EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for Sarah’s muscle pain?

• Prompt: How do you differentiate between medication-related, inflammatory, and systemic causes?
• Prompt: What red flags would prompt urgent investigation?

Q2. What further history and investigations would be useful in this case?

• Prompt: What risk factors would you assess?
• Prompt: What laboratory tests would confirm or rule out potential causes?

Q3. How would you explain the diagnosis and next steps to Sarah?

• Prompt: How do you discuss the possibility of statin-induced myopathy?
• Prompt: What are the next steps in adjusting her management?

Q4. Outline your management plan for Sarah’s myalgia.

• Prompt: When would you stop or switch her statin?
• Prompt: What are the alternative treatment options for her hypercholesterolaemia?

Q5. What are the key preventive health strategies for Sarah moving forward?

• Prompt: How can she minimise the risk of medication side effects?
• Prompt: What lifestyle interventions would support her cardiovascular health?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for Sarah’s muscle pain?

A structured differential diagnosis is crucial to differentiate common vs serious causes of muscle pain (myalgia).

• Medication-Induced Myopathy:
  • Statin-induced myopathy – Muscle pain and weakness, usually symmetrical, onset weeks to months after starting statins.
  • Hypothyroid myopathy – Proximal muscle weakness, fatigue, cold intolerance, weight gain.
• Inflammatory and Autoimmune Myopathies (Red flags):
  • Polymyalgia rheumatica – Proximal muscle pain and stiffness, worse in the morning, age >50, raised ESR/CRP.
  • Inflammatory myopathies (e.g., polymyositis, dermatomyositis) – Progressive muscle weakness, systemic features (rash, dysphagia).
• Metabolic and Infectious Causes:
  • Rhabdomyolysis – Severe muscle pain, dark urine, recent trauma/exertion, CK elevation.
  • Viral myositis – Post-viral myalgia, self-limiting.
• Other Causes:
  • Fibromyalgia – Chronic widespread pain, fatigue, tender points, normal inflammatory markers.
  • Vitamin D deficiency – Generalised muscle aches, often with fatigue and bone pain.

A competent candidate considers medication effects first, ruling out inflammatory or metabolic causes if symptoms persist.

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Q2: What further history and investigations would be useful in this case?

• Further History:
  • Medication use: When did she start atorvastatin? Any recent dose increase?
  • Morning stiffness: Prolonged stiffness suggests inflammatory conditions.
  • Systemic symptoms: Fever, rash, weight loss (inflammatory myopathy, malignancy).
  • Family history: Autoimmune conditions (e.g., rheumatoid arthritis, lupus).
  • Physical activity and trauma: Overuse injury, recent unaccustomed exercise.
• Investigations:
  • Creatine kinase (CK) – Elevated in statin myopathy, rhabdomyolysis, inflammatory myositis.
  • Thyroid function tests (TFTs) – To rule out hypothyroid myopathy.
  • ESR/CRP – Raised in polymyalgia rheumatica, inflammatory myopathies.
  • Vitamin D levels – Deficiency can cause myalgia.
  • Autoimmune markers (ANA, anti-Jo-1, RF) – If inflammatory myopathy suspected.

A competent candidate tailors investigations based on clinical suspicion, ensuring efficient and targeted testing.

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Q3: How would you explain the diagnosis and next steps to Sarah?

1. Acknowledge concerns:
   • “I understand that persistent muscle pain can be concerning, especially when it affects daily life.”
2. Explain likely cause:
   • “One possible explanation is that your statin medication could be contributing to muscle pain. This can happen in some people.”
   • “We also need to rule out other conditions, such as thyroid issues or vitamin deficiencies.”
3. Discuss next steps:
   • “We will do blood tests to check your muscle enzymes (CK), thyroid function, and inflammatory markers.”
   • “If this is statin-related, we may need to pause or switch your medication.”
4. Provide reassurance:
   • “Statin-induced muscle pain usually improves after stopping the medication.”
   • “If tests suggest another cause, we will tailor your treatment accordingly.”

A competent candidate communicates clearly, reassures appropriately, and ensures shared decision-making.

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Q4: Outline your management plan for Sarah’s myalgia.

1. Medication Review:
   • Temporarily stop atorvastatin for 2-4 weeks and assess symptom improvement.
   • If symptoms resolve, consider:
     • Lower dose statin or
     • Alternative lipid-lowering therapy (e.g., ezetimibe, PCSK9 inhibitors).
2. Address Other Potential Causes:
   • If hypothyroidism present, adjust thyroxine dose.
   • If vitamin D deficiency, initiate supplementation.
3. Symptom Management:
   • Paracetamol or NSAIDs for pain relief (short-term).
   • Regular low-impact exercise (e.g., stretching, swimming).
4. Follow-up Plan:
   • Review in 4 weeks to reassess symptoms.
   • If symptoms persist despite stopping statin, refer to a rheumatologist or neurologist.

A competent candidate balances medication review with symptom relief and appropriate follow-up.

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Q5: What are the key preventive health strategies for Sarah moving forward?

1. Lipid Management Alternatives:
   • Consider ezetimibe or PCSK9 inhibitors if statins are not tolerated.
   • Dietary modifications (Mediterranean diet) to support cholesterol reduction.
2. Exercise and Lifestyle Advice:
   • Maintain regular physical activity, avoiding excessive strain.
   • Adequate hydration and stretching to prevent muscle fatigue.
3. Monitoring and Preventative Care:
   • Regular cardiovascular risk assessment (BP, lipids, glucose).
   • Ongoing thyroid function monitoring if on thyroxine.
   • Routine vaccinations and preventive health checks.

A competent candidate ensures long-term cardiovascular and musculoskeletal health, supporting medication adherence and lifestyle changes.

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SUMMARY OF A COMPETENT ANSWER

• Recognises statin-induced myopathy as a likely cause while considering inflammatory, metabolic, and autoimmune conditions.
• Orders targeted investigations, including CK, TFTs, ESR/CRP, and vitamin D.
• Communicates clearly and empathetically, ensuring shared decision-making.
• Implements appropriate medication review, pausing statins and considering alternatives.
• Provides preventive strategies, including long-term cardiovascular risk reduction and lifestyle modifications.

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PITFALLS

• Failing to recognise statin-induced myopathy, leading to unnecessary referrals or prolonged symptoms.
• Over-investigating without clinical justification, causing patient anxiety and increased costs.
• Not addressing the patient’s concerns adequately, leading to poor adherence to medical advice.
• Discontinuing statins permanently without alternative lipid-lowering strategies, increasing cardiovascular risk.
• Neglecting preventive measures, missing an opportunity to optimise overall health.

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REFERENCES

• RACGP – RACGP Guidelines on Muscle Pain Assessment
• GP Exams – Pain, muscle

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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

1. Communication and Consultation Skills

1.1 Communicates effectively and appropriately to provide quality care.
1.3 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information effectively.
2.3 Identifies red flags and important diagnostic features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Applies a structured approach to making a diagnosis.
3.3 Identifies and manages urgent and serious conditions.

Competency at Fellowship Level

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