CCE-CBD-210 - GP Exams

CASE INFORMATION

Case ID: FM-001
Case Name: Anna Williams
Age: 42 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: L18 (Fibromyalgia)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes a supportive, empathetic approach to chronic pain 1.2 Uses clear, patient-centred explanations of fibromyalgia 1.3 Addresses patient concerns and expectations regarding diagnosis and management
2. Clinical Information Gathering and Interpretation	2.1 Takes a comprehensive history of widespread pain, fatigue, and associated symptoms 2.2 Conducts a targeted musculoskeletal and neurological examination 2.3 Recognises features that differentiate fibromyalgia from other conditions
3. Diagnosis, Decision-Making and Reasoning	3.1 Applies the 2016 ACR criteria for fibromyalgia diagnosis 3.2 Differentiates fibromyalgia from inflammatory, neurological, and psychiatric conditions 3.3 Recognises potential comorbidities such as depression, IBS, and sleep disturbances
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an individualised, multidisciplinary management plan 4.2 Explains pharmacological and non-pharmacological treatment options 4.3 Sets realistic expectations for symptom control and long-term self-management
5. Preventive and Population Health	5.1 Promotes regular physical activity and lifestyle modifications 5.2 Screens for mental health concerns and sleep disturbances
6. Professionalism	6.1 Demonstrates compassion and validation of the patient’s symptoms
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate referrals (e.g., physiotherapy, psychology, pain clinic) 7.2 Provides structured follow-up and support for chronic condition management
9. Managing Uncertainty	9.1 Recognises the lack of definitive diagnostic tests and the need for a clinical diagnosis
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and manages comorbid chronic pain syndromes and mental health conditions

CASE FEATURES

Middle-aged woman presenting with chronic widespread pain, fatigue, and cognitive difficulties (“fibro fog”).
Excludes red flags for inflammatory or neurological conditions.
Discussion around non-pharmacological vs pharmacological treatments.
Long-term self-management and multidisciplinary care approach.

CANDIDATE INFORMATION

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: Anna Williams
Age: 42 years
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Paracetamol PRN for pain
Sertraline 50 mg daily (for anxiety and mild depression)
Melatonin 2 mg nightly (for sleep disturbances)

Past History

Chronic widespread musculoskeletal pain for the past 2 years.
Fatigue and cognitive difficulties (“brain fog”) affecting daily function.
No history of inflammatory arthritis or autoimmune disease.
No significant neurological conditions.

Social History

Works part-time as a teacher but struggles with fatigue.
Single mother of two children (ages 10 and 12).
Moderate physical activity, reports exercise worsens pain.
No smoking, alcohol occasional (1-2 drinks per week).

Family History

Mother has rheumatoid arthritis.
No family history of fibromyalgia.

Vaccination and Preventative Activities

Up to date with routine health checks.
No previous screening for diabetes or thyroid disease.

SCENARIO

Anna, a 42-year-old teacher, presents with chronic widespread pain, fatigue, and cognitive issues. She reports aching muscles, stiffness in the morning, poor sleep quality, and difficulties concentrating. She describes tenderness in multiple areas, including the neck, shoulders, back, and thighs.

She has seen multiple doctors and was previously tested for rheumatoid arthritis and lupus, with normal results. She is frustrated, as some doctors dismissed her symptoms as stress-related. She wants to know if she has fibromyalgia and what can be done to manage it.

Your role is to assess Anna’s symptoms, confirm the diagnosis, discuss management options, and provide long-term self-management strategies.

EXAMINATION FINDINGS

General Appearance: Well-groomed but appears fatigued
Vital Signs: Normal
Musculoskeletal Examination:

Tenderness over soft tissues at multiple points (neck, shoulders, back, hips, and thighs).
No joint swelling, erythema, or deformity.
Full range of motion in all joints.

Neurological Examination:

Normal power, sensation, and reflexes.
No focal neurological deficits.

Mental Health Screening:

Mildly anxious, no signs of major depression.
PHQ-9 score: 5 (mild depressive symptoms).

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess Anna to confirm a diagnosis of fibromyalgia?

Prompt: What diagnostic criteria apply?
Prompt: How would you differentiate fibromyalgia from other conditions?

Q2. What investigations would you consider, and why?

Prompt: What conditions should be ruled out?
Prompt: How do you ensure appropriate but not excessive testing?

Q3. What management options would you discuss with Anna?

Prompt: What lifestyle modifications and non-pharmacological treatments are effective?
Prompt: What pharmacological options can be considered?

Q4. How would you counsel Anna about the long-term nature of fibromyalgia and realistic expectations?

