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INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please take a focused history from Anna Wong, and then request appropriate examination and investigation findings from the facilitator. Based on the history, examination and investigation results, please outline your diagnostic impressions and initial management plan to Anna.

Scenario

Anna Wong is a 32-year-old mother of two. During the appointment for her four-month-old son’s immunisation last week, she mentioned that she had been feeling tired and had aching joints. You recommended she try some simple analgesics and make an appointment to see you. She has come back today to discuss her symptoms.

The following information is on her summary sheet:

  • Past medical history

  • Nil significant

  • Medication

  • Nil

  • Allergies

  • Nil known

  • Immunisations

  • Up-to-date

  • Social history

  • Married, two children (four months and two years)

  • Hairdresser, currently on maternity leave

  • Non-smoker, non-drinker.

INSTRUCTIONS FOR THE PATIENT, ANNA WONG

Six weeks ago, your left wrist became painful. Initially, you put it down to the way you were holding your baby to breastfeed. During the following fortnight your other wrist plus feet, ankles and hands started to hurt and have been steadily getting worse. You are also feeling really tired and run-down—a bit like the flu—although you suspect this is due to breastfeeding, lack of sleep and trying to look after your family. You have not noticed a fever.

Paracetamol does not provide much relief. You have avoided anti-inflammatories, as the pharmacist said they weren’t safe to take when breastfeeding.

On specific questioning:

  • You think your wrists and feet have been a bit swollen but you’re not sure. The pain is worse on waking and you have stiffness for the first one to two hours of the day. You have lost three kg in two months without specifically trying, which you are very pleased about (getting rid of the ‘baby bulge’).

  • You have not travelled anywhere recently and have no other contacts with similar symptoms.

  • You have no personal or family history of auto-immune disease or allergies. Your only knowledge of arthritis is that it is a ‘wear and tear disease that old people get’.

The following information is on your summary sheet:

  • Past medical history

  • Nil significant

  • Medication

  • Nil

  • Allergies

  • Nil known

  • Immunisations

  • Up-to-date

  • Social history

  • Married, two children (four months and two years)

  • Hairdresser, currently on maternity leave

  • Non-smoker, non-drinker.

INFORMATION FOR THE FACILITATOR

Clinical examination findings

Each aspect needs to be asked for specifically:

  • Looks tired but has normal colour

  • BP 125/75 mmHg

  • Pulse 82

  • Temperature 36.8°C

  • BMI 23.5

No thyroid enlargement

Cardiovascular, abdominal and respiratory examinations unremarkable

Musculoskeletal examination: no joint deformities; wrists, second and third MCP joints ...

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