I was on completely flat ground, Carmen says. Just suddenly stumbled and pitched forward. I’m trying to get more fit since you told me I have high blood pressure. I’m in my early 40s, so the exercise has to be good right?
When you examine her, her blood pressure is 150/90, without a postural drop. Her knee is stable, no obvious synovitis, and apart from some tenderness over the infrapatellar bursa is asymptomatic.
You give her a new script and advise her to be more careful when running.
[[And you don't see Carmen for six months]].
Carmen tells you that she has been seeing a naturopath who has given her some natural treatments and herbs. She tells you that she has given up jogging because she is a “complete klutz” and has fallen over a few more times. She has aching over both her hips and does indeed feel tired.
Before your examination, what are your thoughts?
[[This sounds like a neurological problem]].
[[This sounds like a rheumatological problem]].
[[This sounds like a musculoskeletal problem]].
[[This sounds like menopause]].
Carmen tells you that she has been seeing a naturopath who has given her some natural treatments and herbs. She says she is tired and feels weak because of the pain in her hips.
Before your examination, what are your thoughts?
[[This sounds like an orthopaedic problem]].
[[This sounds like a musculoskeletal problem]].
[[This sounds like menopause]].
You arrange a work-up which includes Xrays of the hips and knees. The Xray reports that she has no evidence of arthritis or any other bony abnormality. You reassure her that this is probably [[an ageing phenomenon]].Carmen’s physical examination is unremarkable. You arrange a work-up which includes Xrays of the hips which notes that she has no evidence of arthritis or any other bony abnormality. You do note that history of falls, and decide to send her to a physiotherapist for some work [[strengthening her hips]]. Carmen reports that she still has her periods but they are becoming heavier and she has had some symptoms of menopause, including hot flushes, and mood instability. Carmen’s physical examination is unremarkable. You advise her on natural management of menopausal symptoms and encourage her to exercise regularly.
[[Nine months later, Carmen comes to see you again]].Carmen’s physical examination is unremarkable. You do note that history of recurrent falls, and decide to send her to a neurologist for review. In your referral letter, you note that you are concerned about [[multiple sclerosis]].Carmen’s physical examination is unremarkable. You do note that history of falls, and decide to send her to a rheumatologist for review. You arrange a work-up including ANA, Rheumatoid factor, anti-CCP antibodies, FBC.
Since these are all normal, you wonder if she may have[[ fibromyalgia]].You receive a letter from the neurologist saying that he has performed an MRI of her brain, which was unremarkable, and that clinically she had no long track signs suggestive of multiple sclerosis.
[[Nine months later, Carmen comes to see you again]].
You receive a letter from the rheumatologist who notes that by the time she saw him she was complaining of pain hanging out the washing. The rheumatologist had been concerned about a proximal myopathy and had performed a CK (900 U/L), CRP and ESR.
The rheumatologist raises the possibility of [[myositis]] and proposes to do a muscle biopsy. The physiotherapist engages in some treatment, but refers her back to you after five sessions asking if there may be a systemic reason for her pain and weakness. [[Nine months later, Carmen comes to see you again]]. Things have got worse for Carmen. She has ongoing muscle and hip pain – now bilateral. You note that she has difficult getting up out of the chair in the waiting room. She tells you that her husband often has to help her to stand up and that she is finding her teaching job exhausting. She has asked to take on a desk job in the school.
Before your examination, what are your thoughts?
[[It's a neurological problem]].
[[It's a rheumatological problem]].
[[It's a musculoskeletal problem]].
Carmen’s physical examination reveals proximal muscle weakness and tenderness, involving both her upper and lower limbs. You are concerned this is a possible neuromuscular condition, and perform tests for ANA [negative], ESR [24 mmHg], CRP [12 mg/L], and total creatine kinase [900 U/L], as well as FBC [all indices within normal range], iron studies [Ferritin 75 ug/L; iron 28 umol/L; transferrin 3.1 g/L; transferrin saturation 25%] and thyroid function [TSH 3.5 mU/L] to rule out other causes of fatigue. In your letter you note that you are concerned about [[myositis]]. Carmen’s physical examination reveals proximal muscle weakness and tenderness, involving both her upper and lower limbs. You are concerned this is a possible neuromuscular condition, and perform tests for ANA [negative], ESR [24 mmHg], CRP [12 mg/L], and total creatine kinase [900 U/L], as well as FBC [all indices within normal range], iron studies [Ferritin 75 ug/L; iron 28 umol/L; transferrin 3.1 g/L; transferrin saturation 25%] and thyroid function [TSH 3.5 mU/L] to rule out other causes of fatigue. In your letter you note that you are concerned about [[myositis]].Carmen’s physical examination reveals proximal muscle weakness and tenderness, involving both her upper and lower limbs.
