This lady had seen me before. A couple of years back with right sided hip pain predominantly but also multi joint pain including extremities and hypermobility. We were concerned enough to refer for rheumatology. She had subsequently been diagnosed with Rheumatoid Arthritis (RA). She is an active 57yrs old. She was referred to me for management of her symptoms rather than a specific joint. This is unusual as I work in a musculoskeletal service and not a rheumatological one.
She reports seeing a rheumatological physiotherapist initially after diagnosis and given some stretching exercises. The therapist went onto maternity leave and the replacement was not well received. She recalls being told the pain was due to her weakness and lack of movement and that she should do more and sit less. She took offence at this as she reports being active. At this point she asked her GP to send her through to see me again.
After reacquainting ourselves I asked what she is struggling with. She replies prolonged postures are becoming worse with time whether its sitting or standing. She reports multiple joint pain including back, bilateral shoulder, elbow, hands, knees and feet. She reports worsening coldness to her extremities and intermittent numbness or dullness to both feet and occasionally buttocks. She had characteristic global early morning stiffness over 30mins. Her goals are to be able to stand taller to prevent a forward lean and to be able to sit comfortably in a number of positions.
She is under her rheumatologist at 4 month intervals at present and describes taking the highest dose of methotrexate her consultant is happy with, she also takes sulfasalazine and hydroxychloroquine. She doesn’t feel this controls her symptoms well. She also takes ibuprofen and accompanying lansoprazole. She also takes Folic acid and has taken lisinopril for 3yrs (with good control of her blood pressure).
Her dad has history of 2x Myocardial Infarction (MI-first at 47yrs) and stroke whilst his father also had MI. Her mum has history of Raynaud’s disease and widespread Osteoarthritis. Both her mum and sister have diabetes.
She is right handed and works as a cleaning supervisor 25hrs a week. She has gradually increased up to this over the last 2yrs since her RA diagnosis and feels financially compelled to work. She reports when on holiday or days off work she has a big improvement in symptoms. She lives alone with 2 dogs who she walks frequently (3x/day). She does not smoke. She averages 4 glasses of wine/week. She has 1-2 cups of decaf tea or coffee/day. She has deteriorating sleep quality and quantity mainly through discomfort although some stress. She reports significant stress around her health and its impact on her life and reports periods of depression. She reports not cooking a lot due to discomfort so relies on convenience and pre-prepared foods. She reports excellent exercise levels, walks dog 3x/day, she likes to exercise 30mins/day on top of this, she reports step counter device always over 14,000 steps/day. She reports not relaxing well due to activity level and finds relaxation difficult generally even before diagnosis of RA.
On examination her BP was in normal range, she had good active range of movement at the lumbar spine with mild ache reported at end of range only. She had good passive range also although found it difficult to relax fully and tended to join in or control the movement. She had no swollen or red joints. She had some knee pain with supported squat with tendency to hip flex and lumbar extend.
Hopefully this gives you an insight into my encounter with this lady. I’m interested to hear from clinicians which information they attend to most. What really sticks out? What information that might be missing that you’d want? How would you approach ongoing clinical care if this person? What makes this case tough? What might be potential avenues to explore? What does the research say for this person?
These aren’t trick questions. I have not fixed this lady and am looking to catch you out or get the right answer. I’m interested in how people clinically reason. How others approaches may vary. How I might learn form this. I’ve thought about doing this type of thing more regularly if there was enough feedback and engagement. I have purposefully left out my treatment plan so that you can start from a clean slate although I realise even from my writing (which I have tried to keep to chronological verbatim order) this may be apparent. I’d particularly enjoy feedback for whom this case seems outside their scope to see if any differences emerge.
Be more human. Be less robot.
Thanks for reading this far.