Chronic Widespread Pain and Normal Blood Tests — Free SCA Practice Case

Character Overview: You are Lee, a 37-year-old former soldier (British Army), medically discharged partly because of ongoing pain, now unemployed and job-seeking. You have had a dull, constant, aching pain all over — mainly back and shoulders — for about nine months, unrelieved by ibuprofen and paracetamol. You are exhausted all the time, even after sleeping, and small tasks wipe you out. You do not have joint swelling or stiffness, and you would not say your mood is low. You think it might be rheumatoid arthritis (a military friend was diagnosed with it). You are worried about work and money. You are stoical and may be reluctant to discuss military experiences unless asked sensitively.

Opening Sentence: "Hello Doctor. I'm here about my blood results. I've had this aching pain all over for months now — mostly my back and shoulders — and I'm shattered all the time. I just want to know what's causing it."

History if Asked (Data Gathering Phase)

• ●The pain: "A dull, constant ache, all over really, but worst in my back and shoulders. It's been about nine months. It varies but never really goes."
• ●Fatigue: "I'm exhausted all the time. Even sleeping well, I wake up tired. Getting my son ready for school leaves me drained for the rest of the day."
• ●Stiffness/swelling: "No real morning stiffness, and no swollen joints."
• ●Treatment tried: "Ibuprofen and paracetamol — they barely touch it."
• ●What he thinks: "A mate from the Army got rheumatoid arthritis with shoulder pain, so I wondered if it's that."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

• ●Ideas: Lee suspects rheumatoid arthritis, based on his friend's diagnosis. "I've been thinking it might be rheumatoid arthritis, like my mate had."
• ●Concerns: His dominant concerns are the impact on work and finances — he was discharged from the Army because of the pain, is unemployed, and worries about finding work and running out of savings. "My worry is work and money — I lost my Army career to this, I'm out of work, and I'm frightened about the future."
• ●Expectations: He wants the results explained and to know what to do next. "I want to understand the results and have a plan."

If Asked — Fibromyalgia, Red-Flag, and Veteran-Aware Screen

The patient answers these only when directly asked.

• ●If asked about disproportionate fatigue / unrefreshing sleep: "Yes — the tiredness is way out of proportion, and sleep doesn't refresh me."
• ●If asked about associated symptoms (headaches, pins and needles, memory/concentration — 'fibro fog'): "Some headaches, a bit of pins and needles, and my memory and concentration feel foggy."
• ●If asked about morning stiffness duration: "Not much stiffness, and if any, it's brief."
• ●If asked about joint swelling: "No swelling in the joints."
• ●If asked about red flags (weight loss, night sweats, fever, leg weakness, bladder/bowel): "No weight loss, no night sweats or fevers, no leg weakness or bladder/bowel problems."
• ●If asked, sensitively, about mood and PTSD (given his service): "My mood's not really low… but I do get some flashbacks and disturbed sleep from my time in service, and I can be on edge. I don't talk about it much." (Discloses PTSD features only if asked sensitively.)
• ●If asked about triggers / stress: "Stress seems to make the pain and tiredness worse."
• ●If asked about social/support: "I live with my wife and son. Not smoking, not drinking. Just the money worry hanging over us."

Responses to Management (The Negotiation Phase)

• ●If the Doctor explains the bloods are normal and this is likely fibromyalgia: "So it's not rheumatoid arthritis? Fibromyalgia — what is that? Does that mean it's all in my head?" (The tested point is explaining the normal results and fibromyalgia clearly and without dismissal — that it is real, not imagined, and not joint-damaging.)
• ●If the Doctor explains non-drug management (pacing, exercise, CBT): "Talking therapy and exercise? How's that going to help my pain?" (The tested point is explaining non-pharmacological management, including why CBT helps — not because the pain is imagined.)
• ●If the Doctor discusses medication: "Is there a tablet that helps? The painkillers haven't."
• ●If the Doctor sensitively addresses his military background/PTSD: "You're asking about my time in the Army… I suppose it does still affect me." (The tested point is veteran-aware care — screening for and addressing PTSD, and signposting veteran services.)
• ●If the Doctor signposts support: "Is there help out there — for the money side, and for veterans like me?"