GP CCE Cases · musculoskeletal-presentations
Shoulder stiffness in a 72-year-old — CCE clinical encounter
CCE-style clinical encounter: a 72-year-old man with 6 weeks of bilateral shoulder stiffness demanding 'something for the arthritis'. The candidate must reach the PMR diagnosis clinically, screen for GCA, negotiate the steroid decision against his preference for 'a natural approach', and set up bone protection and monitoring.
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Target exams
RACGP CCEFRACGP oralsCFPC SOOs
Prompt
A 72-year-old retired teacher attends: 'My shoulders have seized up over the past month — I can't get my jacket on. My mother had arthritis; I don't want to end up in a wheelchair.' Morning stiffness about 90 minutes. No headaches, no visual change, no jaw or limb claudication. CRP 52 mg/L, ESR 68. RF and anti-CCP negative. BP 138/84, T-score -1.9 at the hip. He is wary of steroids ('they thinned my friend's bones').
Objectives
- Elicit the PMR pattern and confirm the diagnosis clinically with the criteria framework. [1]
- Complete and document the GCA screen before discussing treatment. [2]
- Negotiate the steroid decision honestly: dose, expected response, duration, and the bone-protection plan that answers his fear. [5]
- Set the monitoring and relapse plan so he knows what happens next. [4]
- Safety-net for GCA red flags between visits. [2]
References6ShowHide
- [1]Dasgupta B, Cimmino MA, Kremers HM, et al. 2012 Provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative Arthritis Rheum, 2012.PMID 22389040
- [2]Mukhtyar CB, Nikiphorou E, Bartoletti A, et al. 2025 EULAR recommendations for the management of polymyalgia rheumatica and primary large vessel vasculitis Ann Rheum Dis, 2026.PMID 42481270
- [3]Buttgereit F, Dejaco C, Matteson EL, et al. Polymyalgia Rheumatica and Giant Cell Arteritis: A Systematic Review JAMA, 2016.PMID 27299619
- [4]Floris A, Piga M, Chessa E, et al. Long-term glucocorticoid treatment and high relapse rate remain unresolved issues in the real-life management of polymyalgia rheumatica: a systematic literature review and meta-analysis Clin Rheumatol, 2022.PMID 34415462
- [5]Humphrey MB, Russell L, Danila MI, et al. 2022 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis Arthritis Rheumatol, 2023.PMID 37845798
- [6]Keller KK, Mukhtyar CB, Nielsen AW, et al. Recommendations for early referral of individuals with suspected polymyalgia rheumatica: an initiative from the international giant cell arteritis and polymyalgia rheumatica study group Ann Rheum Dis, 2024.PMID 38050004