Return to Scenario ListShow Learning Points most relevant to Phase 1:

Headache, morning stiffness and shoulder pain

Clinical Discipline(s)/Organ System(s)
Musculoskeletal System, Rheumatology, Anatomical Pathology
Progress Test Topic(s)
A 70 year old NZ European woman sees her GP with a 6 week history of aching and morning stiffness in the shoulders, hip girdle and neck. This has slowly worsened and in the last 2 days she has developed a severe headache with scalp tenderness. Her body mass index (BMI) is calculated and is 18. You organise an erythrocyte sedimentation rate (ESR) and the result is 66 mm in 1 hour (normal 0-30).
Progress Test-Type Questions:   Question 1 | Question 2
Applied Science for Medicine 
   - Structure, function and common pathologies of blood vessels including regulation of blood pressure
   - Acute phase reactants in acute /chronic inflammation
   - Immunophysiology of vasculitis /angiitis /arteritis
   - Classification of the vasculitides by size of vessel involved
   - Disease 'clustering': current hypotheses of infectious and genetic associations in polymyalgia rheumatica (PMR) and giant cell arteritis (GCA)
   - Pharmacology of anti-inflammatory corticosteroids
   - Bone mineralisation and its control
Clinical and Communication Skills 
   - History from a patient with possible vasculitis
   - Systematic examination of a patient with possible vasculitis including fundoscopy, blood pressure measurement, urinalysis
   - Indications for temporal artery biopsy
   - Measure height and weight to calculate Body Mass Index (BMI)
   - Development and exclusion of differential diagnoses in a non-specific presentation
   - Diagnostic criteria of polymyalgia rheumatica and giant cell arteritis; importance of early recognition in view of the threat to vision
   - Presentation and complications of vasculitis including polymyalgia rheumatica and giant cell arteritis
   - Use of immunosuppression and steroids in vasculitis including the importance of bone protection for prevention of steroid-induced osteoporosis; ensuring adequate dose and titration of dose in response to clinical improvement and ESR level
   - Use of bone densitometry in osteoporosis (DEXA scan)
   - Primary and secondary preventative measures in osteoporosis - lifestyle and pharmacological mechanisms of action
   - Use of acute phase reactants in diagnosis and in monitoring disease activity
Personal and Professional Skills 
   - Be able to counsel a patient about long-term steroid use, including appropriate discussion of the therapeutic effects and side effects
   - Be aware of factors influencing length of disability: adherence with treatment, issues of health literacy, attendance for follow-up care, complications of steroid therapy
Hauora Māori 
   - Inequitable access to health care for Māori, including delays in diagnosis
   - Whānau responsibilities of the patient
Population Health 
   - Vasculitides - incidence, risk factors and natural history
   - Effectiveness and cost-effectiveness of screening for and treating osteoporosis
Conditions to be considered relating to this scenario
polymyalgia rheumatica, giant cell arteritis, fibromyalgia, osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus (SLE), hypo /hyperthyroidism, depression
Less common but 'important not to miss'
multiple myeloma
dermatomyositis/polymyositis, inclusion body myositis, myositis associated with neoplasia, carcinoma