Polymyalgia Rheumatica (PMR)

PLAB 2 CaseBank
1

Who you are:
You are an F2 in GP clinic.

Who the patient is:
Mrs. Margret Smith, aged 73, presents to the clinic with aches and pains She had been diagnosed with GE reflux 20 years back and she has been taking Omeprazole.

What you should do:
Please talk to the patient, discuss your initial plan of management with her and address her concerns.

Polymyalgia Rheumatica:

  • It affects shoulder and hip joint + morning stiffness that improves with activity.
  • Don’t forget to ask about GCA arthritis symptoms.
  • Don’t forget to ask about impact of this on life.

P1 (SOCRATES)
Doctor: Hello, how can I help you today?
Patient: I have pain around my shoulder. (+ve finding)
D: Which shoulder? (site)
P: In my right shoulder.
D: What about the left side?
P: That’s fine.
D: Any other joint?
P: There’s also pain in my hip joints (+ve finding)
D: Are you able to use the joints?
P: Yes.
D: Can you tell me more about this pain? When did it start? (onset)
P: 5 weeks ago.
D: How did it start?
P: Gradually.
D: Is the pain continuous or does it come and go?
P: Continuous (+ve finding).
D: Could you please describe the pain for me? (character)
P: It’s a dull pain.
D: Does it go anywhere else? (radiation)
P: No.
D: Is there anything making it worse?
P: No.
D: Is there anything making it better?
P: No.
D: On scale from 1 to 10, with 1 being the mildest and 10 being the most severe, can you rate the pain for me?
P: 4
D: Apart from this pain, anything else?
P: No.
D: What concerns you the most? (concern)
P: Nothing doctor.

OTHER SYMPTOMS:
D: Any swelling or redness?
P: No.
D: Any stiffness?
P: Yes, in the morning, but it improves as the day goes on.
D: Any pain while combing your hair? (GCA)
P: No.
D: Any pain around your jaw while eating?
P: No.
D: Any eye-pain or redness?
P: No.
D: Have you had any recent flu-like symptoms?
P: No.

Differentials (don’t forget septic arthritis)
D: Any fever?
P: No.
D: Any trauma to the joints?
P: No.

+FLAWS

P2
D: Have you had this pain before?
P: No.
D: Do you have any medical condition?
P: Yes, I have reflux.
D: Tell me more about it?
P: I have had it 20 years now.
D: What you are taking for it?
P: Omeprazole.
D: Are you taking it as prescribed?
P: Yes

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: What about your diet?
P: I try to eat healthy.
D: Do you exercise?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements other than omeprazole?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.
D: You have had this pain for 5 weeks now, how is it affecting your life?
P: It’s difficult, but I try to cope with it.

DON’T FORGET ICE

Examination:
Vitals and examination of the joints

Provisional diagnosis
From the chat we just had (mention the positive findings) you told me that you have had pain in your shoulders and around the hip and stuffiness that improves towards the end of the day. Given all that, I suspect you may have Polymyalgia rheumatica, a condition that causes pain, stiffness and inflammation in the muscles around the shoulders, neck and hips.

Management

Senior.

Investigations.

  • Blood
    – Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are to check the
    levels of inflammation in your body.
    – Rheumatoid factor and anti-CCP antibodies may be done to rule out rheumatoid
    arthritis.
    – Blood tests can also help determine whether you have a blood infection.
    – Blood tests can also help determine how well your organs, such as your kidneys, are working.
    – If you have an overactive thyroid gland or an underactive thyroid gland – both conditions can cause muscle pain.
  • A urine test to check how well your kidneys are functioning.
  • X-rays and ultrasound scans may also be used to look at the condition of your bones and joints.

Medications

  • Steroid medicine (prednisolone) is the main treatment for polymyalgia rheumatica (PMR). Prednisolone works by blocking the effects of certain chemicals that cause inflammation inside your body. It is taken as a tablet.
  • Although your symptoms should improve within a few days of starting treatment, you’ll probably need to continue taking a low dose of prednisolone for about 2 years.
  • Do not suddenly stop taking steroid medicine unless your doctor tells you it’s safe to stop. Suddenly stopping treatment with steroids can make you very unwell.
  • Side effects of prednisolone:
    – changes to your mental state (depression – hallucination – suicide).
    – Weight gain
    – High blood pressure
    – Mood changes, such as becoming aggressive or irritable with people.
    – Weakening of the bones
    – Stomach ulcers
    – Immunosuppressant medicine: Sometimes other medicines may be combined with corticosteroids to help prevent relapses or allow your dose of Prednisolone to be reduced.
  • Painkillers, such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs), to help relieve your pain and stiffness while your dose of Prednisolone is reduced.
  • Steroid card
    – If you need to take steroids for longer than 3 weeks, your GP or pharmacist should arrange for you to be given a steroid card.
    – The card explains that you’re regularly taking steroids and your dose should not be stopped suddenly. Always carry the card with you.

Safety netting

  • Temporal arteritis
  • A severe headache that develops suddenly (your scalp may also feel sore or tender).
  • Pain in the jaw muscles when eating.
  • Problems with sight, such as double vision or loss of vision.
  • If you have any of these symptoms, contact a GP immediately, or go to your nearest urgent care service.
  • Side effects of steroids: You may feel depressed and suicidal, anxious or confused.
    Some people also have hallucinations, (seeing or hearing things that are not there).
  • Get immediate medical advice if you think you’ve been exposed to the varicella-zoster virus or if a member of your household develops chickenpox or shingles as taking steroids increases risk of infection.

Follow-up

  • You’ll have regular follow-up appointments to check:
    – how well you’re responding to treatment.
    – if your dose of prednisolone needs to be adjusted.
    – how well you’re coping with any side effects.
  • You’ll have blood tests to check the levels of inflammation inside your body.
  • Follow-up appointments are usually recommended every few weeks for the first 3 months, and then every 3 to 6 months after this time.
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