CASE INFORMATION

Case ID: PAIN-2025-08
Case Name: Lisa Anderson
Age: 45
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A01 (Pain, general/multiple sites)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages effectively with the patient to explore chronic pain symptoms 1.3 Uses empathetic language to discuss the impact of pain on daily life 1.5 Uses shared decision-making to develop a management plan
2. Clinical Information Gathering and Interpretation	2.1 Conducts a thorough pain history and musculoskeletal examination 2.3 Identifies risk factors for chronic pain syndromes
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between musculoskeletal, inflammatory, neuropathic, and functional pain 3.5 Recognises red flags requiring further investigation
4. Clinical Management and Therapeutic Reasoning	4.2 Provides evidence-based pharmacological and non-pharmacological pain management 4.5 Discusses the role of physiotherapy, lifestyle changes, and psychological support
5. Preventive and Population Health	5.1 Encourages strategies for long-term pain self-management 5.3 Discusses the role of exercise, diet, and mental health in pain management
6. Professionalism	6.1 Provides a compassionate and non-judgmental approach to chronic pain
7. General Practice Systems and Regulatory Requirements	7.1 Ensures safe prescribing of analgesia and adherence to opioid guidelines 7.2 Documents clinical findings and management plan clearly
9. Managing Uncertainty	9.1 Addresses patient concerns about undiagnosed pain and prognosis
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises when pain may be related to a systemic condition (e.g., autoimmune disease, malignancy)

CASE FEATURES

Middle-aged woman with widespread musculoskeletal pain for six months.
No significant past medical history but increasing fatigue and sleep disturbances.
Pain is impacting work, relationships, and mental well-being.
Concerns about fibromyalgia or an autoimmune disorder.
Needs comprehensive pain assessment and holistic management approach.

INSTRUCTIONS

Review the following patient record summary and scenario.
Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time for each question will be managed by the examiner.
The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Lisa Anderson
Age: 45
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Occasionally takes ibuprofen for pain relief

Past History

No prior diagnosis of chronic illness

Social History

Works as a teacher, finding it difficult to manage workload
Reports increasing stress and low mood due to pain
Married, two teenage children

Family History

No known family history of rheumatological or autoimmune disease

Smoking

Non-smoker

Alcohol

Drinks 1–2 standard drinks per week

Vaccination and Preventative Activities

Up to date with routine health checks

SCENARIO

Lisa Anderson, a 45-year-old teacher, presents with widespread musculoskeletal pain affecting her neck, shoulders, back, and knees over the past six months. She reports fatigue, poor sleep, and brain fog, making it difficult to function at work.

She has no history of trauma or injury, but her symptoms worsen with stress and exertion. Over-the-counter NSAIDs provide minimal relief.

She is concerned about fibromyalgia or an autoimmune condition and wants to know what investigations are needed.

On examination, she has diffuse tenderness in multiple muscle groups, no joint swelling, and normal neurological function.

She is seeking advice on diagnosis, pain relief, and strategies to improve her quality of life.

EXAMINATION FINDINGS

General Appearance: Well, but appears fatigued
Vital Signs:

Temperature: 36.8°C
Heart Rate: 78 bpm
Blood Pressure: 122/80 mmHg
Respiratory Rate: 16 breaths per minute

Musculoskeletal Examination:

Diffuse tenderness over soft tissues (trapezius, lower back, thighs, knees)
No joint erythema or swelling
Normal power, reflexes, and sensation

Neurological Examination:

Normal cranial nerves and peripheral reflexes

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What aspects of history and examination are critical in assessing this patient’s chronic pain?

Prompt: How do you differentiate between inflammatory, mechanical, and neuropathic pain?
Prompt: What red flags would indicate the need for urgent investigations?

Q2. Based on the findings, what is your differential diagnosis, and what is your working diagnosis?

Prompt: How do you differentiate fibromyalgia from autoimmune or mechanical causes of pain?
Prompt: When would blood tests or imaging be warranted?

Q3. How would you manage Lisa’s chronic pain?

Prompt: What non-pharmacological treatments should be considered?
Prompt: When is medication appropriate, and what options should be used?

Q4. How would you counsel Lisa on lifestyle modifications and coping strategies?

Prompt: What is the role of exercise, diet, and mental well-being in chronic pain?
Prompt: How do you address psychological aspects of chronic pain?

Q5. What follow-up plan would you implement?

Prompt: When should she return for review?
Prompt: When would specialist referral (e.g., rheumatology, pain management) be considered?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What aspects of history and examination are critical in assessing this patient’s chronic pain?

A structured history and focused examination are essential to determine the nature, cause, and impact of Lisa’s chronic pain.

1. History

Pain characteristics:
- Onset, duration (≥3 months), location, radiation
- Type of pain (burning, aching, sharp, dull)
- Aggravating and relieving factors (movement, rest, stress, medications)
Red flag symptoms:
- Night pain, unexplained weight loss, fever, neurological symptoms (weakness, numbness), bowel or bladder dysfunction (suggesting malignancy, infection, or spinal pathology)
Impact on function:
- Activities of daily living, work, relationships, mental health (stress, anxiety, depression)
Past medical history:
- Previous injuries, autoimmune conditions (e.g., rheumatoid arthritis), fibromyalgia, metabolic conditions (diabetes, hypothyroidism)
Medications & previous treatments:
- Analgesia, NSAIDs, antidepressants, physiotherapy, alternative therapies
Psychosocial factors:
- Stress, sleep disturbances, mood disorders, coping strategies

2. Examination

General appearance: Look for fatigue, distress, mobility difficulties
Musculoskeletal exam:
- Palpation for tenderness, joint swelling, range of motion
- Tender points vs. trigger points (fibromyalgia vs. myofascial pain syndrome)
- Strength, reflexes, gait analysis
Neurological exam:
- Reflexes, sensation, muscle tone (rule out radiculopathy, neuropathy)

A thorough history and examination help differentiate between mechanical, inflammatory, neuropathic, and functional pain.

SUMMARY OF A COMPETENT ANSWER

Characterises the pain thoroughly, including red flag symptoms.
Assesses functional impact and psychosocial factors affecting pain perception.
Performs a focused musculoskeletal and neurological examination.
Differentiates between fibromyalgia, inflammatory, mechanical, and neuropathic pain.

PITFALLS

Failing to screen for red flags, missing serious underlying pathology.
Overlooking psychological and social contributors to chronic pain.
Relying solely on imaging without clinical correlation.
Not considering neuropathic pain mechanisms, leading to ineffective treatment.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

2. Clinical Information Gathering and Interpretation

2.1 Conducts a thorough pain history and musculoskeletal examination.
2.3 Identifies risk factors for chronic pain syndromes.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD