DOCTOR’S NOTES

You are an FY2 in a GP surgery

Personal Details:

Name: Margaret Hughes

Age: 64

Medical Record:

Past medical history: Polymyalgia Rheumatica (PMR) diagnosed 1 month ago. Hypertension. Type 2 Diabetes (diet-controlled).

Regular medication: Prednisolone 10mg (reduce by 1mg every 4-6 weeks), Lansoprazole 20mg, Alendronic Acid 70mg once weekly, Amlodipine 10mg OD, Aspirin 75mg OD.

Allergies: None known.

Notes:

Margaret was diagnosed with PMR a month ago and started on steroids, with a good response. She is attending a follow-up.

Task:

Review her PMR and address her concerns

Opening Sentence: “Hello, Doctor. I’m feeling so much better since I started the treatment; the pain and stiffness are gone. I’ve brought my list of tablets, and to be honest, I’d like to stop the steroids now.”

Open History (to give freely): I feel back to my normal self, so I don’t see why I need to keep taking them. I’ve heard that steroids are bad for you and have lots of side effects. I don’t want to be on them long-term.”

Cues to give: “Why am I taking all these other tablets? The Lansoprazole and the Alendronate one? I didn’t take them before.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I think now that the pain is gone, I don’t need the treatment anymore.”

Concerns: “Why do I need to continue steroids, as I’m feeling well? I’m worried about the side effects.”

Expectation: “I’m hoping you’ll agree that I can stop the steroids.”

How to Act: You are a sensible, well-informed patient. You are not being difficult, but you have valid concerns and want a clear explanation.

More History (only if asked): Before starting the steroids, you had terrible pain and stiffness in your shoulders and hips, especially in the mornings. You couldn’t even lift your arms to brush your hair. Now, that is completely gone. You are retired and live with your husband.

Social History: You are retired.

Questions to ask:

“What will happen if I just stop them?”

“How long will I have to be on them?”

Assessing Treatment Response:

Hello Margaret, it’s good to see you. How have you been feeling since starting the Prednisolone? You mentioned the stiffness has vanished. That’s wonderful. On a scale of to, how would you rate your symptoms now compared to a month ago?

Screening for GCA (Giant Cell Arteritis): I need to ask a few important safety questions. Since we last met, have you had any new headaches, any problems with your vision, or any pain in your jaw when you chew?

Exploring Steroid Side Effects & Concerns: Have you noticed any side effects from the tablets so far? You mentioned you’ve read the leaflet. What particular side effects are you most worried about?

ICE (Ideas, Concerns, Expectations):

What are your own thoughts about being on steroids long-term?

Your main concern is the side effects. What were you hoping we could do about that today?

You asked about stopping them. What made you think that might be an option?

Acknowledgement:

Hi Margaret, it’s great to hear how much better you’re feeling. It sounds like the steroids have worked very well, which is excellent news. I understand completely why you’re asking about stopping them. It’s very sensible to question the medications you’re on.

Addressing and answering the patient’s ICE:

You’re feeling well because the steroids are doing a fantastic job of controlling the inflammation that causes PMR. However, the underlying condition is still there. If you were to stop the steroids suddenly, the inflammation would come back with a vengeance, and all the pain and stiffness would return. Also, stopping steroids abruptly can make you very unwell, as your body gets used to them.

Explain the plan of steroid intake

The treatment for PMR involves taking steroids for a longer period, usually for about one to two years, but we don’t keep you on the starting high dose. The plan is to very slowly reduce the dose over many months. We call this ‘tapering’. We reduce it by a tiny amount, wait a few weeks to ensure the symptoms don’t return, and then reduce it again. It’s a very gradual process to find the lowest possible dose that keeps you symptom-free.

Discuss possible side effects

You are right to be concerned about side effects, and that’s exactly why we have you on the other medications. You asked about the Lansoprazole and Alendronic Acid. Steroids can sometimes irritate the stomach lining, so we give you Lansoprazole to protect your stomach. Steroids can also thin the bones over time, so we give you Alendronic Acid, which is a bone-strengthening medication, to protect your bones. We are actively managing and preventing the side effects.

So, while you will be on steroids for a while longer, the dose will be coming down, and we are protecting you against the main side effects. It’s a balance of risks, and for PMR, the benefits of being on a low dose of steroids far outweigh the risks.

Addressing ideas, concerns, and expectations: Validate her concerns about steroids. Correct her idea that feeling better means the condition is cured. Explain the rationale for long-term, tapering treatment.

Explain the purpose of the other medications (Lansoprazole for gastric protection, Alendronic Acid for bone protection) as a way of demonstrating proactive management of side effects. Reassure her that the goal is the lowest effective dose for the shortest necessary time.

What is scenario testing? This is a medication counselling and shared decision-making station. It tests the candidate’s ability to persuade a patient to adhere to a long-term treatment plan by explaining the risks of stopping and the measures in place to mitigate side effects. It requires a good understanding of the principles of steroid treatment and tapering.