CCE-CE-099

CASE INFORMATION

Case ID: CCE-2025-07
Case Name: Michael Anderson
Age: 42
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L18 (Muscle pain)

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Establishes rapport and engages with the patient empathetically.
1.2 Uses clear, patient-centred language to explore symptoms and concerns.
1.4 Elicits the patient’s ideas, concerns, and expectations.
2. Clinical Information Gathering and Interpretation2.1 Takes a structured musculoskeletal pain history, identifying red flags.
2.2 Assesses differentials for muscle pain, including trauma, myopathy, and systemic causes.
2.3 Identifies risk factors for myositis, statin-induced myopathy, and fibromyalgia.
3. Diagnosis, Decision-Making and Reasoning3.1 Differentiates between localised vs. generalised muscle pain.
3.3 Determines when further investigations (blood tests, imaging, referral) are required.
4. Clinical Management and Therapeutic Reasoning4.1 Develops an appropriate acute and long-term management plan.
4.3 Provides patient-centred education on lifestyle modifications, exercise, and medication use.
4.5 Recognises when referral to a rheumatologist or neurologist is warranted.
5. Preventive and Population Health5.2 Discusses workplace ergonomics, injury prevention, and medication review.
6. Professionalism6.1 Ensures empathetic and non-judgemental communication.
7. General Practice Systems and Regulatory Requirements7.2 Follows appropriate guidelines for chronic pain management and prescribing.
9. Managing Uncertainty9.1 Recognises when further workup vs. reassurance is required.
10. Identifying and Managing the Patient with Significant Illness10.1 Recognises serious systemic conditions causing muscle pain (e.g., polymyositis, rhabdomyolysis).

CASE FEATURES

  • Middle-aged man with persistent muscle pain of uncertain cause.
  • Distinguishing between mechanical, inflammatory, metabolic, and medication-related causes.
  • Assessing for red flags that may indicate a systemic condition.
  • Balancing reassurance with appropriate investigations and follow-up.
  • Addressing patient concerns about chronic pain and disability.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

  1. Take an appropriate history.
  2. Outline the differential diagnosis and key investigations required.
  3. Address the patient’s concerns.
  4. Develop a safe and patient-centred management plan.

SCENARIO

Michael Anderson, a 42-year-old construction worker, presents with widespread muscle aches and stiffness over the past three months. The pain is worse in the morning and after physical activity, but he does not recall any specific injury. He describes feeling more fatigued than usual and has occasional joint pain in his knees and shoulders.

He is concerned that this could be something serious, as his work performance is declining due to fatigue and pain.

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Anderson
Age: 42
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Atorvastatin 40 mg OD (for hyperlipidaemia)

Past History

  • Hyperlipidaemia (on statin therapy for 2 years)
  • Mild osteoarthritis of the knees

Family History

  • Father had type 2 diabetes and hypertension
  • No known family history of autoimmune disease or muscle disorders

Smoking and Alcohol

  • Non-smoker
  • Drinks alcohol socially (1–2 drinks per week)

Vaccination and Preventative Activities

  • Routine vaccinations up to date

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, I’ve been having muscle aches all over my body for the last few months, and I don’t know why. It’s making work really hard.”

General Information

You are Michael Anderson, a 42-year-old construction worker. You’ve always been active and strong, but over the past three months, you’ve been experiencing persistent muscle pain and stiffness.

The pain isn’t sharp or localised, but rather a general ache that affects your arms, legs, shoulders, and back. It’s worst in the mornings, making it hard to get out of bed and start moving. It eases slightly as the day goes on, but by the evening, after a full day of work, you feel exhausted and sore again.

Specific Information

(Revealed When Asked)

Background Information

You haven’t had any injuries or accidents. At first, you thought it was just normal wear and tear from physical work, but it hasn’t gone away. It’s getting worse, and you wake up feeling more tired than usual.

You are worried this could be something serious, like an autoimmune disease or a nerve problem. You don’t want to end up unable to work, especially since you support your family financially.

Pain Characteristics:

  • Dull, aching muscle pain in legs, arms, shoulders, and back.
  • Worse in the mornings and after work.
  • No sharp, shooting, or stabbing pain.
  • No swelling, redness, or heat in the muscles.
  • No numbness or tingling.

