Widespread Pain Who Wants More Scans and A Rheumatology Referral — Free SCA Practice Case

Character Overview: You are Lakshmi Varghese, a 45 year old domiciliary care worker. You visit people in their own homes, helping them wash, dress, eat and move, and some calls need two carers and a hoist. You work about 36 hours a week on early and late rounds and drive your own car between clients. You live with your husband Anil, who works in the council housing office, and your daughter Meera, who is 15. About a year ago you had a heavy flu like illness, and since then you have ached all over and never felt rested. You have been to the surgery four times. One doctor said the blood tests were fine and it was probably stress, and another told you to get more exercise. You went away feeling you had been called a time waster. You are quietly determined and polite. When you talk about not being believed your voice becomes thin and wobbly, and when you talk about your daughter it softens. You speak in short, tired sentences.

Opening Sentence: "Hello doctor. I've been aching all over for about a year now and nothing is getting better. All my blood tests come back normal but I know something is wrong with me, so I'd like a proper scan and to see a rheumatologist, please."

History if Asked (Data Gathering Phase)

• ●How it started: "About a year ago I had a horrible flu, in bed for a week. The fever went but the aching never did. It came on gradually all over and has just stayed."
• ●Where it is: "Everywhere really. My neck, shoulders, upper back, hips, thighs and knees, both sides, top half and bottom half. It moves about. Some days it's mostly my shoulders and the next it's my legs."
• ●What it feels like: "A deep, heavy ache, and sometimes burning. My skin feels sore. Even Meera hugging me can hurt. Most days it's about five out of ten and after a long round it goes up to eight."
• ●Morning and stiffness: "I'm stiff when I get up, but it loosens within about fifteen minutes. I don't have swollen or hot joints and nothing has gone red."
• ●Weakness: "My arms feel heavy and tired, but I'm not actually weak. I can still use the hoist and help people up."
• ●Tiredness: "I'm exhausted all the time, even after a day off. I wake up feeling like I haven't slept."
• ●Sleep: "I take about an hour to get off, then I wake three or four times. I get maybe four or five hours. Anil says I twitch and turn but he says I don't snore."
• ●Thinking and memory: "I'm foggy. I lose words in the middle of a sentence and I forget things I'd normally put in the client notes."
• ●Other symptoms: "Headaches most weeks, and my usual bowel trouble is a bit up and down."
• ●What eases and worsens it: "Heat helps a bit, a hot bath especially. A long round or a stressful day makes it worse. If I've done a lot, I'm flat for two days afterwards."
• ●What I've taken: "Ibuprofen 400 up to three times a day on bad weeks, and paracetamol up to four times a day. They barely touch it."
• ●Exercise: "I used to walk 5 kilometres with a friend every weekend. I stopped because I was in bits for two days after. I haven't been back."
• ●Mood: "I'm low a lot of the time and tearful, and I snap at Anil. I don't enjoy things like I used to. But I've never wanted to harm myself and I wouldn't do anything like that."
• ●Periods: "They've gone a bit irregular over the last six months, anything from three to six weeks apart, lighter than before. I get hot flushes at night some weeks."
• ●What was tested: "I've had a lot of blood tests and a shoulder X ray and everything was normal. Nobody has sent me for a scan or to a specialist."

Ideas, Concerns, Expectations

Gating note: Lakshmi does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

• ●Ideas: She believes an autoimmune illness such as lupus or rheumatoid arthritis is being missed, because a colleague had lupus that took years to find. She thinks tests can miss things and that only a scan of her whole body would show what is happening. "A girl at work had lupus and it took them years. I think I've got something like that and it's just not showing up yet."
• ●Concerns: Her biggest worry is that she is not believed and is seen as a time waster. She is also afraid that if no one finds the cause she will get worse and be unable to work or look after her daughter. "I feel like nobody believes me. If they don't find it, what happens, am I going to end up in a wheelchair?"
• ●Expectations: She came for a full body scan and a referral to a rheumatologist. She would also like something stronger for the pain and a name for what she has. "A scan of everything, and a specialist. And something stronger, because the ordinary tablets don't work."

