CASE INFORMATION

Case ID: MUS-001
Case Name: John Thompson
Age: 52
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L18 – Muscle symptom/complaint NOS

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their concerns, ideas, and expectations 1.2 Provides clear explanations tailored to the patient’s level of health literacy 1.4 Uses effective consultation techniques, including active listening and empathy
2. Clinical Information Gathering and Interpretation	2.1 Takes a focused history to explore musculoskeletal symptoms, relevant medical history, and risk factors 2.2 Selects appropriate investigations based on clinical presentation
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis for muscle pain 3.2 Identifies potential red flags indicating serious underlying conditions
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a safe and effective management plan 4.2 Provides advice on pharmacological and non-pharmacological management
5. Preventive and Population Health	5.1 Discusses lifestyle modifications for musculoskeletal health
6. Professionalism	6.1 Maintains patient confidentiality and demonstrates ethical practice
7. General Practice Systems and Regulatory Requirements	7.1 Documents accurately and ensures appropriate follow-up
9. Managing Uncertainty	9.1 Provides reassurance and safety-netting when the diagnosis is unclear
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises features suggestive of a systemic or serious pathology requiring urgent intervention

CASE FEATURES

Middle-aged male with muscle pain of unclear cause
Differential diagnoses include myalgia due to viral illness, statin-induced myopathy, polymyalgia rheumatica, or an underlying systemic condition
Importance of thorough history and examination to exclude serious pathology
Addressing patient concerns regarding ongoing pain and functional limitations
Role of investigations such as inflammatory markers, creatine kinase, and thyroid function tests

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:

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

SCENARIO

John Thompson, a 52-year-old office worker, presents with muscle pain affecting both thighs and upper arms over the past month. He describes a dull ache that worsens in the morning and after prolonged sitting. He denies any recent trauma or intense physical activity but mentions starting a statin medication three months ago. He has also been feeling more fatigued than usual.

PATIENT RECORD SUMMARY

Patient Details

Name: John Thompson
Age: 52
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Atorvastatin 40 mg once daily
Perindopril 5 mg once daily

Past History

Hypertension
Hyperlipidaemia

Social History

Works as an accountant, mostly sedentary

Family History

Father: Hypertension, died of myocardial infarction at 65
Mother: Rheumatoid arthritis

Smoking

Non-smoker

Alcohol

Drinks socially, approximately 5-6 standard drinks per week

Vaccination and Preventative Activities

Up to date with vaccinations, including influenza and COVID-19 booster

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 this muscle pain for weeks now, and it’s not going away. Could it be something serious?”

General Information

You are a 52-year-old man who works as an accountant. You spend most of your day sitting at a desk but try to stay active by jogging and doing light weights a few times a week.
About a month ago, you started noticing a dull, aching pain in your thighs and upper arms. It’s not sharp or shooting, but it’s persistent and uncomfortable.
The pain is worse in the mornings and after sitting for long periods. It improves slightly with movement but never fully goes away.

Specific Information

(Reveal only when prompted)

Background Information

You feel more tired than usual. You don’t think you’ve had any fevers, but you have been feeling a bit “run down.”
You haven’t changed your exercise routine recently and haven’t had any injuries or accidents.
You started taking atorvastatin for high cholesterol three months ago and are wondering if it could be causing this.

Pain Characteristics

The pain is a dull ache, mainly in the thighs and upper arms.
It started about four weeks ago and has slowly worsened.
It does not radiate to other areas, and there is no numbness, tingling, or weakness.
There are no muscle cramps or twitching.
You have mild morning stiffness lasting around 30 minutes but no significant joint swelling or redness.

Impact on Daily Life

The pain makes it difficult to get out of bed and start the day.
Sitting for long periods, such as at your desk, makes the pain worse.
You’ve had to cut back on jogging because of discomfort.
Your energy levels are lower than usual, making work and daily activities more challenging.

Concerns and Expectations

You’re worried that this could be something serious, like a neurological disease or an inflammatory condition.
You have a family history of rheumatoid arthritis (your mother), and you’re concerned that you might be developing it.
You’ve read that statins can cause muscle problems and wonder if you should stop taking atorvastatin.
You’re hoping the doctor can figure out what’s wrong and offer some treatment to help with the pain.
You’d like to know if you need any blood tests or scans.

Red Flag Symptoms (Reveal only when asked directly)

No history of falls or balance issues.
No difficulty swallowing or speaking.
No recent rashes or unexplained fevers.
No bowel or bladder problems.
No unexplained weight loss.

Emotional Cues & Body Language

At the start of the consultation, you appear concerned and slightly anxious. You lean forward in your chair and furrow your brows when discussing your symptoms.
When talking about your concerns regarding a serious illness, you sound worried and hesitant. You might even pause before asking about conditions like rheumatoid arthritis or neurological diseases.
If reassured appropriately, you relax slightly but still seek clarity about next steps.
If the doctor dismisses your concerns too quickly, you might become frustrated and say something like, “But the pain is really affecting my life—I just want to make sure we’re not missing something serious.”
If the doctor suggests lifestyle changes (like stopping exercise temporarily), you may express mild resistance: “But I don’t want to stop jogging completely. It helps with my stress.”

