EXAMINER ONLY INFORMATION

QUESTIONS

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

• Prompt: How do you differentiate between medication-related, inflammatory, and metabolic 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 John?

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

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

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

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

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

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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

A structured approach is required to differentiate between medication-induced, inflammatory, metabolic, and serious causes of myalgia.

• Medication-Induced Myopathy (Most Likely in This Case):
  • Statin-induced myopathy – Symmetric proximal muscle pain, without significant weakness.
  • Statin-induced myositis or rhabdomyolysis – Severe myalgia, dark urine, marked CK elevation.
• Inflammatory and Autoimmune Causes:
  • Polymyalgia rheumatica – Age >50, morning stiffness, elevated ESR/CRP.
  • Inflammatory myopathies (e.g., polymyositis, dermatomyositis) – Progressive muscle weakness, systemic symptoms, rash.
• Metabolic and Endocrine Causes:
  • Hypothyroid myopathy – Proximal muscle weakness, fatigue, cold intolerance.
  • Electrolyte disturbances (low potassium, calcium, magnesium) – Cramping, weakness.
• Serious Causes (Red Flags to Exclude):
  • Rhabdomyolysis – Marked CK elevation, renal dysfunction, dark urine.
  • Neurological disorders (e.g., motor neurone disease, myasthenia gravis) – Progressive weakness, fasciculations, reflex abnormalities.

A competent candidate prioritises statin-related myopathy but screens for red flags indicating serious pathology.

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

• Further History:
  • Medication history: Duration of statin use, recent dose changes, other lipid-lowering agents (e.g., fibrates, niacin, grapefruit juice interaction).
  • Onset and progression: Gradual vs sudden, worsening with activity.
  • Neurological symptoms: Numbness, weakness, gait disturbance.
  • Systemic symptoms: Fever, weight loss, joint pain.
• Investigations:
  • Creatine Kinase (CK) – Elevated in statin-induced myopathy, inflammatory myopathies, and rhabdomyolysis.
  • Liver Function Tests (LFTs) – Elevated ALT/AST may indicate statin hepatotoxicity.
  • Thyroid Function Tests (TFTs) – Hypothyroidism can mimic statin myopathy.
  • Renal Function (U&E, eGFR) – Assess for rhabdomyolysis-associated kidney injury.
  • Inflammatory markers (ESR, CRP) – Elevated in inflammatory myopathies and polymyalgia rheumatica.

A competent candidate gathers a focused history and orders relevant investigations to confirm or exclude differential diagnoses.

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

1. Acknowledge concerns:
   • “I understand that persistent muscle pain can be frustrating, and you’re wondering if your statin could be the cause.”
2. Explain likely cause:
   • “Your symptoms are consistent with statin-induced myopathy, which can occur in some people taking cholesterol-lowering medication.”
3. Discuss next steps:
   • “We will check your muscle enzyme levels (CK) and assess for any other potential causes.”
   • “In the meantime, I recommend stopping your statin temporarily for 2–4 weeks to see if your symptoms improve.”
4. Provide reassurance and safety-netting:
   • “Most cases resolve within weeks after stopping the medication, but if symptoms persist or worsen, we may need further tests or specialist referral.”

A competent candidate provides clear explanations, reassures the patient, and ensures appropriate next steps are taken.

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

1. Statin Discontinuation and Monitoring:
   • Stop atorvastatin for 2–4 weeks and reassess symptoms.
   • If symptoms improve, consider lower-dose statin or alternative therapy.
2. Alternative Lipid-Lowering Strategies:
   • Switch to a different statin (e.g., pravastatin or rosuvastatin, which have lower muscle toxicity).
   • Non-statin therapy (ezetimibe, PCSK9 inhibitors) if statins are not tolerated.
3. Lifestyle and Cardiovascular Risk Management:
   • DASH or Mediterranean diet – Encourages plant-based, heart-healthy eating.
   • Regular exercise – Avoiding excessive exertion until symptoms resolve.
   • Weight loss and smoking cessation if applicable.
4. Follow-Up and Referral:
   • Review in 4 weeks with repeat CK if necessary.
   • Refer to neurology or rheumatology if symptoms persist despite stopping statin.

A competent candidate ensures a structured management plan, including medication review and alternative lipid-lowering options.

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

1. Minimising Medication Risks:
   • Start with the lowest effective dose when reintroducing statins.
   • Avoid drug interactions (e.g., fibrates, grapefruit juice).
2. Lifestyle Modifications for Cardiovascular Risk Reduction:
   • Optimised diet (Mediterranean/DASH diet).
   • Regular physical activity (moderate-intensity, 150 min/week).
   • Blood pressure and glucose monitoring.
3. Ongoing Monitoring and Review:
   • Routine cholesterol checks every 6–12 months.
   • Regular cardiovascular risk assessments.

A competent candidate integrates lifestyle strategies with safe medication use to optimise long-term cardiovascular health.

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SUMMARY OF A COMPETENT ANSWER

• Recognises statin-induced myopathy as the most likely diagnosis, while screening for inflammatory and metabolic causes.
• Orders appropriate investigations, including CK, LFTs, TFTs, and renal function tests.
• Clearly explains the diagnosis and next steps, addressing the patient’s concerns.
• Implements an evidence-based management plan, including statin withdrawal, alternative lipid-lowering options, and lifestyle modifications.
• Provides preventive health strategies, ensuring ongoing cardiovascular risk reduction and safe medication use.

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PITFALLS

• Failing to consider alternative causes, such as inflammatory myopathies or metabolic disorders.
• Not ordering CK, missing rhabdomyolysis or underlying muscle pathology.
• Stopping statins without alternative lipid management, leading to increased cardiovascular risk.
• Neglecting patient concerns, resulting in poor adherence to future medication recommendations.
• Not providing follow-up, leading to delayed recognition of ongoing pathology.

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REFERENCES

• RACGP – RACGP Guidelines on Anticoagulation Management
• GP Exams – Complication of medical treatment

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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