If Asked: Medical History and Medications

Gating note: Lakshmi answers each of these plainly when the doctor asks about it.

• ●Other health problems: "Irritable bowel in my thirties. Nothing else. I had a caesarean for Meera."
• ●Medicines: "Only the ibuprofen and paracetamol I buy at the chemist. Nothing on prescription and no herbal things."
• ●Allergies: "None."
• ●Family history: "My mum has high blood pressure. No one has arthritis or anything like that."
• ●Alcohol and caffeine: "I hardly drink. About four cups of tea or coffee a day."

Social History and Lifestyle Impact

• ●Work: Lakshmi does 36 hours a week, often seven days in a fortnight, with some double up calls using a hoist. If asked about adjustments, she says she has never asked, because she is afraid of being given fewer hours. Her manager has called a formal attendance review because she has had 11 days off sick this year.
• ●Home: Anil does the cooking when he can and Meera helps with the washing up. She feels guilty about being too tired for Meera.
• ●Driving: She drives between clients all day and cannot afford to feel drowsy at the wheel.
• ●Weight and activity: About 11 stone, and gaining a little. Apart from work she is hardly active now.
• ●Availability to be seen: She can come to the surgery after an early round, or on her day off in the middle of the week.

If Asked: Associated Symptoms

Gating note: Lakshmi answers these only when asked. Every one is negative unless stated.

• ●If asked about fever, night sweats or weight loss: "No. My weight is about the same, apart from creeping up."
• ●If asked about a rash, mouth ulcers, dry eyes, white or blue fingers, or sun sensitivity: "None of those."
• ●If asked about joint swelling, redness or heat: "No, my joints look normal. It's the muscles and everywhere around them that ache."
• ●If asked about numbness, pins and needles or true weakness: "Sometimes my hands tingle after a long round, but it passes. I'm not weak."
• ●If asked about bladder or bowel changes, bleeding or lumps: "No change apart from my usual bowel."
• ●If asked about feeling cold, dry skin or constipation: "No."
• ●If asked about thoughts of harming herself: "No. I get low, but I'd never do that. I have Meera."

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that the tests are normal and a scan or a rheumatology referral is not needed now:
  • ●Reaction: Hurt and defensive. "So you're saying there's nothing wrong with me? It hurts every single day." She softens if told her pain is real, that normal tests mean there is no joint damage or inflammation, and that she would be referred if certain signs appeared. "So what would make you send me?" She asks, "Will a scan not show something the bloods can't?"
• ●If the doctor explains a diagnosis for her widespread pain:
  • ●Reaction: Wary. "A condition? Is it real, or are you saying it's in my head?" If told it is real and common and not caused by damage, she says, "So why does it hurt so much, then?" She settles when told the nervous system is turning the pain up. "Okay. That makes some sense. Nobody's explained it like that."
• ●If the doctor suggests exercise, pacing or talking therapy:
  • ●Reaction: Doubtful. "Exercise? I'm in bits for two days when I walk. And talking therapy, I'm not mad." If it is explained that the exercise starts very gently in a group and builds slowly, and that talking therapy helps people live with pain, not because it is imagined: "A gentle group might be all right. I'd do that if it's slow."
• ●If the doctor discusses medicines:
  • ●Reaction: Hopeful, then cautious. "Is there not something stronger? A colleague takes pregabalin, and my friend was on tramadol." If told these are not recommended because they do not help and can cause harm or dependence: "Right, I don't want to get hooked." If a low dose tablet at night is offered, she asks, "Will it make me drowsy? I drive for work."
• ●If the doctor discusses work, a fit note or occupational health:
  • ●Reaction: Anxious. "I've got an attendance review. Will a sick note count against me?" If offered a note supporting adjusted duties or fewer double up calls: "Could you write it so they can see it's a medical thing?" If told to stop work: "I can't just stop. We need my wage."
• ●If the doctor describes the outlook, follow up or safety netting:
  • ●Reaction: Wants specifics. "Will it ever go away? When do I see you again?" If safety netting is vague, such as "come back if it gets worse": "It's bad already. What would make you worry?" She repeats back clearly when given specific signs and what to do.