Questions for the Candidate

(Ask these naturally throughout the consultation)

“Do you think this could be a side effect of my medication?” (Ask early in the consultation, especially if the doctor hasn’t mentioned statins yet.)
“Do I need any tests to figure out what’s going on?“ (Ask if the doctor hasn’t mentioned investigations yet, or if they seem hesitant about ordering tests.)
“What can I do to help with the pain?“ (Ask towards the end of the consultation if the doctor hasn’t already addressed management.)
“Is this something that will go away on its own, or do I need treatment?” (You want clarity on prognosis.)
“Should I stop taking my statin?“ (You are particularly concerned about this and may ask more than once if the answer isn’t clear.)

Key Behaviours & Approach

You expect the doctor to take your concerns seriously and provide a clear explanation of what could be causing your symptoms.
You are cooperative and willing to answer questions but will ask for explanations if something isn’t clear.
If the doctor gives a vague or uncertain answer, you might press them for more details: “So, what exactly do you think is causing this?”
If you feel dismissed, you might say, “I’m not sure I feel reassured. The pain is really affecting my life, and I just don’t want to ignore something important.”
You appreciate a structured plan and a follow-up appointment if needed.

THE COMPETENT CANDIDATE

Task 1: Take an appropriate history from the patient, considering possible causes of muscle pain.

The competent candidate should:

Use open-ended questions to allow the patient to describe their symptoms in their own words.
Elicit details of onset, duration, character, location, exacerbating and relieving factors of the muscle pain.
Explore morning stiffness, exercise tolerance, and functional limitations to assess the impact on daily life.
Review medication history, specifically atorvastatin, as a potential cause of muscle symptoms.
Ask about systemic symptoms (fatigue, fever, weight loss, skin rashes) that may indicate inflammatory, autoimmune, or metabolic causes.
Screen for neurological symptoms (weakness, numbness, difficulty swallowing) to exclude neuromuscular disorders.
Take a past medical history, including autoimmune diseases, metabolic disorders, and recent infections.
Explore family history of musculoskeletal or autoimmune conditions (e.g., rheumatoid arthritis).
Obtain social and occupational history, including physical activity levels and any recent changes.
Address the patient’s ideas, concerns, and expectations regarding the symptoms.

Task 2: Formulate a differential diagnosis and explain it to the patient.

The competent candidate should:

Outline a structured differential diagnosis, considering:
- Common causes: Statin-induced myopathy, viral myalgia, fibromyalgia, age-related muscle pain.
- Inflammatory causes: Polymyalgia rheumatica, inflammatory myositis (e.g., dermatomyositis, polymyositis).
- Metabolic causes: Hypothyroidism, vitamin D deficiency, electrolyte imbalances.
- Neuromuscular conditions: Motor neurone disease (if weakness present).
Explain the likelihood of each diagnosis based on the patient’s history.
Discuss red flag symptoms that might require urgent investigation.
Provide clear, non-alarmist explanations using layman’s terms.
Check for patient understanding and concerns.

Task 3: Address the patient’s concerns empathetically and discuss any red flags.

The competent candidate should:

Acknowledge and validate the patient’s concerns about serious illness.
Provide reassurance where appropriate, explaining that most muscle pains are benign but require evaluation.
Discuss red flag symptoms, such as progressive weakness, difficulty swallowing, unexplained weight loss, or systemic symptoms, and their implications.
Ensure shared decision-making, allowing the patient to express fears and ask questions.
Offer safety netting by advising the patient when to seek urgent care.

Task 4: Develop an initial management plan, including relevant investigations and follow-up.

The competent candidate should:

Order appropriate investigations based on the differential diagnosis:
- Blood tests: FBC, ESR, CRP (for inflammation); CK (for muscle injury); TSH (for hypothyroidism); electrolytes and calcium (for metabolic causes); vitamin D levels.
- Consider imaging: If inflammatory myopathy is suspected, MRI or muscle biopsy may be needed.
Discuss medication review, including possible trial cessation of atorvastatin.
Provide non-pharmacological management, including stretching exercises and heat therapy.
Arrange follow-up in one to two weeks to review symptoms and test results.
Provide patient education about potential causes and lifestyle modifications.

SUMMARY OF A COMPETENT ANSWER

Uses structured history-taking to explore symptoms, risk factors, and functional impact.
Develops a broad but relevant differential diagnosis, explaining each possibility clearly.
Addresses patient concerns empathetically, ensuring shared decision-making.
Identifies red flag symptoms that require urgent intervention.
Plans evidence-based investigations and provides clear follow-up instructions.

PITFALLS

Failing to consider medication-related causes, especially statin-induced myopathy.
Overlooking inflammatory conditions like polymyalgia rheumatica in an older patient.
Missing neurological symptoms that may suggest a serious underlying disorder.
Dismissing patient concerns without appropriate reassurance and safety netting.
Failing to order necessary investigations, leading to diagnostic delay.
Providing vague or unclear explanations, leaving the patient anxious or confused.

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

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 symptoms, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Elicits a comprehensive history focused on muscle pain.
2.2 Orders appropriate investigations to differentiate potential causes.

3. Diagnosis, Decision-Making and Reasoning

3.1 Develops a structured differential diagnosis for muscle pain.
3.2 Identifies red flags requiring further investigation.

4. Clinical Management and Therapeutic Reasoning

4.1 Formulates an evidence-based management plan.
4.2 Provides pharmacological and non-pharmacological treatment options.

5. Preventive and Population Health

5.1 Discusses lifestyle modifications and self-management strategies.

6. Professionalism

6.1 Maintains confidentiality and ethical decision-making.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures accurate documentation and appropriate follow-up.

9. Managing Uncertainty

9.1 Provides reassurance and safety netting when the diagnosis is unclear.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises serious or systemic illness requiring further assessment.

Competency at Fellowship Level

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