Last updated on 23 Jan 2013 at 12:34 PM (Rh06)

Headache, morning stiffness and shoulder pain
A 70 year old NZ European woman sees her GP with a 6 week history of aching and morning stiffness in the shoulders, hip girdle and neck. This has slowly worsened and in the last 2 days she has developed a severe headache with scalp tenderness. Her body mass index (BMI) is calculated and is 18. You organise an erythrocyte sedimentation rate (ESR) and the result is 66 mm in 1 hour (normal 0-30).

 

Applied Science for Medicine
Structure, function and common pathologies of blood vessels including regulation of blood pressure
Acute phase reactants in acute /chronic inflammation
Immunophysiology of vasculitis /angiitis /arteritis
Classification of the vasculitides by size of vessel involved
Disease 'clustering': current hypotheses of infectious and genetic associations in polymyalgia rheumatica (PMR) and giant cell arteritis (GCA)
Pharmacology of anti-inflammatory corticosteroids
Bone mineralisation and its control

Clinical and Communication Skills
History from a patient with possible vasculitis
Systematic examination of a patient with possible vasculitis including fundoscopy, blood pressure measurement, urinalysis
Indications for temporal artery biopsy
Measure height and weight to calculate Body Mass Index (BMI)
Development and exclusion of differential diagnoses in a non-specific presentation
Diagnostic criteria of polymyalgia rheumatica and giant cell arteritis; importance of early recognition in view of the threat to vision
Presentation and complications of vasculitis including polymyalgia rheumatica and giant cell arteritis
Use of immunosuppression and steroids in vasculitis including the importance of bone protection for prevention of steroid-induced osteoporosis; ensuring adequate dose and titration of dose in response to clinical improvement and ESR level
Use of bone densitometry in osteoporosis (DEXA scan)
Primary and secondary preventative measures in osteoporosis - lifestyle and pharmacological mechanisms of action
Use of acute phase reactants in diagnosis and in monitoring disease activity

Personal and Professional Skills
Be able to counsel a patient about long-term steroid use, including appropriate discussion of the therapeutic effects and side effects
Be aware of factors influencing length of disability: adherence with treatment, issues of health literacy, attendance for follow-up care, complications of steroid therapy

Hauora Māori
Inequitable access to health care for Māori, including delays in diagnosis
Whānau responsibilities of the patient

Population Health
Vasculitides - incidence, risk factors and natural history
Effectiveness and cost-effectiveness of screening for and treating osteoporosis

 

Conditions to be considered relating to this scenario

Common

polymyalgia rheumatica, giant cell arteritis, fibromyalgia, osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus (SLE), hypo /hyperthyroidism, depression

Less common but 'important not to miss'

multiple myeloma

Uncommon

dermatomyositis/polymyositis, inclusion body myositis, myositis associated with neoplasia, carcinoma