Box 1.

A potential referral letter to the rheumatology clinic

Dear colleague,
Could I ask you to see my patient, Patient A? She is 24-years-old and has just transferred to the practice, having had some issues with her previous general practitioner.
Her main complaints are chronic muscle and joint pain. All muscle groups are involved, but her shoulders and back seem to be the worst areas affected. There is no clear history of joint swelling and, on examination, no deformities or synovitis. She has been troubled by these pains since adolescence, though she informed me she was a keen gymnast at school.
The other concerning issue is severe fatigue. This dates from a holiday in Spain last summer when she apparently developed a febrile illness, precipitating her early return, at which time she also split up from her long-term boyfriend. She now has very poor exercise tolerance, becoming fatigued and dizzy after walking for more than 10 minutes on the flat, and has been off work (she is a university administrative assistant) for the last 3 months, and indicated that she is quite likely to lose her job.
I have accessed her previous records, and I note that she was investigated for an irregular bowel habit while at college, but a faecal calprotectin and other tests were normal, and a putative diagnosis of irritable bowel syndrome was made. This problem seems to have settled. While at school, she was also investigated for a chronic headache, attributed then to excessive screen use. Computed tomography of the brain was normal, and she is no longer under neurological follow-up.
Current medications include etoricoxib, 60 mg once per day, and nortriptyline, 50 mg nocte. She also takes co-codamol, one tablet three times per day, prescribed by a colleague, but does, I think, obtain additional supplies from an online pharmacy, which is clearly a matter of concern. She does not feel that any of these medications really help her pain. I have been reluctant to start gabapentin, or anything similar, in the absence of a clearer diagnosis.
I have performed some baseline blood tests: full blood count, urea and electrolytes, and thyroid function tests are normal; C-reactive protein <5 mg/L; rheumatoid factor was negative.
Many thanks for your help,
Yours etc