Associated Symptoms:

  • Fatigue—you feel more exhausted than usual, even after a full night’s sleep.
  • Occasional joint pain in knees and shoulders, but not severe.
  • No fever, night sweats, or unexplained weight loss.
  • No muscle weakness—you can still lift and carry things but feel more tired and sore afterwards.
  • No difficulty swallowing or breathing.

Medical History and Risk Factors:

  • Hyperlipidaemia—on atorvastatin 40 mg OD for 2 years.
  • Mild osteoarthritis in both knees.
  • No history of autoimmune disease, thyroid problems, or recent infections.
  • No recent change in diet, exercise, or work routine.

Social History:

  • Non-smoker, drinks 1–2 alcoholic drinks per week.
  • Works full-time in construction, does heavy lifting and long hours.
  • Lives with wife and two young children.

Emotional Cues and Body Language

  • Concerned but not overly anxious—you just want a clear answer.
  • You become more worried if the doctor mentions autoimmune diseases.
  • If the doctor dismisses it as ‘just work soreness’, you get frustrated.
  • If the doctor explains things well, you feel reassured but will still ask for tests.

Patient Concerns and Questions

1. “Why am I getting this muscle pain everywhere?”

  • You want a clear explanation—is this something normal, or a disease?

2. “Could this be something serious like an autoimmune disease?”

  • You are worried about long-term disability and whether this will affect your ability to work.

3. “Is my medication causing this?”

  • You read online that statins can cause muscle pain and wonder if this is the cause.
  • If the doctor suggests stopping the statin, you will ask, “Will that put me at risk for heart problems?”

4. “Will I be able to keep working?”

  • You are worried about how this will affect your job and your ability to provide for your family.

5. “What tests do I need?”

  • You expect blood tests or scans to rule out serious conditions.
  • If the doctor does not suggest tests, you might say, “But how do we know for sure?”

Possible Reactions Based on the Doctor’s Approach

If the doctor reassures you and explains things well:

  • You feel more at ease and are open to lifestyle changes or a medication review.
  • You agree to monitoring and follow-up if it makes sense to you.
  • You may say, “Alright, I’ll try that and see if things improve.”

If the doctor dismisses your symptoms as ‘just normal muscle soreness’:

  • You become frustrated and push for further tests.
  • You might say, “But this has been going on for months. Shouldn’t we check my blood or something?”

If the doctor focuses too much on stress or mental health as a cause:

  • You feel misunderstood because you don’t feel anxious or depressed.
  • You might say, “This doesn’t feel like stress—it feels like something is wrong with my muscles.”

If the doctor explains statin-related muscle pain but doesn’t suggest what to do next:

  • You might ask, “So should I stop taking my medication, or is there another option?”

Your Expectations from This Consultation

  • You want a clear diagnosis or at least a logical explanation for the pain.
  • You need to know whether you should be worried about a serious condition.
  • You expect some form of investigation—you don’t want to leave without a plan.
  • You want to know what you can do to improve your symptoms.
  • You don’t want to be dismissed as just overworked.

End of Consultation Cues

  • If the doctor provides a clear explanation and plan, you feel relieved and reassured.
  • If the doctor brushes off your concerns, you push for tests.
  • If the doctor suggests a trial of stopping statins, you want clear follow-up instructions.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including pain characteristics, risk factors, and concerns.

The competent candidate should:

  • Elicit a detailed history of muscle pain, including:
    • Onset, duration, and progression (acute vs. chronic, episodic vs. persistent).
    • Location (localised vs. generalised).
    • Nature of pain (aching, stiffness, cramping, weakness).
    • Aggravating and relieving factors (exercise, rest, medications, temperature).
  • Assess associated symptoms:
    • Fatigue, joint pain, morning stiffness, weakness (suggests inflammatory or systemic causes).
    • Swelling, redness, or tenderness (suggests inflammatory or infectious causes).
    • Fever, weight loss, rash, or difficulty swallowing (red flags for systemic disease).
  • Review past medical history and risk factors, including:
    • Medication history, particularly statins, corticosteroids, or fluoroquinolones.
    • Family history of autoimmune or neuromuscular disorders.
    • Lifestyle factors, including exercise, physical activity, occupational risks.
  • Explore patient concerns and expectations, including:
    • “What are you most worried this might be?”
    • “How has this pain affected your daily life and work?”
    • “What would you like to achieve from today’s visit?”

Task 2: Formulate a differential diagnosis, distinguishing between mechanical, inflammatory, metabolic, and medication-related causes.

