History Taking · Intermediate · Rheumatology

Shoulder and Hip Pain in a 68-Year-Old Woman

Practise this PLAB 2 history taking station on Polymyalgia Rheumatica. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mrs Shannon Galloway, a 68-year-old woman, has come to see you complaining of pain and stiffness in both shoulders and hips that started gradually over the past four weeks. She is struggling with daily activities and appears fatigued. Please take a focused history and discuss your initial management plan.

Background notes: PMH: Hypertension, Hypercholesterolaemia, Osteoporosis, Appendectomy, Hysterectomy

What this station tests

  • PMR pattern recognition: bilateral proximal girdle pain and stiffness, morning stiffness >1 hour, constitutional symptoms, age >50
  • GCA screening in every PMR patient: headache, jaw claudication, visual symptoms, scalp tenderness
  • Prednisolone as both treatment and diagnostic test: dramatic improvement within 1 to 3 days confirms PMR
  • Excluding PMR mimics: malignancy, myeloma (protein electrophoresis), myositis (CK), hypothyroidism, late-onset RA
  • Bone protection alongside steroids: calcium, vitamin D, bisphosphonate consideration, especially with existing osteoporosis

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

PMR stations test pattern recognition: bilateral proximal girdle stiffness in a patient over 50 with elevated inflammatory markers. The candidate must also screen for GCA, which coexists in 15% of PMR patients. Mrs Galloway is 68, presenting with 4 weeks of bilateral shoulder and hip pain with morning stiffness lasting over an hour. She is struggling to dress, wash her hair, and get out of chairs. Open with: 'Mrs Galloway, tell me about the pain and stiffness and how it is affecting your daily life.'

Core approach

The PMR pattern: bilateral shoulder and hip girdle pain and stiffness, gradual onset over weeks, morning stiffness lasting over an hour (often 1 to 2 hours), improving through the day with activity. Difficulty raising arms (washing hair, hanging laundry), difficulty rising from chairs, difficulty climbing stairs. Constitutional symptoms: fatigue, weight loss, reduced appetite, low-grade fever. These support the diagnosis.

Screen for GCA urgently. Headache? Jaw claudication? Visual symptoms? Scalp tenderness? These coexist in 15% of PMR patients, and GCA is an emergency (risk of blindness). She reports none, which is reassuring but does not exclude future development.

Distinguish from other causes of proximal pain. RA: typically small joints, symmetrical, but can overlap. Fibromyalgia: widespread pain but normal inflammatory markers. Hypothyroidism: check TFTs (she already has hypothyroidism, check if adequately treated). Malignancy: cancer can present with PMR-like syndrome. Late-onset RA: can mimic PMR in elderly patients.

ICE: She thinks it is arthritis. She is worried about weight loss and fatigue (cancer concern). She wants to get back to gardening and retirement activities.

Closing and safety netting

Investigations: ESR and CRP (expected to be significantly elevated), FBC, U&E, LFTs, calcium, TFTs, protein electrophoresis (exclude myeloma), CK (exclude myositis). If ESR and CRP are elevated with the classic clinical picture, the diagnosis is PMR.

The diagnostic test for PMR is the response to prednisolone. 'If this is PMR, you should notice a dramatic improvement within 1 to 3 days of starting prednisolone.' Start 15mg daily (NICE/BSR guideline). If no response within a week, reconsider the diagnosis. Gradual taper over 12 to 18 months. Bone protection: calcium, vitamin D, and consider bisphosphonate given her osteoporosis history.

GCA safety netting is critical: 'If you develop a new headache, pain when chewing, or any change in your vision, contact us immediately or go to A&E. These could indicate a related condition that needs urgent treatment.' Follow-up in 1 week to assess steroid response and bloods.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for polymyalgia rheumatica. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: PMR pattern confirmed (bilateral proximal, stiffness >1 hour, constitutional symptoms). GCA screening performed. Differential considered (myeloma, myositis, hypothyroidism). Functional impact assessed. Osteoporosis history noted for bone protection.

Costs marks: Not screening for GCA. Not considering myeloma. Not assessing stiffness duration. Incomplete functional assessment.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Correct investigations including protein electrophoresis. Prednisolone 15mg started. Response assessment planned at 1 week. Bone protection initiated. GCA safety netting. Gradual taper plan mentioned.

Costs marks: No GCA safety netting. Wrong steroid dose. No bone protection. No response assessment. Missing protein electrophoresis.

Domain 3: Interpersonal Skills (Throughout)

Scores well: Addressing cancer concern (weight loss and fatigue). Providing hope about steroid response. GCA warning delivered clearly without causing panic. Acknowledging impact on retirement activities.

Costs marks: Not addressing cancer concern. Alarming about GCA without context. Not providing treatment hope.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Not screening for GCA. PMR and GCA coexist in 15% of patients. Missing GCA risks irreversible blindness. Candidates must ask about headache, jaw claudication, and visual symptoms in every PMR patient.
  2. Not using prednisolone response as a diagnostic criterion. If a patient with suspected PMR does not improve dramatically within 1 to 3 days of starting prednisolone, the diagnosis should be reconsidered. Candidates who start steroids without planning to assess response miss this diagnostic tool.
  3. Not excluding myeloma. Protein electrophoresis should be part of the PMR workup because myeloma can present with similar symptoms. Candidates who order standard bloods without protein electrophoresis miss this differential.

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How do I approach the consultation in this polymyalgia rheumatica station?

PMR stations test pattern recognition: bilateral proximal girdle stiffness in a patient over 50 with elevated inflammatory markers. The candidate must also screen for GCA, which coexists in 15% of PMR patients. Mrs Galloway is 68, presenting with 4 weeks of bilateral shoulder and hip pain with morning stiffness lasting over an hour.

What does a strong performance look like to the examiner in this station?

Strong performances show: PMR pattern confirmed (bilateral proximal, stiffness >1 hour, constitutional symptoms). GCA screening performed. Differential considered (myeloma, myositis, hypothyroidism). Weak performances: Not screening for GCA. Not considering myeloma. Not assessing stiffness duration. Incomplete functional assessment.

What is the biggest pitfall in this polymyalgia rheumatica station?

Not screening for GCA. PMR and GCA coexist in 15% of patients. Missing GCA risks irreversible blindness.

How should I prepare for polymyalgia rheumatica if I have never seen it in practice?

This station rewards process over personal experience. The skill being assessed: GCA screening in every PMR patient: headache, jaw claudication, visual symptoms, scalp tenderness. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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