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IM7.1-22 | Rheumatologic Problems — Assignment

CLINICAL SCENARIO

This assignment requires you to construct a comprehensive clinical case report for a patient presenting with inflammatory joint disease in the general medicine outpatient setting of a teaching hospital in India. You will approach the case as the treating intern under supervision — performing the clinical assessment, selecting and interpreting investigations, developing a management plan, communicating with the patient, and identifying red flags requiring specialist referral. You may base this on an actual patient encounter, a case from your clinical log, or the provided reference scenario below.

Instructions

Write a structured clinical case report following the five sections below. Use precise clinical and pharmacological language. When quoting diagnostic criteria (e.g., ACR/EULAR 2010 for RA, SLICC 2012 or ACR/EULAR 2019 for SLE), name the criteria set you are applying. For any drug you prescribe, state the dose, frequency, and monitoring plan. Do not copy SDL text verbatim — demonstrate integration of clinical reasoning. If basing the report on a real patient, mask all identifying information. Word limit: 1,200–1,600 words.

Length: 1,200–1,600 words across all five sections

What to Submit

Section 1: Clinical Assessment and Differential Diagnosis

Guidance: Describe the presenting complaint, history of joint pain (number, distribution, temporal pattern, morning stiffness duration, response to rest and activity), and examination findings (look-feel-move at affected joints; periarticular versus articular; signs of systemic involvement). Using these features, classify the joint disease as inflammatory or mechanical with explicit reasoning. Then construct a ranked differential diagnosis of at least 3 conditions, with 2-3 supporting and 1-2 refuting features for each. Approximately 350 words.

Section 2: Investigation Selection and Interpretation

Guidance: List the investigations you would order in order of priority, justified by your working hypothesis. Do NOT order an undifferentiated autoimmune panel — explain why each test was selected. Interpret each result you report (whether actual from the patient or expected): for RF and anti-CCP, state the sensitivity and specificity of each for RA; for ANA, state what a positive result means and what you would order next. If arthrocentesis was done or is indicated, describe the synovial fluid findings expected. If plain X-rays are available, describe the relevant findings. Approximately 350 words.

Section 3: Treatment Plan

Guidance: Develop a complete pharmacological and non-pharmacological treatment plan for your working diagnosis. For pharmacological treatment: name the first-line DMARD, the starting dose, the dose-titration strategy, the treat-to-target goal (DAS28 or equivalent), and the specific safety monitoring plan (which tests, at what intervals). If biologic therapy would be considered, state the criteria that would need to be met. For non-pharmacological management: name specific interventions (physiotherapy, joint protection, occupational therapy, exercise recommendations, patient education) and explain the rationale for each. Approximately 300 words.

Section 4: Patient Communication and Follow-Up Plan

Guidance: Write the explanation you would give to your patient about their diagnosis, using language a patient without medical training can understand. Address: what the disease is, why the joints are affected, how the treatment works, what the medication can and cannot do, and the importance of adherence and monitoring. Then outline your follow-up plan — who reviews the patient, what is checked at each visit, how quickly, and what would prompt an earlier review. Consider the patient's specific concerns: prognosis, ability to work, pregnancy planning (if relevant), or family implications. Approximately 250 words.

Section 5: Complication Awareness and Referral Decision

Guidance: Identify the two most important potential disease complications and the two most important potential treatment complications for your working diagnosis. For each, describe the clinical sign you would watch for and the monitoring strategy. State clearly the criteria under which you would refer this patient to a specialist rheumatologist — using clinical thresholds rather than vague terms like 'if not improving'. Discuss at least one systemic or extra-articular complication specific to the disease. Approximately 200 words.

Grading Rubric — Rheumatology Case Report Rubric

Criterion	Points	Full-marks descriptor
Clinical Assessment and Differential Diagnosis (Section 1): Accurately characterises the joint disease as inflammatory versus mechanical using history and examination findings; generates a ranked differential diagnosis with explicit supporting and refuting features for each diagnosis.	20 pts	Inflammatory versus mechanical distinction made correctly with ≥3 specific clinical features cited; differential includes ≥3 diagnoses each with clear supporting and refuting features; reasoning is explicit and pathophysiology-based.
Investigation Selection and Interpretation (Section 2): Selects appropriate investigations based on the working hypothesis; correctly interprets serological results (RF, anti-CCP, ANA, anti-dsDNA) applying specificity and sensitivity principles; discusses synovial fluid findings or X-ray interpretation where relevant.	25 pts	Investigations selected hypothesis-first (not undifferentiated panel); each serological result interpreted with correct sensitivity/specificity context; synovial fluid or X-ray findings interpreted accurately and linked to diagnosis; operating characteristics of at least 2 autoantibodies discussed.
Treatment Plan (Section 3): Develops a specific, evidence-based treatment plan aligned to the working diagnosis; names the first-line DMARD with dose and monitoring plan; discusses biologic or second-line therapy criteria if applicable; addresses non-pharmacological management.	25 pts	Correct first-line DMARD named with starting dose, titration strategy, and specific monitoring plan (FBC, LFT, renal function frequency); biologic/second-line escalation criteria stated correctly (DAS28 threshold or equivalent); non-pharmacological measures specifically named and rationale given.
Patient Communication and Follow-Up (Section 4): Demonstrates ability to communicate the diagnosis clearly to a patient with appropriate language; outlines a structured follow-up and monitoring plan including specific parameters and timeframes; addresses patient concerns about prognosis and lifestyle.	20 pts	Diagnosis explanation uses lay language without jargon; specific follow-up parameters listed with timeframes (e.g., FBC every 6 weeks for first 3 months on MTX); at least two patient-specific concerns addressed (prognosis, work, fertility, side effects); monitoring plan reflects real clinical practice.
Complication Awareness and Referral Decisions (Section 5): Identifies the most important potential complications of the condition and of the treatment; states correct criteria for specialist rheumatology referral; discusses at least one systemic or extra-articular complication relevant to the diagnosis.	10 pts	≥2 disease complications and ≥2 treatment complications named with specific clinical manifestations and monitoring strategies; referral criteria stated precisely; systemic/extra-articular complication discussed with management.

PEER REVIEW

Review your peer's case report using the rubric provided. For each section, assign a score and write one specific comment. For Section 2 (Investigations): check that autoantibody interpretation includes at least one operating characteristic (sensitivity or specificity value) and that the student does not state a positive ANA alone is diagnostic of SLE. For Section 3 (Treatment): verify that methotrexate is correctly prescribed as weekly (not daily), with folic acid co-prescription stated. For Section 5 (Complications): verify that tuberculosis screening before biologic therapy is mentioned if the treatment plan includes biologics. Complete your review within 72 hours and provide at least one constructive suggestion per section.