Cases/Musculoskeletal Health

Woman Whose Polymyalgia Came Back As Her Steroids Were Reduced — Free SCA Practice Case

Woman whose polymyalgia came back as her steroids were reduced

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

Try 5 free cases

Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Hazel Kerslake

Age

71 years

Consultation Type

Video

Age

Situation

Video Consultation. Routine appointment booked by the patient.

Reason for Encounter

"My stiffness has come back. I'd like to talk about my steroid tablets."

Medical Records

●PMH: Polymyalgia rheumatica, diagnosed 9 months ago. Hypercholesterolaemia.
●Medications: Prednisolone 7.5 mg daily (10 mg until 7 weeks ago), atorvastatin, calcium with vitamin D, paracetamol.
●Allergies: NKDA.
●Social: Retired. Non smoker.

Recent Notes

●7 weeks ago: CRP 4, ESR 15. HbA1c 40.
●2 days ago: BP 132/78, weight 71 kg. CRP 31, ESR 49. Blood count, calcium, kidney function, ALP, TSH and CK normal.

Patient Script

For the friend playing the patient role

Character Overview: You are Hazel Kerslake, a 71 year old retired school cook. You live with your husband Alun, 74, a retired joiner, in a terraced house with the bedrooms upstairs, and you look after your granddaughter Mabel, who is 4, after nursery twice a week. Nine months ago you were diagnosed with an inflammatory stiffness in your shoulders and hips and started steroid tablets (prednisolone). They worked within days. Seven weeks ago the dose went down to 7.5 mg. About three weeks after that the stiffness crept back, and for the last two weeks it has been bad again. You are fed up and a little low. Since starting the tablets you have put on about a stone, your face has gone round, you are hungry all the time and you do not recognise yourself in the mirror. You have half decided to stop the tablets for good because you would rather be stiff than fat, and last week you deliberately left one morning's tablet out to see what would happen. You call your condition "the stiffness" and never use a medical name for it. You are polite and straightforward, and your voice wobbles when you talk about how you look.

Opening Sentence: "Hello, doctor. The stiffness has come back. It's been bad again for about two weeks now and I'm honestly fed up. I want to talk about coming off these steroid tablets, because I hate what they're doing to me."

History if Asked (Data Gathering Phase)

●Where it is: "Both shoulders and both hips, same as it was last year. It's the tops of my arms and my thighs, really. Both sides the same."
●Morning stiffness: "Worst when I wake up. I'm up about seven and it's gone nine before I'm moving properly. I stiffen up again if I sit for a while."
●When it came back: "I went down to 7.5 about seven weeks ago. I was fine for three weeks or so, then it started creeping back. It's been properly bad for the last two weeks, and it's a bit worse every week. It's exactly the same kind of stiffness as last year, only not quite as bad yet. Two thirds as bad, maybe."
●What she cannot do: "I can't get my arms up to put a cardigan on or reach the top cupboard. I have to roll onto my side to get out of bed. I can't pick Mabel up any more, and getting down on the floor to play with her is a real struggle."
●Pain or weakness (if asked): "It's aching and stiffness rather than weakness. Paracetamol does very little. I've tried nothing else."
●Dose history and how she takes it (if asked): "I started on 15 and it went down in steps. I was on 10 for months and felt wonderful. Then they dropped me to 7.5. I take a 5 and a 2.5 every morning with breakfast."
●Missed or changed doses (if asked whether she takes them every day, or has missed, skipped or changed any): "I haven't changed the dose. But I did leave one out last week, on purpose, to see what would happen. I didn't feel any different that day, so I took it again the next morning."

Ideas, Concerns, Expectations

Gating note: Hazel does not volunteer any of the following. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, what she means by hating the tablets, or what she was hoping for from today.

●What she means by hating the tablets (if asked): "I've put on about a stone since I started them. My face has gone all round and puffy, and none of my clothes fit. I'm starving all the time. I don't see me in the mirror."
●Ideas: She thinks the tablets have stopped working and she is just getting fat on them for nothing. "If the stiffness comes back anyway, what's the point of me being on them?"
●Concerns: How she looks and feels about herself. What the tablets are doing inside her. "My friend Bronwen's sister was on steroids for years and ended up with a broken back." And whether it will ever end. "Am I on them for the rest of my life?"
●Expectations: She wants to stop the tablets, or at least leave with a date for when she can. If asked what she has been thinking of doing: "I've thought about just stopping them myself. I haven't. Not yet." "I was hoping you'd tell me I could come off them."