Prompt: How do you validate her symptoms while setting realistic goals?
Prompt: What strategies can help her manage work and daily activities?

Q5. What long-term follow-up and referral strategies would you recommend?

Prompt: What multidisciplinary support can be beneficial?
Prompt: How often should she be reviewed?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess Anna to confirm a diagnosis of fibromyalgia?

1. History-Taking

Widespread pain lasting >3 months: Symmetrical, involving axial skeleton and limbs.
Fatigue and cognitive symptoms (“fibro fog”): Difficulty concentrating, unrefreshing sleep.
Psychological comorbidities: Depression, anxiety.
Exacerbating factors: Stress, cold weather, physical activity.
Rule out inflammatory or autoimmune conditions: Morning stiffness, fever, rashes, joint swelling.
Functional impact: Work limitations, social withdrawal.

2. Application of 2016 ACR Criteria for Fibromyalgia

Widespread Pain Index (WPI) ≥7 and Symptom Severity (SS) Scale score ≥5.
No other identifiable disorder explaining symptoms.

3. Differentiating from Other Conditions

Rheumatoid arthritis/SLE: Absence of joint swelling, inflammatory markers.
Hypothyroidism: Absence of weight gain, cold intolerance.
Myofascial pain syndrome: Localised trigger points rather than widespread pain.

Conclusion: Anna’s symptoms fulfil ACR criteria for fibromyalgia, supported by a negative inflammatory and neurological examination.

Q2: What investigations would you consider, and why?

1. Blood Tests to Exclude Differential Diagnoses

FBC, CRP, ESR: Rule out inflammatory conditions.
TSH, T4: Exclude hypothyroidism.
Vitamin D, iron studies: Assess for deficiencies.
CK: Rule out myopathy.

2. Imaging (Only if Red Flags Present)

X-ray or MRI if neurological signs or persistent localised pain.

3. Avoid Unnecessary Testing

No specific test confirms fibromyalgia.
Minimise excessive investigations to prevent medical anxiety.

Conclusion: Fibromyalgia remains a clinical diagnosis, with investigations aimed at ruling out mimics.

Q3: What management options would you discuss with Anna?

1. Non-Pharmacological Strategies (First-Line)

Regular exercise (graded activity, low-impact e.g., swimming, yoga).
Cognitive-behavioural therapy (CBT) for pain coping.
Sleep hygiene strategies.

2. Pharmacological Treatment (If Non-Pharmacological Measures Inadequate)

Amitriptyline (low-dose) or duloxetine.
Pregabalin or gabapentin for neuropathic pain.
Paracetamol may be used, but avoid opioids and NSAIDs.

3. Multidisciplinary Support

Referral to physiotherapy, pain clinic, psychology.

Conclusion: Holistic, multimodal approach with emphasis on non-pharmacological strategies.

Q4: How would you counsel Anna about the long-term nature of fibromyalgia and realistic expectations?

1. Validating Symptoms

Acknowledge her distress: “Fibromyalgia is real and affects many aspects of life.”
Explain the central sensitisation theory: Pain perception is altered, rather than tissue damage.

2. Setting Realistic Goals

Emphasise symptom management rather than cure.
Small, gradual improvements in function and pain tolerance expected.

3. Lifestyle and Coping Strategies

Identify triggers and pacing activities.
Encourage self-management tools (journals, relaxation techniques).

Conclusion: A patient-centred approach with an emphasis on empowerment and realistic expectations.

Q5: What long-term follow-up and referral strategies would you recommend?

1. Regular GP Reviews

Monitor symptom progression and treatment efficacy.
Screen for depression, anxiety, and medication side effects.

2. Allied Health Involvement

Physiotherapy for movement therapy.
Psychologist for CBT and pain coping mechanisms.
Pain specialist referral if severe, refractory pain.

3. Support Networks

Encourage support groups and online resources.
Provide educational materials on fibromyalgia management.

Conclusion: A multidisciplinary approach is essential for optimising long-term outcomes.

SUMMARY OF A COMPETENT ANSWER

Uses 2016 ACR criteria to diagnose fibromyalgia clinically.
Orders only necessary investigations to rule out mimics.
Emphasises non-pharmacological management as first-line.
Sets realistic expectations for long-term self-management.
Implements a multidisciplinary care plan with allied health involvement.

PITFALLS

Over-reliance on investigations despite fibromyalgia being a clinical diagnosis.
Failure to validate symptoms, leading to frustration and poor doctor-patient rapport.
Prescribing opioids or NSAIDs, which are ineffective and may lead to dependency.
Neglecting the psychological and lifestyle aspects of management.
Not screening for comorbidities such as depression and sleep disturbances.

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

Competency at Fellowship Level

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