CASE INFORMATION

Case ID: FM-005
Case Name: Rachel Simmons
Age: 42
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L18 (Fibromyalgia/Generalised Musculoskeletal Pain)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages the patient effectively 1.3 Uses a patient-centred approach to discuss chronic pain 1.5 Explains medical information in an understandable and supportive way
2. Clinical Information Gathering and Interpretation	2.1 Takes a thorough history of pain, fatigue, and associated symptoms 2.2 Conducts a targeted physical examination to exclude other causes of chronic pain
3. Diagnosis, Decision-Making and Reasoning	3.1 Recognises the characteristic features of fibromyalgia and applies diagnostic criteria 3.4 Considers differential diagnoses such as inflammatory arthritis, chronic fatigue syndrome, and neuropathic pain
4. Clinical Management and Therapeutic Reasoning	4.2 Provides an individualised, multidisciplinary management plan 4.4 Addresses pharmacological and non-pharmacological treatment options
5. Preventive and Population Health	5.2 Educates the patient on self-management strategies and long-term outcomes
6. Professionalism	6.2 Demonstrates empathy and avoids dismissive attitudes towards chronic pain
7. General Practice Systems and Regulatory Requirements	7.2 Uses appropriate referral pathways (e.g., pain specialists, rheumatologists, physiotherapists, psychologists)
9. Managing Uncertainty	9.1 Explains the diagnosis and addresses concerns about the condition being misunderstood
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises the impact of fibromyalgia on daily functioning and mental health

CASE FEATURES

Primary complaint: Widespread musculoskeletal pain, fatigue, and cognitive difficulties
Key symptoms: Persistent pain in multiple areas, sleep disturbance, brain fog, and emotional distress
Patient concerns: Struggling with daily tasks, worried about being dismissed or told “it’s all in her head”
Importance of diagnosis: Exclusion of other conditions such as inflammatory arthritis and autoimmune disease
Multidisciplinary care approach: Emphasis on non-pharmacological management and patient education

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 a physical 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

Rachel Simmons, a 42-year-old woman, presents to your general practice with widespread body pain, fatigue, and difficulty concentrating for the past 12 months. She describes the pain as aching, constant, and affecting multiple areas including her neck, shoulders, lower back, and thighs. The pain varies in intensity but never fully goes away.

She reports severe fatigue, saying she wakes up unrefreshed even after 8+ hours of sleep. She also describes “brain fog”, making it hard to focus at work.

PATIENT RECORD SUMMARY

Patient Details

Name: Rachel Simmons
Age: 42
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Occasional ibuprofen or paracetamol for pain

Past Medical History

No autoimmune disease or inflammatory arthritis
No history of significant mental health conditions

Social History

Occupation: Office administrator, finding it difficult to keep up with work

Family History

Mother had chronic pain but never formally diagnosed

Smoking

Non-smoker

Alcohol

Drinks occasionally (1-2 times per month, socially)

Investigations to Date

Full blood count, inflammatory markers, thyroid function, autoimmune screening – all normal
X-rays of the spine and hands – no abnormalities

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 in pain for over a year, and no one seems to know what’s wrong with me. I just want some answers.”

General Information

(Freely Given if Asked Open-Ended Questions)

Pain started about 12 months ago, gradually worsening over time with no clear trigger.
Pain is widespread—mainly in the neck, shoulders, lower back, thighs, and arms.
Aching, deep muscle pain that feels like she has been “hit by a truck” on bad days.
Fatigue is constant, even after 8-9 hours of sleep, and she often wakes up feeling unrefreshed.

Specific Information

(Only Given if Asked Direct Questions)

Background Information

Describes “brain fog”—difficulty concentrating, remembering things, and keeping up at work.
Has seen multiple doctors, had blood tests and scans, all coming back normal.
Feels frustrated and dismissed, has been told it’s just stress or in her head.
Symptoms worsen with stress, cold weather, and overexertion.
Some relief with warm baths, massage, and rest, but painkillers don’t work well.

Pain Characteristics

Pain is symmetrical, affecting both sides of the body.
No joint swelling, redness, or deformity.
No numbness, tingling, or weakness in the limbs.
Pain intensity fluctuates—some days are manageable, others feel overwhelming.

