had this awful pain. It shoots along the tops of both shoulders. It’s easily a 7/10 when it is at its worst. It does get better throughout the day but you really don’t understand it: there’s no other pattern to it. When you take it easy and just watch TV (you do love your soaps), it gets worse and worse. Once you thought it got worse when TOWIE was on, but then life does generally seem a lot worse when that is on. You thought that bed rest would help but it seems to be better when you are actually using the muscles. When it gets bad it can even be sore to touch the area, your bra straps even become too painful. You made the appointment a few days ago because you actually woke up early because of the pain. Even when you had to admit you should take paracetamol they haven’t really helped.

You haven’t had any weakness though. You thought it might happen but you can still open all your jars without your husband. You do sometimes have trouble pushing up on your hands to sit up in bed on a morning. It’s just all so stiff until you stretch yourself out. It is easily over an hour of stiffness before things are even vaguely right.

You haven’t had any headaches, pain to touch on your head or changes to your vision. You’ve never had any trauma and can’t understand why this pain is going on - have you pulled a muscle? Could it be arthritis? You thought it was old people who got that, and you don’t feel that old!

PMH: You know you have had high blood pressure but the doctors seemed to be happy with that now.

DH: You take Ramipril for the blood pressure. Been unsuccessfully trying paracetamol for the pain for the last week. You’d quite like something stronger, thank you very much!

FH: You don’t think there is anything relevant here to know about.

SH: You live at home with your husband. He’s an accountant but is starting to go to work later and later so he can help you while you loosen up.

Observe the student and give appropriate feedback for their history taking. A shoulder examination is the appropriate choice following the history. Ask them to summarise their findings succinctly and then present their differentials.

Differentials should include polymyalgia rheumatica, rheumatoid arthritis, osteoarthritis, rotator cuff injuries or other muscle injuries. It should be important to include screening for giant cell arteritis in the history or discussion, as this is an important complication as it may lead to blindness.

Questions for discussion may include:

  • How would this lady be investigated in the acute setting?
  • What is the criteria for diagnosis of PMR?
  • How is PMR managed?
  • What complications may be associated with PMR?
  • What are the side effects of steroid therapy?