EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Andrew’s muscle symptoms?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What alternative conditions should be considered?

Q2. What red flags would indicate the need for urgent referral or further investigations?

• Prompt: What features would suggest a serious neuromuscular disorder?
• Prompt: What initial investigations would you consider?

Q3. How would you manage Andrew’s condition?

• Prompt: What lifestyle and medication changes would you recommend?
• Prompt: When would you consider referral to a specialist?

Q4. Andrew is concerned about having a serious muscle disease. How would you counsel him?

• Prompt: How would you provide reassurance while ensuring appropriate follow-up?
• Prompt: What support services or resources could you offer?

Q5. What preventive strategies can Andrew implement to reduce his risk of further muscle symptoms?

• Prompt: How can he modify his lifestyle and medications to prevent recurrence?
• Prompt: What role does exercise and dietary management play?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Andrew’s muscle symptoms?

Andrew’s most likely diagnosis is statin-induced myopathy, given his proximal muscle weakness, history of atorvastatin use, and absence of neurological symptoms.

Key Differential Diagnoses:

1. Statin-Induced Myopathy (Most Likely) – Symmetric muscle pain and weakness, proximal limb involvement, with possible elevated CK.
2. Polymyalgia Rheumatica (PMR) – Common in >50 years, presents with morning stiffness and proximal pain, often with elevated ESR/CRP.
3. Inflammatory Myositis (Polymyositis/Dermatomyositis) – Progressive weakness, possible skin rashes (in dermatomyositis), elevated CK/ANA/Mi-2 antibodies.
4. Hypothyroid Myopathy – Fatigue, cold intolerance, bradycardia, with elevated TSH.
5. Diabetic Neuropathy/Myopathy – Progressive weakness with sensory loss, usually distal involvement.

Further assessment, including blood tests (CK, TSH, inflammatory markers, and metabolic panel), is required to confirm the diagnosis.

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Q2: What red flags would indicate the need for urgent referral or further investigations?

Red flags requiring urgent referral or investigation:

• Severe muscle pain, dark urine (concern for rhabdomyolysis).
• Rapidly progressive weakness, difficulty swallowing or breathing (concern for neuromuscular disorders or myositis).
• Neurological signs (e.g., sensory loss, fasciculations, asymmetry) suggesting neuropathy or motor neuron disease.
• Unexplained weight loss or systemic symptoms (concern for malignancy-related myopathy).

Recommended Investigations:

• Creatine Kinase (CK) – Elevated in statin myopathy, myositis, and rhabdomyolysis.
• TSH & Free T4 – Rule out hypothyroid myopathy.
• ESR/CRP – Elevated in PMR, inflammatory myositis.
• Electromyography (EMG) or MRI – If neuromuscular disease suspected.
• Autoimmune Panel (ANA, Anti-Mi-2, Anti-Jo-1) – If inflammatory myositis suspected.

If rhabdomyolysis or myositis is suspected, urgent hospital referral is required.

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Q3: How would you manage Andrew’s condition?

1. Immediate Steps:

• Cease atorvastatin and reassess symptoms in 2–4 weeks.
• Encourage hydration if mild myopathy, monitor for dark urine (rhabdomyolysis risk).

2. Pharmacological Management:

• Consider switching to lower-dose statin or alternative lipid-lowering therapy (e.g., ezetimibe) if dyslipidaemia persists.
• NSAIDs or paracetamol for symptom relief, if needed.

3. Lifestyle Modifications:

• Weight reduction and dietary changes to improve metabolic health.
• Regular, low-impact exercise to improve muscle strength.

4. Follow-Up and Specialist Referral:

• Review in 4 weeks, recheck CK and symptoms.
• If symptoms persist despite statin withdrawal, refer to neurology/rheumatology for further assessment.

Management should focus on minimising cardiovascular risk while balancing muscle health.

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Q4: Andrew is concerned about having a serious muscle disease. How would you counsel him?

1. Acknowledge and Address Concerns
   • “It’s understandable to be worried, but most cases of muscle pain with statins resolve after stopping the medication.”
2. Explain the Likely Diagnosis
   • “Your symptoms are consistent with statin-induced myopathy, which is common and usually reversible.”
3. Discuss Next Steps and Monitoring
   • “We will stop your statin, monitor your symptoms, and consider an alternative approach if needed.”
   • “If your symptoms don’t improve, we will do further testing to rule out other conditions.”
4. Provide Reassurance and Follow-Up Plan
   • “I will review you in 4 weeks to assess progress and adjust your treatment plan if needed.”

Empathetic communication ensures patient engagement and reduces anxiety.

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Q5: What preventive strategies can Andrew implement to reduce his risk of further muscle symptoms?

1. Optimising Medication Use:
   • Use lowest effective dose of statins to reduce risk.
   • Consider non-statin alternatives (ezetimibe, PCSK9 inhibitors).
2. Lifestyle Modifications:
   • Reduce alcohol intake (6–8 drinks/week is above recommended limits).
   • Increase physical activity with low-impact resistance training.
   • Weight loss (target BMI <25).
3. Regular Health Monitoring:
   • Routine CK monitoring if symptoms recur with statin reintroduction.
   • Annual cardiovascular risk assessment.
4. Dietary Considerations:
   • Increase omega-3 intake (fish, nuts, flaxseeds).
   • Reduce processed food and sugar intake to improve metabolic health.

Long-term muscle health depends on optimised statin use, lifestyle changes, and regular monitoring.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, considering statin myopathy, myositis, endocrine causes, and neuromuscular disorders.
• Identification of red flags, ensuring urgent investigations if needed.
• Structured evidence-based management plan, including statin withdrawal, symptom monitoring, and alternative lipid-lowering therapy.
• Clear patient-centred counselling, addressing concerns about muscle disease and ensuring follow-up.
• Preventive strategies, including lifestyle changes, medication review, and exercise guidance.

PITFALLS

• Failing to assess for serious conditions, missing rhabdomyolysis, inflammatory myositis, or neuropathy.
• Continuing statin therapy despite clear symptoms, leading to progression of muscle damage.
• Overlooking lifestyle factors, such as alcohol use, diet, and weight.
• Not considering alternative lipid-lowering options, leading to poor cardiovascular risk management.
• Lack of structured follow-up, missing progression of symptoms or treatment failure.

REFERENCES

• 
  RACGP – RACGP Guidelines for Managing muscle pain in primary care
• GP Exams – Muscle symptom/complaint NOS

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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 Takes a detailed history to assess muscle symptoms and functional impact.
1.2 Provides clear explanations of the diagnosis, investigations, and next steps.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a systematic musculoskeletal and neurological examination.
2.2 Identifies red flags requiring urgent referral.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common muscle complaints.
3.2 Determines when further investigations are warranted.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate management plan, including lifestyle, pharmacological, and referral options.
4.2 Ensures treatment is aligned with best-practice guidelines.

5. Preventive and Population Health

5.1 Provides education on risk factors for muscle conditions and preventive strategies.

6. Professionalism

6.1 Acknowledges patient concerns and maintains a patient-centred approach.

Competency at Fellowship Level

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