The scenarios are fictitious but similar to those experienced by real patients, and are designed to help you reflect on what you have learnt after reading the article. They could be also be used for group discussion in an education or practice meeting. There are no right or wrong answers but some pitfalls to avoid.
The following case studies written by Dr Louise Warburton relate to her expert article, Top tips: joint pain. In her article, Dr Warburton discusses ways of obtaining a good history from anyone presenting with joint pain for the accurate diagnosis and management of their condition.
Case 1: Sheila, 58 Years Old
Sheila consults you with an aching knee. She has had symptoms for a couple of years but recently after a walk in the local park she slipped and her knee has become swollen and more painful.
Sheila is overweight with a body mass index (BMI) of 32 and she works as a care assistant in the local nursing home. She walks to and from work (through the park) but this only amounts to about 3000 steps per day. Apart from this she has a sedentary lifestyle and has type 2 diabetes managed on metformin. In the mornings she can get out of bed without too much trouble, but after being on her feet all day, both her knees are aching. She can’t walk more than 2 miles without pain. She is asking for painkillers.
Sheila is noted to be overweight and struggles to get up on the examination couch. Her knees are both quite large with bony osteophytes and the painful right knee is swollen and painful to bend. In addition, the range of movement in her right hip is reduced and painful.
Questions for Reflection
- What is the likely diagnosis here?
- Would you prescribe analgesia?
- What would your longer-term management plan be?
How to Manage This PatientIt is likely that Sheila has osteoarthritis (OA) of her knees (she has pain in both knees after walking and exercise), morning stiffness is minimal, she is over 45 years of age, and there are osteophytes on examination of her knees. Her right hip is also possibly affected by OA.
When she slipped she could have sustained a meniscal tear. This can be part of the degenerative process in knee OA and doesn’t require any particular intervention as the joint will usually settle down. If her knee is locking or giving way though, she may require more treatment and investigation.
It is reasonable to prescribe analgesia such as paracetamol or co-codamol and physical methods such as ice or heat packs on the affected joint. Topical Nonsteroidal anti-inflammatory drugs (NSAIDs) might help in the short term while the joint swelling is settling, but avoid in anyone with impaired renal function.
The long-term management plan would be to encourage Sheila to lose weight to normalise her BMI and to begin an exercise programme, perhaps with the help of a healthy-lifestyles coach. Also offer her educational information such as the OA Patient Booklet from Keele University.
Case 2: Angela, 42 Years Old
Angela comes to see you because of a swollen finger, which has been hard to bend and sometimes gets stuck when she is trying to extend the finger. She works in admin, uses a computer most of the time, and is finding work difficult.
Angela is otherwise well. You notice that she has a prescription for a coal tar/salicylic acid therapeutic shampoo in her repeat medications and she tells you that she has a crusty rash in the nape of her neck which flares up from time to time and responds to the prescription shampoo.
2 years ago she had a swollen knee for no apparent reason, which settled spontaneously.
On examination the left middle finger is uniformly swollen and tender and difficult to actively and passively bend. In fact, on extending the finger she finds it sticks and is triggering.
Examination of her scalp reveals a psoriatic rash in the nape of her neck.
Questions for Reflection
- What blood tests would you request?
- What was the likely cause of the swollen knee 2 years ago and the current finger problem?
- What would you do next?
How to Manage This PatientAngela has dactylitis which is an inflammation of the whole finger including joints, tendons, and entheses. It can happen in any finger or toe and is characteristic of the spondyloarthritides. The triggering of Angela’s finger is characteristic of inflammation due to an inflammatory process, but can also happen due to mechanical processes.
Angela has psoriasis and the diagnosis here is likely to be psoriatic arthropathy. The swollen knee 2 years ago is most likely to be part of the same inflammatory process and if a careful history is taken, Angela may have had other episodes of joint pain and swelling and maybe inflammatory back pain.
Blood tests are unlikely to be helpful here; the inflammatory markers are often not raised at all in psoriatic arthropathy because synovium is not commonly affected and the synovium would drive an inflammatory response (rheumatoid).
The correct course of action would be to refer Angela to a rheumatology service as soon as possible.
It would be possible to inject the trigger finger in primary care before referral if the finger is very troublesome, but ask Angela to take a photo of her finger before you do this as the dactylitis may resolve with a steroid injection.
Case 3: Mark, 72 Years Old
Mark is a window cleaner. He visits you to complain that his back seems to be aching all the time and he is struggling in the mornings to get out of bed.
You have known Mark for some time; he has had various jobs and not managed to stay very long in any of them. Back pain has featured on his previous fit notes. You note that he has a repeat prescription for co-codamol 30/500.
Mark lives with his partner and three children.
A couple of years ago he had lumbar–spine magnetic resonance imaging (MRI), which was largely normal.
Mark exhibits a few yellow flags when you examine him, such as excessive groaning when he gets up on to the examination couch. However, he does seem to have genuine difficulty touching his toes and his spine is stiff. Both hips seems very stiff with reduced flexion and rotation.
Questions for Reflection
- What would you do next?
- What is the likely diagnosis?
- What other medications might be helpful?
How to Manage This PatientThe correct course of action would be to ask more about family history of spondyloarthritis (or other back problems in relatives), or psoriasis.