If Asked: Medical History and Medications

Gating note: Hazel answers each of these plainly when the doctor asks about it.

●Other health problems and medicines: "Just the cholesterol. I've been on atorvastatin for years with no aches from it. I take two chewable calcium and vitamin D tablets a day since I started the steroids. Paracetamol now and then. No herbal things."
●Indigestion, heartburn or swallowing: "No. No indigestion or heartburn, and I can swallow fine."
●Sugar and blood pressure: "My sugar and blood pressure were fine at the review. No thirst, and I'm not passing more water."
●Mood, sleep, skin and eyes: "A bit snappy and low because of how I look, but I'm not depressed and have no thoughts of harming myself. I wake in the early hours most mornings and can't get back off. My forearms bruise if I so much as look at them. My eyes are the same. No infections lately."
●Allergies: "None."

If Asked: Bone Health

Gating note: Hazel answers these when the doctor asks about bones, falls, fractures or family history.

●Fractures, falls and height: "I've never broken a bone. No falls. I'm careful on the stairs because my hips are so stiff. I don't think I've shrunk."
●Family, lifestyle and scans: "My mum broke her hip when she was 79. I've never smoked and have three medium glasses of wine a week. Teeth fine at my check up last year. I've never had a bone scan."

Social History and Lifestyle Impact

●Home and family: "Alun doesn't mind how I look, but he can't see why I won't stay on the tablets if they work." Daughter Delyth lives close by. "I do Tuesdays and Thursdays with Mabel after nursery, and I'm dreading telling Delyth I can't manage it."
●Exercise and the aqua class: "I stopped going to my Wednesday aqua class about a month ago. Partly because I can't get my arms over, and partly because I hate being seen in a swimming costume now. I miss it."
●Food and work: "I'm hungry all the time since the steroids. Biscuits with my tea, and I'm up at the fridge in the night. I still help at the community cafe on Mondays and can just about manage the trays."

If Asked: Associated Symptoms

●Giant cell arteritis questions (new headache, scalp tenderness, jaw or tongue pain on chewing, blurred or double vision or dimming sight): "No. No headaches, my scalp's fine, and I had a crusty roll at the lunch club with no trouble. My eyes are fine."
●Other illness features (fever, night sweats, weight loss, numbness or true weakness, swollen or painful hands, wrists, knees or feet, rash, cough, water infections, anything new): "No to all of that. Weight loss is the opposite, I've put weight on and I'm always hungry. Just the shoulders and hips. Nothing new."
●If asked to lift her arms or check her own blood pressure or weight on camera: Declines politely. "It hurts, and I haven't got a machine. The nurse did both two days ago. If you need to see me properly I can come in."

Responses to Management (The Negotiation Phase)

●
If the doctor proposes going back up to 10 mg, or talks about the dose coming down more slowly:
- ●Reaction: Dismayed. "Going up? That's going backwards. I thought the whole idea was to come off them." If told it is to settle things before trying again more slowly: "How soon would I feel better? And how long would it be, altogether? Another year?" She is reassured by a rough timescale. If told the weight gain is a steroid effect: "So it isn't just me being greedy? What can I actually do?"
●
If the doctor says she should not stop the tablets suddenly, or explains the steroid card and illness advice:
- ●Reaction: Challenges. "But I left one out last week and nothing happened. What would actually happen if I just stopped?" If the body's own steroid supply is explained, she listens: "I didn't know that. Nobody told me it was dangerous." On the card: "What do I do if I get a stomach bug and can't keep the tablet down?"
●
If the doctor offers a tablet to protect her bones:
- ●Reaction: Wary and curious. "Another tablet? Is that because of the steroids? Bronwen's sister had one of those and I think she had trouble with her jaw." If the doctor puts the jaw risk in proportion: "Right. And how do I take it? Is it every day?" She asks which day of the week and what to do about her calcium tablets.
●
If the doctor suggests seeing a rheumatologist or mentions methotrexate:
- ●Reaction: Unsure. "How long would that take? Will they just keep me on the steroids?" She accepts it if it is a way to bring the steroid dose down: "If it means I can get off them sooner, then yes." On methotrexate, alarmed: "Isn't that chemotherapy?" She calms down if told it is a low dose, once a week, with blood checks and the specialist deciding.
●
If the doctor gives vague safety netting, such as "come back if it gets worse", or asks about headaches, scalp pain, jaw pain or eyesight:
- ●Reaction: "Worse how? It's already bad. What would mean I need to ring the same day?" If told these can go with this stiffness: "What do I do if my eyes go funny, ring you or go to the hospital?"
●
If the doctor agrees a plan and asks her to repeat it back:
- ●Reaction: She states it, a little hesitantly. "So 10 milligrams from tomorrow, I don't stop, and I come back in a week." She asks one last thing: "And if I'm still stiff then?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 24 indicators checked+0−0

