Cases/Musculoskeletal Health

Woman of 68 with Shoulder and Hip Girdle Stiffness Worst in the Morning — Free SCA Practice Case

Woman of 68 with shoulder and hip girdle stiffness worst in the morning

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Margaret Boyle

Age

68 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation.

Reason for Encounter

"For the last few weeks I've had terrible stiffness and aching in my shoulders and hips, worst first thing in the morning. I can barely get going."

Medical Records

●PMH: Hypertension. Otherwise well.
●Medications: Amlodipine 5 mg OD.
●Allergies: NKDA.
●Recent contact: No recent consultations. No recent bloods.

Patient Script

For the friend playing the patient role

Character Overview: You are Margaret, a 68-year-old retired librarian. For about four weeks you have had severe aching and stiffness across both shoulders and both hips, dramatically worse in the mornings — it takes a couple of hours to loosen up. You struggle to lift your arms to brush your hair and to get out of a chair or turn over in bed. You feel a bit washed out. You have no headache or visual problems (unless asked). You are worried this is the start of severe arthritis. You are cooperative and want an explanation and relief.

Opening Sentence: "Hello Doctor. For about a month now I've had this awful aching and stiffness in both my shoulders and my hips. It's worst in the mornings — I'm so stiff I can barely get out of bed or lift my arms, and it takes a couple of hours to ease. It's really frightening me. What's going on?"

History if Asked (Data Gathering Phase)

●The symptoms: "Aching and stiffness across both shoulders and both hips — symmetrical, both sides. Worst first thing; it takes a good couple of hours to loosen up."
●Function: "I can't lift my arms properly to wash my hair, and getting out of a chair or turning in bed is a real struggle. It came on over a week or two."
●Systemic symptoms (if asked): "I've felt a bit washed out and tired, maybe slightly off my food. No real fevers."
●Duration: "About four weeks now, and not settling."
●What she thinks: "I'm terrified it's severe arthritis setting in and I'll end up seizing up."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

●Ideas: Margaret assumes this is severe arthritis or "wear and tear" catching up with her. "I've assumed it's arthritis — that my joints are going."
●Concerns: She is frightened of becoming disabled/seizing up and losing her independence; she has not connected the tiredness to anything serious. "I'm scared I'll seize up and lose my independence."
●Expectations: She wants to know what it is and to get relief from the stiffness and pain. "I want to know what this is and to get some relief — I can't go on like this."

If Asked — GCA Screen and Mimic Screen

The patient answers these only when directly asked.

●If asked about new headache or scalp tenderness: "No headaches, and my scalp feels normal — no tenderness when I brush my hair." (No GCA — but the candidate must ask.)
●If asked about jaw pain/claudication when chewing: "No, no pain in my jaw when I eat."
●If asked about visual symptoms (blurring, double vision, loss of vision): "No — my eyesight's fine, no blurring or double vision."
●If asked about true muscle weakness vs pain/stiffness: "It's more the pain and stiffness that stop me — the muscles themselves don't feel weak once I get moving."
●If asked about small-joint pain/swelling (hands/feet): "No swollen fingers or hand-joint pain."
●If asked about weight loss, night sweats, fever: "A little off my food and tired, but no real weight loss, night sweats, or fever."
●If asked about thyroid symptoms: "No — no weight or temperature changes I've noticed."

Responses to Management (The Negotiation Phase)

●If the Doctor explains this is likely polymyalgia rheumatica: "Polymyalgia rheumatica? I've never heard of it. Is it arthritis? Is it serious?" (The tested point is explaining PMR clearly and reassuringly, and distinguishing it from joint-destroying arthritis.)
●If the Doctor recommends blood tests and a steroid trial: "So a blood test, and then steroids? Will the steroids really help that quickly?" (The tested point is explaining the ESR/CRP work-up and the characteristic rapid response to steroids.)
●If the Doctor counsels on steroids: "Are steroids safe? How long would I be on them? I've heard they have side effects." (The tested point is steroid counselling — not stopping abruptly, side effects, bone protection, steroid card, long slow course.)
●If the Doctor safety-nets for GCA: "You mentioned warning signs about my head and eyes — what exactly should I look out for?"
●If the Doctor arranges follow-up: "When would I be seen again to check it's working?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Polymyalgia Rheumatica (PMR)

●PMR causes bilateral, symmetrical shoulder and pelvic-girdle pain and stiffness, with prolonged morning stiffness (typically >45 minutes), in people over 50 (usually over 65), often with systemic features (fatigue, malaise, low-grade symptoms). It does not destroy joints like rheumatoid arthritis.

Investigations

●Check ESR and CRP (usually raised) and baseline bloods (FBC, U&E, LFTs, TFTs, calcium, CK — CK is normal in PMR and helps exclude myositis); consider RF/anti-CCP and urinalysis. Obtain baseline tests before starting steroids.

The Steroid Trial Is Part of the Diagnosis

●PMR shows a rapid, dramatic response to low-dose oral steroids (typically ~15 mg prednisolone daily) — improvement within days is characteristic. A poor response should prompt reconsideration of the diagnosis.

Giant Cell Arteritis — the Critical Association

●PMR is associated with giant cell arteritis (GCA), a sight-threatening emergency. Screen for and safety-net on new/severe headache, scalp tenderness, jaw claudication, and visual symptoms — these require urgent same-day assessment, high-dose steroids, and urgent referral (ophthalmology/rheumatology).

Steroid Counselling and Protection

●Counsel on not stopping abruptly, a steroid card and sick-day rules, the long slow taper (often 1–2 years), and side effects. Consider bone protection (calcium/vitamin D ± bisphosphonate) and gastric protection.

Monitoring and Referral

●Arrange early follow-up to confirm the response, monitor side effects, and plan the taper, with inflammatory-marker monitoring. Refer to rheumatology for diagnostic uncertainty, atypical features, poor response, relapse, or steroid difficulties.

Reassurance

●Reassure that PMR is treatable and responds well, distinguishing it from joint-destroying arthritis, while being honest about the steroid course.

Common Candidate Mistakes in This Case

●Not screening for or safety-netting GCA: the critical omission in any PMR presentation.
●Starting steroids without investigations: omitting ESR/CRP and baseline bloods.
●Inadequate steroid counselling: not covering abrupt cessation, duration, side effects, and protection.
●Mislabelling it as osteoarthritis/RA: missing the girdle pattern and prolonged morning stiffness.
●No follow-up or monitoring: failing to review the response and plan the taper.

Free MRCGP SCA practice case for GP registrars covering Woman of 68 with Shoulder and Hip Girdle Stiffness Worst in the Morning — Musculoskeletal Health. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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