Sleep and Fatigue

Struggles with falling and staying asleep, waking up feeling just as tired.
Has tried melatonin but it didn’t help much.

Emotional and Psychological Impact

Feeling anxious and low, unsure if she has a serious disease.
Frustrated with past medical consultations, feels like no one believes her.
Sometimes feels helpless about the future.

Impact on Daily Life

Struggles to keep up with work—forgetting tasks, losing focus.
House chores feel overwhelming, relies on her husband and children for help.
Stopped exercising because it worsens her pain.
Avoids socialising because of fatigue and feeling “not herself”.

Emotional Cues

Becomes teary and frustrated when discussing how the pain affects her daily life.
Shows relief when the doctor listens attentively and validates her concerns.
Appears anxious when discussing the possibility of an underlying disease.
Visibly distressed if the doctor suggests it could be psychological, unless explained sensitively.

Patient Concerns and Expectations

Wants to know what is causing her symptoms—fears she has an autoimmune disease.
Worried she will never feel normal again.
Hoping for a treatment plan that actually helps.
Concerned about work, afraid she may have to reduce hours or quit.
Wants to know if fibromyalgia is a real condition—she has read conflicting opinions online.

Questions the Patient Might Ask

“Do I actually have a real condition, or is this just stress?”
“What tests can confirm fibromyalgia?”
“Is there a cure for this?”
“Will I need medication forever?”
“Should I see a specialist?”
“Is this going to get worse?”
“How do I explain this to my family and employer?”

Escalating the Scenario Based on the Candidate’s Approach

If the candidate dismisses or minimises symptoms, Rachel will become frustrated and withdraw emotionally, saying: “So you’re telling me this is just in my head?”
If the candidate shows empathy and validation, Rachel will engage more openly and feel relieved.
If the candidate only focuses on medications, Rachel will say: “I don’t want to just take pills. Is there anything else I can do?”
If the candidate provides a well-rounded plan, Rachel will feel hopeful and ask about practical steps.
If the candidate fails to discuss the chronic nature of fibromyalgia, Rachel may ask: “Will I ever get rid of this completely?”

Final Patient Reactions Depending on the Consultation Quality

If the candidate provides a thorough and empathetic response, Rachel will say:
“Thank you, Doctor. I finally feel like someone is listening. What should I do next?”
If the candidate is vague or dismissive, Rachel will say:
“So, basically, you don’t know what’s wrong with me either?”
If the candidate suggests fibromyalgia but doesn’t explain it well, Rachel will respond:
“But I’ve had real pain for over a year! Are you saying it’s not real?”
If the candidate reassures her but doesn’t provide a clear management plan, Rachel will ask:
“So what do I actually do to feel better?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, focusing on the nature of pain, associated symptoms, and psychosocial impact.

The competent candidate should:

Establish rapport and create a safe, non-judgmental environment to discuss chronic pain.
Use open-ended questions to explore the location, duration, and characteristics of pain.
Assess fatigue, sleep quality, and cognitive symptoms (e.g., brain fog, poor concentration).
Identify exacerbating and relieving factors (e.g., stress, physical activity, weather changes).
Screen for associated symptoms, such as headaches, irritable bowel syndrome, and mood changes.
Assess the impact on daily activities, including work, relationships, and mental well-being.
Explore previous investigations and treatments, acknowledging the patient’s frustration.
Identify patient concerns, including fear of a serious disease, long-term disability, or disbelief by doctors.

Task 2: Discuss your differential diagnosis, explaining how fibromyalgia is distinguished from inflammatory and neuropathic conditions.

The competent candidate should:

Explain fibromyalgia as a clinical diagnosis, requiring widespread pain lasting >3 months, fatigue, and cognitive symptoms, without an alternative cause.
Differentiate from:
- Inflammatory arthritis (e.g., rheumatoid arthritis, lupus): Would show joint swelling, morning stiffness >1 hour, and elevated inflammatory markers.
- Chronic fatigue syndrome (CFS/ME): Significant post-exertional malaise, but less widespread pain.
- Neuropathic pain (e.g., peripheral neuropathy): More burning/electrical pain with sensory loss.
- Myofascial pain syndrome: Localised trigger points, rather than widespread pain.
Explain that fibromyalgia does not cause joint damage or deformity, but can still significantly impact quality of life.
Reassure the patient that their symptoms are real, even if test results are normal.

