Widespread pain, fatigue, and a request for indefinite sick leave
Ms C, 47, a call-centre team leader, has had 9 months of widespread pain, poor sleep (4–5 hours), and fatigue. Pain is 7/10 most days and worse with stress. She reports 45 minutes of morning stiffness in the hands and knees, dry eyes, and occasional mouth ulcers. She takes cocodamol 30/500 four times daily and has been off work for 6 weeks. Examination shows 14/18 tender points, no synovitis, normal power, CRP 3 mg/L, ESR 12 mm/h, RF negative, anti-CCP negative, TSH normal, vitamin D 38 nmol/L, and BMI 32. She asks whether she has fibromyalgia and whether she should be signed off indefinitely.
1. Interpret the findings and formulate the problem. What would you include in the differential, and what would you do next?
Read the worked answer
The picture is consistent with fibromyalgia-like central sensitisation, but the 45 minutes of morning stiffness, dry eyes, and mouth ulcers mean I would not close the case as fibromyalgia alone. The normal CRP, ESR, RF, anti-CCP, and TSH lower the probability of rheumatoid arthritis, lupus, and thyroid disease, but they do not exclude seronegative inflammatory disease or sicca syndrome.
I would ask targeted questions about inflammatory back pain, psoriasis, IBD, Raynaud phenomenon, sicca symptoms, and family history, and examine hands, feet, and entheses again. I would not order a broad autoantibody panel reflexively; I would check ANA only if sicca or systemic features persist, and consider referral to rheumatology if objective synovitis, rash, or persistent inflammatory stiffness emerges.
The tender-point count is supportive but not diagnostic. The main formulation is widespread pain amplified by poor sleep, stress, low vitamin D, and deconditioning, with unresolved inflammatory uncertainty. This framing matters because labelling her as 'just fibromyalgia' could miss early connective tissue disease, while over-investigating reinforces illness worry.
2. What are your first three management priorities, including the opioid issue?
Read the worked answer
- Address sleep and activity gently. Agree a consistent sleep window, reduce caffeine after midday, and start graded activity rather than boom–bust cycles. I would explain that pain does not mean tissue damage and set a baseline of 10–15 minutes of walking, increasing by 10% weekly.
- Review analgesia and taper the opioid. Cocodamol four times daily provides little proven benefit in central sensitisation and carries dependence and rebound-headache risk. I would agree a slow reduction, substitute regular paracetamol if needed, and consider duloxetine or amitriptyline for sleep and pain. I would not start a strong opioid.
- Treat reversible contributors and offer non-drug therapy. Correct vitamin D deficiency, address weight and sleep apnoea risk, and refer to a pain-management programme offering CBT and graded exercise.
I would explain that these are active treatments, not dismissal. I would review in 2–4 weeks and monitor mood and function rather than pain score alone.
3. How would you respond to her request for indefinite sick leave?
Read the worked answer
I would not agree to indefinite signing off because prolonged absence predicts poorer work outcomes and reinforces fear-avoidance. I would acknowledge that her pain and fatigue are real and that full-time call-centre work with fixed targets is currently difficult.
I would offer a phased return with temporary adjustments: reduced hours, more frequent breaks, a headset that allows standing, and a staged increase over 4–6 weeks. I would use a fit note with 'may be fit for work with adjustments' rather than a permanent sick line.
I would agree a review date and safety-net advice: return sooner if she develops swollen joints, rash, fever, or neurological symptoms. If she cannot engage with a return plan because of distress or safeguarding concerns, I would involve occupational health and consider a psychological assessment. The reasoning is to preserve function and role identity while treating the pain syndrome, rather than making work absence the default solution.