Positive (0/12)

Negative (0/12)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Hazel has polymyalgia rheumatica (PMR) and her stiffness has returned about three weeks after a reduction from 10 mg to 7.5 mg. She wants to stop prednisolone because of weight gain and fear for her bones, and has left out a dose. The skill is recognising a relapse, restoring control and keeping her on treatment she is tempted to abandon.
●Model plan: confirm a relapse (return of symptoms with raised CRP and ESR, no giant cell arteritis or alternative cause), go back to 10 mg each morning, review in one week, then taper more slowly. Explain why she must not stop, give a steroid card and illness advice, offer a bisphosphonate with calcium and vitamin D, and involve rheumatology or set a clear trigger for referral. Address weight gain with practical advice, and give a specific safety net.
●Acceptable alternatives: the EULAR/ACR route summarised in NICE CKS (go to the pre relapse dose, then come down within 4 to 8 weeks to the dose at which she relapsed); a step to 12.5 mg or 15 mg with a stated plan to come back down; treating in primary care first with clear referral triggers; a bone density scan first with treatment planned from the result (weaker, not a fail).

Confirming a Relapse and Not Something Else

●Relapses are common as the dose falls, and more likely if steroids are reduced too quickly. At each review ask about giant cell arteritis (GCA) symptoms and relapse symptoms (proximal pain, fatigue, morning stiffness), and reassess the diagnosis if symptoms return.
●Atypical features that should prompt a rethink or referral include age under 60, weight loss, night pain or neurological features, normal inflammatory markers, a very high ESR or CRP, and a chronic onset.
●Her markers rose from CRP 4 and ESR 15 to CRP 31 and ESR 49 as the symptoms returned. An isolated raised ESR or CRP without symptoms is not a definite relapse, so symptoms and markers are read together.
●Mimics include arthritis, thyroid disease, statin related myalgia, infection and cancer. Her TSH, CK, calcium, ALP and blood count are normal, she has taken atorvastatin for years without symptoms, and she has no fever, night sweats or weight loss.

Adjusting the Steroid Dose

●CKS: for relapsing symptoms, increase prednisolone to the previous dose that controlled symptoms and monitor the response. Here that is 10 mg once daily in the morning. If symptoms settle, continue and then taper more cautiously with smaller steps or longer at each dose. If they do not settle, seek specialist advice.
●Her 2.5 mg step from 10 mg was larger than the 1 mg steps CKS suggests every 4 to 8 weeks (or 1.25 mg steps using alternate day doses), so the next reduction should be smaller. Check for a newer UK guideline, as the British Society for Rheumatology guideline behind CKS is under revision.
●Review one week after any dose change and at least every three months in the first year, checking blood count, ESR or CRP, urea and electrolytes, blood pressure and glucose.
●Be honest about the road ahead: treatment typically lasts one to two years, flares are common, and most people do come off steroids.

Why She Cannot Simply Stop

●After prolonged corticosteroid treatment the adrenal glands can stay suppressed for years. Abrupt withdrawal can cause acute adrenal insufficiency, low blood pressure and death (BNF), and would also bring a worse relapse. One missed dose after nine months is unlikely to have caused harm, so use it as the way into the explanation rather than as a reproach.
●CKS says to provide a blue steroid treatment card. The Steroid Emergency Card (NHS England alert, August 2020) is for adults on prednisolone 5 mg or more for more than 4 weeks. Hazel qualifies for both cards, and the emergency card does not replace the blue one.
●The BNF says any significant intercurrent illness, trauma or surgery needs a temporary dose increase, so she should seek advice early in a fever or infection. Persistent vomiting needs injected hydrocortisone in hospital. Exact sick day dosing for prednisolone is not marked in this case, only early advice.

