OSCE — assessment of suspected fibromyalgia in a middle-aged woman with chronic widespread pain · MBBS OSCE

Brief (to candidate)

A 45-year-old woman presents with a 6-month history of widespread aching pain across her neck, back, chest wall and all four limbs, with profound fatigue, unrefreshing sleep and difficulty concentrating at work. She reports bloating, intermittent headaches and low mood. Examination by her primary-care physician was reported as normal. You have 10 minutes to take a focused history, perform a relevant examination, make a positive clinical diagnosis, and outline your management plan including investigations, non-pharmacological and pharmacological therapy.

Candidate instructions

Take a focused biopsychosocial history of pain, fatigue, sleep, cognition, somatic symptoms, mood and prior healthcare.
Perform a structured examination — general, joint, neurological and bedside sensory testing for allodynia.
Apply the ACR 2016 criteria (WPI + SSS) and state your diagnostic threshold.
List the baseline investigations you would request to exclude mimics.
Outline the stepwise management — non-pharmacological first line plus appropriate pharmacological adjuncts, and the drugs you would avoid.

Examiner checklist (mark each domain / 10)

Domain	Key actions expected
Pain history (site, duration, character, aggravating/relieving factors)	Establishes widespread pain (axial + bilateral, upper and lower), present ≥ 3 months, deep aching/burning, aggravated by stress/sleep loss, partially relieved by gentle activity and warmth
Core symptom cluster	Asks specifically about fatigue, unrefreshing sleep ("refreshed on waking?"), cognitive dysfunction (attention, memory, word-finding), mood (depression, anxiety, catastrophising, suicidal ideation)
Somatic co-symptoms	Screens for IBS (bloating, alternating constipation/diarrhoea), headache, dysmenorrhoea / pelvic pain, TMJ pain, bladder urgency, non-dermatomal paraesthesiae, Raynaud-like, restless legs, multiple drug/food sensitivities
Psychosocial history	Adverse childhood events; ongoing stressors; work impact; prior healthcare experience (often felt disbelieved); social support; sleep pattern; caffeine, alcohol, screen use
Red-flag screen	Actively excludes weight loss, fever, night pain/sweats, neurological deficit, joint swelling, focal/progressive symptoms
Examination	Documents normal general, joint and neurological examination apart from soft-tissue tenderness / widespread allodynia; explicitly records absence of synovitis, weakness, sensory level, organomegaly, rash
Diagnostic scoring	Applies ACR 2016: counts Widespread Pain Index (19 body areas) and Symptom Severity Scale (fatigue + unrefreshing sleep + cognitive + somatic); states WPI 7+ SSS 5+ or WPI 4 to 6 SSS 9+, symptoms ≥ 3 months, no alternative diagnosis required
Investigations	TSH, FBC, ESR/CRP, CK, renal and liver function, vitamin D, calcium, fasting glucose; autoantibodies and imaging only if clinically indicated; no screening whole-body imaging
Diagnosis	States fibromyalgia as a positive clinical diagnosis — chronic nociplastic pain (central sensitisation); a diagnosis permitted alongside other conditions, not one of exclusion^[1]
Management — non-pharmacological first line	Patient education and validation ("pain is real but due to a sensitised nervous system, not tissue damage"); graded aerobic exercise ("start low, go slow"); CBT; sleep hygiene and pacing; multidisciplinary care with a single coordinating clinician
Management — pharmacological adjunct	Drug chosen by predominant symptom: duloxetine 30 to 60 mg daily (pain + depression) OR low-dose amitriptyline 10 to 25 mg nocte (pain + sleep) OR pregabalin 75 to 300 mg daily (pain + sleep + anxiety); titrate slowly, review at 4 to 8 weeks^[2]
Drugs to AVOID	Strong opioids (ineffective, cause hyperalgesia, dependence); corticosteroids and immunosuppressants (no role); minimise benzodiazepines; treats comorbid depression/anxiety actively
Disposition & safety-net	Single coordinating clinician (usually GP/primary-care); refer to rheumatology once for diagnosis confirmation, physiotherapy for graded exercise, psychology for CBT, sleep medicine if STOP-BANG positive; explain realistic goal of improved function rather than zero pain

Model key actions

Establishes positive diagnosis using ACR 2016 — does not present fibromyalgia as a diagnosis of exclusion.^[1]
Validates the patient — explains nociplastic pain in plain language; acknowledges the suffering and the years of disbelieved symptoms.
Orders focused baseline panel — TSH, FBC, ESR/CRP, CK, renal and liver function, vitamin D, calcium, fasting glucose; autoantibodies only if features suggest an inflammatory disease.
Prescribes graded aerobic exercise as the single best-evidenced intervention; sets a "start low, go slow" plan; warns against boom-bust.
Recommends CBT plus sleep hygiene and pacing; coordinates multidisciplinary care.
Selects one pharmacological adjunct by predominant symptom — duloxetine, amitriptyline or pregabalin — with explicit dose, titration and review schedule.^[2]
Refuses strong opioids; explains the iatrogenic harm and the alternative of structured taper if already on opioids.
Identifies and addresses red flags — none present in this stem; explains the safety-net.
Sets realistic expectations — meaningful improvement in function rather than zero pain; chronic but non-progressive disease.

Common errors

Treating fibromyalgia as a diagnosis of exclusion and ordering a cascade of imaging and autoantibodies without indication.
Failing to validate the patient or dismissing the pain as "all in the head" — destroys the therapeutic alliance and prevents engagement with non-pharmacological therapy.
Prescribing a strong opioid, corticosteroid or benzodiazepine — all ineffective or harmful.
Starting exercise too aggressively, without "start low, go slow" advice, triggering a flare and dropping out.
Missing a comorbid mood disorder — depression and anxiety are not "soft" comorbidities; they independently worsen pain and require active treatment.
Overlooking obstructive sleep apnoea — STOP-BANG positive patients benefit hugely from CPAP, sometimes more than from any drug.
Missing the overlap with inflammatory rheumatic disease (no synovitis, normal CRP, but widespread tenderness) and escalating immunosuppression unnecessarily.
Failing to provide a single coordinating clinician — duplicated investigation, polypharmacy and contradictory advice follow.

References2Show

[1]Murphy AE, Minhas D, Clauw DJ. Identifying and Managing Nociplastic Pain in Individuals With Rheumatic Diseases: A Narrative Review. Arthritis Care and Research, 2023.PMID 36785994
[2]Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Annals of the Rheumatic Diseases, 2017.PMID 27377815