The competent candidate should:

  • Differentiate between key causes of muscle pain:
    • Mechanical:
      • Overuse or strain – recent activity, improves with rest.
      • Fibromyalgia – widespread pain, fatigue, sleep disturbances.
    • Inflammatory/autoimmune:
      • Polymyalgia rheumatica – >50 years old, morning stiffness, raised inflammatory markers.
      • Polymyositis/Dermatomyositis – proximal weakness, skin rash, raised CK.
    • Metabolic and endocrine:
      • Hypothyroidism – generalised muscle pain, fatigue, weight gain.
      • Vitamin D deficiency – diffuse musculoskeletal pain, weakness.
    • Medication-induced:
      • Statin-induced myopathy – bilateral muscle pain, resolves on cessation.
      • Corticosteroids or fluoroquinolones – can cause muscle damage.
  • Determine need for investigations, including:
    • Blood tests (CK, ESR/CRP, thyroid function, vitamin D, renal/liver function).
    • EMG or muscle biopsy (if neuromuscular disease suspected).

Task 3: Explain the likely diagnosis to the patient, addressing concerns empathetically.

The competent candidate should:

  • Acknowledge patient concerns:
    • “I understand that persistent muscle pain can be frustrating, especially when it affects your work.”
  • Explain the most likely diagnosis based on history:
    • “Your symptoms are consistent with statin-induced myopathy, which is a known side effect of your cholesterol medication.”
  • Reassure while emphasising need for further testing:
    • “We will do some blood tests to check your muscle enzymes and other possible causes.”
  • Address patient’s work concerns:
    • “If this is due to your medication, adjusting or stopping it may help improve your symptoms over time.”
  • Ensure patient understanding using teach-back techniques.

Task 4: Develop a management plan, including investigations, symptom relief, and follow-up.

The competent candidate should:

  • Short-term management:
    • If statin-induced myopathy is suspected, consider stopping the statin for 2–4 weeks and monitoring symptoms.
    • Arrange blood tests (CK, ESR/CRP, thyroid function, vitamin D, renal/liver function).
  • Symptom relief:
    • Encourage gentle exercise and stretching.
    • Consider paracetamol or NSAIDs (if no contraindications) for symptom control.
  • Further investigations/referral if symptoms persist:
    • If symptoms continue after stopping the statin, refer for rheumatology or neurology assessment.
  • Preventive care and education:
    • If statin is discontinued, discuss alternative lipid-lowering strategies (diet, exercise, other medications like ezetimibe).
    • Provide workplace ergonomic advice if mechanical strain is a factor.
  • Safety-netting and follow-up:
    • “If you develop muscle weakness, dark urine, or worsening pain, return immediately.”
    • “We will review your symptoms and blood results in two weeks.”

SUMMARY OF A COMPETENT ANSWER

  • Takes a structured history, assessing muscle pain characteristics and risk factors.
  • Considers a broad differential diagnosis, distinguishing inflammatory, metabolic, and medication-related causes.
  • Explains findings clearly and empathetically, addressing patient concerns.
  • Develops an appropriate management plan, including stopping statins if indicated, ordering investigations, and providing symptom relief.
  • Provides clear safety-netting and follow-up instructions.

PITFALLS

  • Failing to consider medication-induced myopathy, missing an opportunity for early intervention.
  • Overlooking inflammatory or metabolic causes, delaying necessary investigations.
  • Not ordering appropriate tests, leading to diagnostic uncertainty.
  • Reassuring the patient too quickly without a clear plan, missing the chance for proper workup.
  • Neglecting to address the patient’s work concerns, reducing adherence to management strategies.

REFERENCES

MARKING

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

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

Competency Areas Assessed

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history of muscle pain and associated symptoms.
2.2 Assesses risk factors for myopathy, inflammatory, and metabolic causes.
2.3 Identifies indications for further testing or referral.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between mechanical, inflammatory, metabolic, and medication-induced muscle pain.
3.3 Determines when referral or further investigations are required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate management plan, including symptom relief and investigation.
4.3 Provides patient-centred education on lifestyle modifications and medication review.
4.5 Recognises when referral to a rheumatologist or neurologist is warranted.

5. Preventive and Population Health

5.2 Discusses workplace ergonomics, injury prevention, and medication review.

7. General Practice Systems and Regulatory Requirements

7.2 Follows appropriate guidelines for chronic pain management and prescribing.

Competency at Fellowship Level

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