Return to Scenario ListShow Learning Points most relevant to Phase 1:

Painful hands in the cold

Clinical Discipline(s)/Organ System(s)
Musculoskeletal System, Rheumatology
Progress Test Topic(s)
A 37 year old NZ European woman presented to her GP with a recent history of painful 'weak' hands. She has also been quite lethargic the last few weeks, complains of low mood and aches all over her body. She has had Raynaud's phenomenon since her early teens which she manages by avoiding cold exposure and she is not prescribed any regular medications. On examination she has a positive Tinel's sign bilaterally.
Progress Test-Type Questions:   Question 1 | Question 2
Applied Science for Medicine 
   - Structure and function of pain perception
   - Pain pathways and neuronal excitation/inhibition at a spinal level
   - Structure, function and common pathologies of connective tissue
   - Immunology of autoimmune disease
   - Mechanisms underlying systemic symptoms resulting from inflammation
   - Outline the pharmacology of analgesics for chronic pain (including non-steroidal anti-inflammatory drugs)
Clinical and Communication Skills 
   - History of possible autoimmune disease vs fibromyalgia
   - Focused musculoskeletal examination and demonstrate the tender points required to make a diagnosis of fibromyalgia
   - Examine the skin and describe features of systemic sclerosis
   - Differential diagnosis of autoimmune disease and fibromyalgia
   - Classification of systemic sclerosis (diffuse vs limited)
   - Serological markers of systemic sclerosis and other connective tissue disease
   - Diagnosis of carpal tunnel syndrome; use of imaging and nerve conduction studies
   - Use of pulmonary function tests and echocardiography as screening for interstitial lung disease and pulmonary vascular disease
   - Management of pain with no obvious organic cause and the rationale for, and mechanism of action of antidepressant drugs in fibromyalgia
   - Treatment of primary and secondary Raynaud's phenomenom and drugs which exacerbate it
   - Treatment of carpal tunnel syndrome and indications for surgical release
   - Effectiveness of treatment options in fibromyalgia: graded exercise; psychotherapy; antidepressants
   - Prophylactic use of proton pump inhibitors to prevent oesophageal stricture
Personal and Professional Skills 
   - Negotiating agreed management, explaining, planning, sharing information and ensuring understanding
   - Supportive treatment: counselling, patient and family/whānau education, patient support groups, appropriate reliable web-based sites for information
   - Empathise with patient's concern re prognosis and physical deterioration
   - Providing advice and support in relation to employment issues and activities of daily living
Hauora Māori 
   - Low prevalence among Māori doesn’t mean zero prevalence – so still need to keep it in the differential diagnosis
Population Health 
   - Epidemiology of systemic sclerosis: age, gender, ethnicity
   - Provision of health services for long-term conditions
Conditions to be considered relating to this scenario
systemic sclerosis, localised scleroderma (morphoea), fibromyalgia, primary and secondary Raynaud's phenomenon, carpal tunnel syndrome, systemic lupus erythematosus (SLE), polymyalgia rheumatica, depression, acromegaly
Less common but 'important not to miss'
cervical cord compression
polymyositis, dermatomyositis, mixed connective tissue disease, POEMS syndrome