Box 4.

Possible response to the potential referral letter to the rheumatology clinic in Box 1; Dr C

Dear Doctor,
re Patient A
Thank you for your helpful letter about Patient A. I saw her in my multidisciplinary rheumatology new patient clinic this week.
Reviewing her history, the active clinical problems today are widespread muscle pain and sensitivity, extreme fatigue and poor exercise tolerance, limited mainly by lack of energy, but also by a feeling of dizziness. This last symptom has bothered her for many years, and she has had a number of ‘faints’, one of which resulted, 2 years ago, in a visit to the emergency department. At which point, she had electrocardiography which showed a sinus tachycardia, but no other abnormality.
The illness you mention is Spain sounds very much like an attack of holiday diarrhoea. She still experiences occasional intestinal hurry, but this is usually associated with the use of over-the-counter proton pump inhibitors, which she uses regularly on an as needed basis.
Since she was investigated in her teens, she has had only occasional headaches, but she does complain of poor concentration and ‘brain fog’.
She sleeps poorly, and wakes feeling unrefreshed. Due to her fatigue, she often sleeps for short periods in the day.
Patient A also describes having a dry mouth, much worse since starting treatment with nortriptyline, but no ocular sicca, and only a very occasional mouth ulcer. Her weight is stable, and appetite fair. As you note, she has been off work for some time, and she was informed that an occupational health review is pending, something about which she is understandably very concerned. She does not have a regular partner at present and is not sexually active.
On examination, Patient A looked well, but came across as very anxious. She was able to give a very good account of herself and brought along copies of a number of letters from specialists she had seen in the past. There was no lymphadenopathy, clubbing or rash, and a Shirmer's test was normal. Her resting pulse rate was 98 beats per minute, blood pressure (prone) 130/90 mmHg; blood pressure (standing) 100/70 mmHg. Cardiovascular, respiratory and abdominal examinations were all otherwise normal. Reflexes were brisk and symmetrical, with no evidence of a peripheral neuropathy or radiculopathy and, with encouragement, normal power in all muscle groups. Musculoskeletal examination revealed no joint deformity or swelling, a good range of back movement and no evidence of sacroiliac pathology. However, Patient A is clearly a hypermobile individual: Beighton score = 9, with markedly hyperextensible knees and elbow joints in particular. There was localised pain and tenderness referable to the parasternal area bilaterally, both elbows, buttocks and the muscles of the shoulders and neck on both sides.
My view is that this patient has fibromyalgia, in association with anxiety, hypermobility and autonomic dysfunction (manifest as postural orthostatic tachycardia syndrome (PoTS)), ie FAHA. Many features in the history and examination support this diagnosis, notably the non-restorative sleep pattern and fatigue, widespread pain, and previous history of irritable bowel syndrome, ‘brain fog’ and headaches.
I am rechecking her blood count and thyroid function tests, as well as calcium, magnesium (low magnesium is common in proton pump inhibitor (PPI) users) and vitamin D levels. No other blood tests or imaging are required. I shall discuss the results with her as part of a planned telephone follow up in 3 weeks.
My colleague Dr D also reviewed the patient in our multidisciplinary clinic, and she was also assessed by our speciality physiotherapist, who is planning a graded exercise programme, and has referred her to our nurse-led fibromyalgia support group for advice on pain-management in particular. Dr D's letter is appended.
I explained the clinical problem to Patient A, particularly the relevance of her hypermobility, and provided her with the Versus Arthritis information leaflets on both hypermobility and fibromyalgia, as well as a number of links to informative websites, with a view to discussing any specific issues at our future telephone consultation.
We agreed to cease her PPI use, aim to reduce and stop her opiates, and also her etoricoxib in due course. I would recommend continuing nortriptyline for the time being and you may also wish to consider melatonin, 2 mg nocte for 2 months or so to try to normalise her sleep pattern. I have also agreed, with appropriate consent, to provide a report for the occupational health department at the university.
Yours etc