Task 3: Explain your management plan, including lifestyle interventions, pharmacological treatment, and supportive care.

The competent candidate should:

Reassure the patient that fibromyalgia is a recognised condition and that symptoms can be managed effectively.
Lifestyle modifications:
- Regular low-impact exercise (e.g., swimming, walking, yoga) to improve pain tolerance.
- Sleep hygiene strategies (consistent schedule, avoiding stimulants).
- Stress reduction techniques, including mindfulness and cognitive behavioural therapy (CBT).
Pharmacological options (if needed):
- Amitriptyline or duloxetine for pain modulation and sleep improvement.
- Pregabalin or gabapentin for neuropathic features.
- Paracetamol and NSAIDs are generally ineffective.
Encourage self-management with pain diaries, graded exercise, and pacing strategies.

Task 4: Discuss referral options and follow-up, ensuring long-term support and multidisciplinary involvement.

The competent candidate should:

Refer appropriately:
- Rheumatologist if diagnosis remains unclear or autoimmune disease suspected.
- Physiotherapist for graded exercise therapy and mobility improvement.
- Psychologist for CBT and support in coping with chronic pain.
- Pain specialist if symptoms are severe and unresponsive to first-line treatments.
Discuss regular GP follow-up every 4-6 weeks initially to monitor response to treatment.
Encourage patient engagement in support groups (e.g., Fibromyalgia Australia).
Provide safety-netting advice, including when to seek reassessment (e.g., new neurological symptoms, worsening function).

SUMMARY OF A COMPETENT ANSWER

Uses a structured pain history, addressing widespread pain, fatigue, and cognitive symptoms.
Explains the differential diagnosis clearly, ruling out inflammatory, neuropathic, and autoimmune conditions.
Provides a multimodal management plan, including exercise, sleep, psychological support, and medication if needed.
Discusses realistic expectations, emphasising long-term symptom management rather than cure.
Uses a patient-centred approach, validating the patient’s symptoms and concerns.

PITFALLS

Failing to acknowledge the patient’s frustration, leading to poor engagement.
Over-reliance on medications, without discussing lifestyle modifications and psychological support.
Not ruling out alternative diagnoses, particularly autoimmune or inflammatory conditions.
Minimising the condition, making the patient feel dismissed.
Failing to offer follow-up and referrals, leaving the patient without ongoing support.

REFERENCES

MARKING

Each competency area is assessed on the following scale:

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

1. Communication and Consultation Skills

1.1 Uses appropriate communication, ensuring a supportive discussion about chronic pain.
1.3 Engages the patient using a patient-centred approach, acknowledging frustration and concerns.
1.5 Explains fibromyalgia in an understandable and non-dismissive manner.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough pain history, identifying fibromyalgia symptoms.
2.2 Conducts a focused assessment, ruling out alternative diagnoses.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises the characteristic features of fibromyalgia and applies diagnostic criteria.
3.4 Differentiates fibromyalgia from inflammatory, neuropathic, and autoimmune conditions.

4. Clinical Management and Therapeutic Reasoning

4.2 Provides a multimodal management plan, balancing lifestyle, psychological, and pharmacological interventions.
4.4 Incorporates a multidisciplinary approach, including physiotherapy, psychology, and pain management.

5. Preventive and Population Health

5.2 Educates the patient on self-management strategies and long-term expectations.

6. Professionalism

6.2 Demonstrates empathy and avoids dismissive attitudes towards chronic pain.

7. General Practice Systems and Regulatory Requirements

7.2 Uses appropriate referral pathways (e.g., pain specialists, rheumatologists, physiotherapists).

9. Managing Uncertainty

9.1 Explains the diagnosis clearly, addressing misconceptions and ensuring patient understanding.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises the impact of fibromyalgia on daily functioning and mental health.

Competency at Fellowship Level

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