Also ask about a personal history of uveitis, which is associated with spondyloarthropathy (SpA), and about features of inflammatory back pain that might indicate SpA.
Assess whether Mark has enough features for referral to a rheumatology clinic. If you are in doubt, or unable to request an HLA-B27 blood test, then refer Mark anyway.
Do not request another MRI scan unless you have access to a spondyloarthritis protocol for imaging.
The diagnosis is likely to be axial SpA.
NSAIDs, at the lowest effective dose, might be more useful than co-codamol. An attempt to wean Mark off his high-strength co-codamol should be made with substitution of an NSAID.
Discuss the fit note situation while he is awaiting diagnosis as he may be supported by an ‘amended duties’ fit note to allow a reduction in working hours and later start in the morning.
Case 4: Shayma, 45 Years Old
Shayma is a frequent attender at the surgery. Today she is complaining of pains in her shoulders, knees, and hands. She is not working but struggling to keep up with her household duties.
On previous visits to the surgery Shayma, who is always accompanied by a male relative, seems depressed but it is difficult to get a good history from her as English is not her first language.
Most of the treatments you have tried in the past have not worked.
A difficult examination reveals very little organic in Shayma’s joints. She is very tender on palpation of all her muscles.
Questions for Reflection
- What investigations would you perform, if any?
- Would you refer Shayma to a rheumatology clinic?
- Would you try any new medications?
How to Manage This PatientCommunication with Shayma is difficult because of the language barrier and presence of the male relative. Booking an interpreter may help and asking Shayma to return for a longer appointment with a female clinician may remove the need for the male relative to be present, allowing Shayma to express some of her ideas, concerns, and expectations.
As treatment has so far not helped, a new course of action is required. It may be that Shayma has depression and that referral to psychological therapies might help.
It is likely that Shayma has fibromyalgia but there may be concomitant mental health issues, as discussed, or even issues in the family such as domestic abuse which are affecting her.
Referral to a rheumatology clinic is unlikely to help as you have not found any evidence of organic joint disease: Shayma is tender all over and is more likely to have fibromyalgia.
Routine screening blood tests would be recommended to rule out causes of fatigue and pain, such as full blood count to screen for anaemia, vitamin D levels to exclude osteomalacia, thyroid function, and glycated haemoglobin (HbA1c).
If there is a definite diagnosis of depression, it may be worth trying medical treatment such as a selective serotonin reuptake inhibitor (SSRI). Amitriptyline in small doses is useful for insomnia, which can exacerbate pain and fibromyalgia symptoms.
Case 5: Reginald, 65 Years Old
Reginald is a retired businessman. A few years ago he had trouble with gout in his big toe, but this settled. He came to see you because of pain and swelling in his foot. The pain is mainly around the ankle and mid-foot and has been there for a few days.
You suspect that Reginald drinks rather too much alcohol as he is rather evasive when asked about his consumption. He is also overweight and has prediabetes. His current medication included atorvastatin, and bendromethfluazide for mild hypertension. He did take allopurinol for a short time 2 years ago but quickly stopped taking it.
Questions for Reflection
- What might be going on in Reginald’s foot?
- What blood tests and other investigations would you request?
- What treatment would you start?
How to Manage This Patient
It is likely that Reginald has gout. We know that he had gout a few years ago and had limited treatment for this with the short course of allopurinol. Gout will not go away unless the patient takes uric acid lowering drugs or has a major change in lifestyle. Gout starts in the toes and then progresses to the mid-foot and ankle and then on to become poly-articular.
It would be useful to arrange a foot and ankle X-ray in case there is a traumatic cause for the ankle pain. Also, erosions from rheumatoid arthritis would be visible on an X-ray or changes due to OA.
Blood tests for uric acid are best taken 2–4 weeks after the acute attack; uric acid levels are low in the acute attacks as most of the uric acid crystals are in the affected joint and not circulating. Levels of more than 320 mcmol/l are above the crystallisation point of uric acid and can cause precipitation in joints and acute gout.
It is useful to check renal function, as a reduced estimated glomerular filtration rate (eGFR) (chronic kidney disease [CKD]) will pre-dispose to gout due to reduced filtration and excretion of uric acid.
Reginald is taking bendromethfluazide, which also has the potential to increase urate levels by reducing urate excretion; it might be worth stopping the diuretic and using an alternative treatment for the gout, such as losartan, which reduces urate levels.
Lifestyle measures such as reducing alcohol consumption and losing weight will also help to reduce uric acid levels.
Finally in the acute stage, oral colchicine 0.5 mg two to four times daily will settle an acute attack of gout. Alternative treatments are nonsteroidal anti-inflammatory drugs (caution in CKD) and steroids (a short course of prednisolone, e.g. 30–35 mg daily for 3–5 days; low-to-moderate doses are thought to be relatively safe and likely to have a rapid response. Historically, lower doses of prednisolone have also been used for gout in UK clinical practice).
As per British Society of Rheumatology guidance, allopurinol should be commenced once conservative measures have failed and the uric acid level remains above 300 mcmol/l. Allopurinol should be titrated up until the uric acid levels fall below 300 mcmol/l.
Allopurinol treatment will then be lifelong and this must be explained to Reginald.