Bone Protection

●CKS osteoporosis: offer an oral bisphosphonate without waiting for bone density assessment to women aged 70 or over taking glucocorticoids, and to postmenopausal women taking 7.5 mg or more of prednisolone daily for over three months, with a DXA scan to follow. Hazel meets both criteria. NOGG agrees, and no FRAX calculation is needed first.
●First line is alendronate 70 mg or risedronate 35 mg once weekly, with ibandronate monthly if neither is tolerated. Alendronate is contraindicated with oesophageal abnormalities or hypocalcaemia and avoided if creatinine clearance is below 35 mL/minute. Hers is about 73 and her calcium is normal.
●How to take it: whole, with plain water, on an empty stomach at least 30 minutes before breakfast or other medicines, staying upright for 30 minutes, calcium at a different time. Stop and seek advice for new heartburn, pain on swallowing or pain behind the breastbone.
●Her friend's jaw worry is osteonecrosis of the jaw, much more likely with intravenous bisphosphonates for cancer than with oral tablets for osteoporosis. Advise oral hygiene, dental checks and reporting mouth symptoms.
●Continue the bisphosphonate and calcium and vitamin D while steroids continue, and reassess fracture risk when they stop.

Steroid Side Effects and the Weight Gain

●At every review ask about weight gain, dyspepsia, muscle weakness and bruising, and check blood pressure and glucose every three months. Hers are currently normal.
●Appetite, a rounder face, bruising and poor sleep are recognised effects. Practical advice: regular meals with fewer snacks, puddings as an occasional treat, returning to the aqua class or other weight bearing exercise (which helps her bones), and taking the dose in the morning.
●Weight often eases as the dose falls but may not fall quickly, so never promise it will disappear. Her distress about her appearance is the lever for agreeing the longer plan.

When to Refer and the Steroid Sparing Option

●CKS: refer if steroids cannot be reduced at reasonable intervals, are needed for over two years, flares repeat, or adverse effects (or high risk of them) are present.
●Hazel has relapsed on her first taper, has gained a stone and is at raised fracture risk, so referral or advice and guidance now is reasonable, though primary care first with a clear trigger is also acceptable.
●Steroid sparing drugs, such as interleukin 6 receptor inhibitors or methotrexate in the 2025 EULAR recommendations, are specialist decisions with dose and monitoring set by rheumatology. Methotrexate for inflammatory disease is a much lower dose than in cancer, taken weekly with blood monitoring.

Safety Netting

●GCA can appear as steroids are reduced. Tell her to contact the practice the same day for new headache, scalp tenderness, or jaw or tongue pain on chewing. For any loss of vision, double vision or change in her sight she should seek emergency help the same day, through emergency eye services or 999, as CKS treats new visual symptoms as needing urgent same day ophthalmology assessment.
●Adrenal problems: urgent medical help if she is vomiting and cannot keep the tablet down, or feels faint or collapses, and early advice in any significant illness.
●Relapse: if the stiffness is not clearly improving, she should be seen sooner than the review.

Talking With Someone Who Wants to Stop Treatment

●Her wish to stop is a reasoned response to weight gain, a changed face and fear for her bones, not simply poor adherence. Asking what is behind it brings out the missed dose and her friend's story.
●Begin with her goal of coming off the tablets, and show that the plan (return to 10 mg, a slower taper, a bone tablet and specialist input) is the route to it. Put harms in proportion, since overstating them in either direction makes her less likely to take the advice.
●Ask her to say the plan back, since a plan with four parts is easy to leave with half remembered.
●Offer a face to face visit if examination or measurements are needed.

Common Mistakes in This Station

●Offering painkillers and leaving the dose at 7.5 mg, or reducing again straight away.
●Treating the relapse as giant cell arteritis, with a high dose, imaging or biopsy, when there are no GCA features.
●Not screening for headache, scalp tenderness, jaw pain and visual symptoms.
●Agreeing that she can stop, or not explaining why stopping suddenly is unsafe.
●Offering calcium and vitamin D alone to a woman of 71 with nine months of prednisolone.
●Not issuing or checking a steroid card, and giving no illness advice.
●Dismissing the weight gain or promising it will drop off.
●No review one week after the dose change, and no plan for how the dose will come down.
●No thought of specialist input, and vague safety netting such as "come back if it gets worse".

Mapped to the RCGP curriculum topic: Musculoskeletal Health.

← Back to Free SCA Practice Cases