[[You decide to refer to a physiotherapist]].
[[You reassure her that this is a common ageing phenomenon]].The physiotherapist engages in some treatment, but refers her back to you after three sessions asking if there may be a systemic reason for her weakness.
You reasess. You wonder if [[It's a rheumatological problem]].Carmen does not return to see you.
Three years later you hear that she has had to leave her work due to her ongoing illness.
(link:"Start Again")[(goto:"BEGIN")]
Carmen does not return to see you.
(link:"Start Again")[(goto:"BEGIN")]
Carmen comes back to see you to review the results from the specialist. An EMG and muscle biopsy have confirmed that she has inclusion body myositis <iframe width="670" height="377" src="https://www.youtube.com/embed/Fo1yhVPHmws" title="Inclusion Body Myositis (IBM) Disease Overview : Johns Hopkins Myositis Center" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen></iframe>
Together you discuss the condition. You explain that there is no curative treatment, but you will work together to [[manage symptoms]]. Carmen says that she feels some tenderness just below her kneecap. When you examine her, her knee is stable, no obvious synovitis, and apart from some tenderness over the infrapatellar bursa is asymptomatic. Her blood pressure is 150/90.
You give her a new script for her antihypertensive medication, and advise her to be more careful when running.
[[And you don't see her for another six months]].(align:"=><=")[''(text-colour:blue)[CARMEN'S STORY]'']
(align:"=><=")[''A diagnostic journey '']
(align:"=><=")[Your task is to solve the diagnosis.
If you do not solve the diagnosis,
go back to the beginning
and start again. ]
(align:"=><=")[[[BEGIN]]]
Carmen’s husband Elham is your tax accountant.
Six months later you take your shoebox of receipts to him and while he is working his way through them he casually mentions that Carmen has become more tired and now had some pain in her hip.
You tell him that Carmen should make an appointment to see you [[to discuss it further]].Carmen’s husband Elham is your tax accountant. Six months later you take your shoebox of receipts to him and while he is working his way through them he casually mentions that Carmen has become more tired and has given up on all exercise.
You tell him that Carmen should make an appointment to see you [[to discuss it further with you]].(align:"<==")+(box:"=XX=")[(text-colour:blue)[''''''CARMEN'S STORY'''''']]
Carmen’s search for a diagnosis begins in the middle of nowhere. She’s jogging along at the rear of the Year 8 cross-country run when she trips over and falls forward onto her knees. Fifteen teenagers crowd around to pull her up. At least one is filming their teacher covered in mud.
Go to your GP, says the principal. Get a letter of clearance.
That’s what brings Carmen in to see you. You’ve known her for six years, though she mostly comes in to see you with her two primary school age children.
[[You ask Carmen how she came to fall over]].
[[You ask Carmen about her injured knee]].(align:"==><===")[TWO YEARS LATER ]
Carmen continues to work, though she has cut down her hours. She has joined a support group to learn from peers about living with myositis, and is planning to travel to visit family.
Carmen and you reflect on her diagnostic journey. In retrospect, Carmen's "clumsiness" and falls were an early sign of muscle weakness, though they were easily missed. Her diagnostic journey went down several blind alleys, which is typical of the diagnostic journey for myositis. Carmen's persistence and your own willingingness to re-examine and re-assess while still managing symptoms were both necessary to reach a diagnosis.
(link:"Read more about myositis.")[(gotoURL:"https://myositis.org.au/")]
(link:"Start Over")[(goto:"BEGIN")]
(link: "End Game")[<script>window.close()</script>]
[[Credits]]
''(text-colour:blue)[This game was developed by
(text-colour:white)[The Australian National University]]
''Christine Phillips
Jane Desborough
Anne Parkinson
Tergel Namsrai''
''//School of Medicine and Psychology
National Centre for Epidemiology and Population Health//
''(text-colour:blue)[Game development consultant]''
(link:"Ruqiyah @ ub4q")[(gotoURL:"https://ub4q.games/")]
''(text-colour:blue)[Advisers] ''
Anita Chalmers OAM, Myositis Association Australia
Christine Lowe, Myositis Association Australia
Carolyn Dews, Immune Deficiencies Foundation Australia
Elaine Kelly, Sarcoidosis Lyme Australia
Dianne Gregory, Sarcoidosis Lyme Australia
''(text-colour:blue)[This project was funded by ]''
The Commonwealth of Australia represented by the Department of Health Australia as part of the Rare Diseases - Support, Education and Training, Activity grant program # 4-G60XELC
This game was made with Twine 2.8.1 and Harlowe 3.3.8.
Carmen does not return to see you.
[[
↶↷CARMEN'S STORY
A diagnostic journey
Your task is to solve the diagnosis.
If you do not solve the diagnosis,
go back to the beginning
and start again.
BEGIN