CCE-CE-031 - GP Exams

Case ID: ANK-2025-002
Case Name: Michael Reynolds
Age: 32
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L77 – Sprain/strain ankle

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their symptoms, ideas, concerns, and expectations. 1.4 Communicates examination findings and management plan effectively.
2. Clinical Information Gathering and Interpretation	2.1 Gathers a focused musculoskeletal history, including mechanism of injury. 2.2 Applies the Ottawa Ankle Rules to determine need for imaging.
3. Diagnosis, Decision-Making and Reasoning	3.1 Demonstrates structured clinical reasoning in assessing ankle injuries. 3.3 Differentiates between ankle sprain, fracture, and other causes of ankle pain.
4. Clinical Management and Therapeutic Reasoning	4.2 Develops an appropriate management plan, considering pain relief and functional recovery. 4.5 Advises on rehabilitation and injury prevention strategies.
5. Preventive and Population Health	5.1 Provides patient education on ankle strengthening and future injury prevention.
6. Professionalism	6.3 Ensures patient safety by correctly applying clinical guidelines (Ottawa Ankle Rules).
8. Procedural Skills	8.1 Performs an appropriate musculoskeletal examination, including weight-bearing assessment.
9. Managing Uncertainty	9.2 Safely manages the patient with an unclear diagnosis and provides a follow-up plan.

CASE FEATURES

Mechanism of injury: Rolled ankle while playing indoor soccer
Application of Ottawa Ankle Rules to assess need for imaging
Differentiating sprain vs. fracture using clinical reasoning
Patient concern about ligament damage and long-term recovery
Management plan: RICE (Rest, Ice, Compression, Elevation), analgesia, rehabilitation
When to refer for imaging or specialist input

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take an appropriate history from Michael
Explain your differential diagnosis
Provide a clear management plan
Address Michael’s concerns

SCENARIO

Michael Reynolds, a 32-year-old male, presents to your general practice clinic after rolling his right ankle while playing indoor soccer last night. He describes feeling a sudden sharp pain on the outer side of his ankle when he landed awkwardly. He was able to walk off the court but found it painful. The ankle has since become swollen and bruised. He is concerned about whether he has broken a bone or torn a ligament and is unsure if he needs an X-ray.

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Reynolds
Age: 32
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Past History

No previous ankle injuries
No chronic medical conditions

Social History

Works as a carpenter

Family History

No history of osteoporosis or connective tissue disorders

Smoking

Alcohol

Occasional, socially

Vaccination and Preventative Activities

Up to date

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, I rolled my ankle playing soccer last night, and now it’s really swollen. Do you think it’s broken?”

General Information

You were playing indoor soccer when you landed awkwardly on your right foot and twisted your ankle.
You felt immediate sharp pain on the outer side of your ankle.
You were able to walk off the court, but weight-bearing was painful.
Over the next few hours, your ankle became swollen and bruised.
You are worried about whether it’s a fracture or ligament damage.
You need to know if you need an X-ray and how long this will take to heal.

Specific Information

(To be provided only when asked relevant questions)

Pain Characteristics

The pain was sharp and intense immediately after the injury but has now settled into a throbbing ache.
Pain is worse with movement, especially twisting motions.
Resting with the foot elevated seems to help.
It is most painful around the outer part of the ankle, just below the bony bump.
There is no pain in the midfoot or other areas of the foot.
No numbness or tingling in the foot.

Swelling and Bruising

The ankle became swollen within an hour after the injury.
The swelling is mainly on the outside of the ankle and has not spread much.
There is some bruising developing along the side of the foot, but it is not excessive.

Weight-Bearing Ability

You were able to walk off the court immediately after the injury, though it was painful.
You can put some weight on it now, but you are limping due to the pain.
It feels unstable when walking, but you haven’t fallen.

Concerns & Emotional Reactions

You are worried about whether you’ve broken a bone and need an X-ray.
You have never injured your ankle before, so you don’t know what to expect.
You are a carpenter, and your job requires standing, climbing ladders, and moving around all day.
You are concerned about how long you’ll be off work if it is serious.
You’ve heard of long-term ankle instability after sprains and want to avoid future injuries.
You don’t want to rush back and make it worse, but you also don’t want to waste time with unnecessary tests.

Questions for the Doctor

“How do you know if it’s a sprain or a fracture?”
“Do I need an X-ray?”
“How long will this take to heal?”
“What can I do to recover faster?”
“When can I go back to work?”
“Will I need to see a physio?”

Emotional Cues & Body Language

You appear slightly anxious about the possibility of a fracture and how long you might need to rest.
You frown and rub your ankle gently when describing the pain.
If the doctor seems uncertain or dismissive, you press for more information about X-rays and long-term recovery.
If the doctor provides clear explanations and a plan, you visibly relax and feel reassured.

Expected Outcome

If the doctor explains the Ottawa Ankle Rules and justifies whether imaging is needed, you accept the recommendation.
If reassured about management and recovery timeline, you feel more at ease.
If concerns about long-term function and prevention are addressed, you are satisfied with the consultation.
You are relieved if told that the injury is likely a sprain rather than a fracture.
If told to modify activity and return to work gradually, you appreciate the practical advice.

Additional Information for Role-Player Flexibility

If the candidate does not address your weight-bearing ability, you should press for an X-ray:

“But I can still kind of walk on it… does that mean it’s not broken?”

If the candidate does not mention rehabilitation or prevention, you should ask:

“How do I stop this from happening again?”
“Will my ankle be weaker after this?”

If the candidate does not give a timeframe for recovery, you should ask:

“So when do you think I’ll be back to normal?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from Michael, including the mechanism of injury, pain characteristics, and functional impact.

The competent candidate should:

Use open-ended questions to explore how the injury occurred and establish the exact mechanism of injury.
Clarify pain characteristics, including onset, location, severity, aggravating and relieving factors.
Ask about weight-bearing ability since the injury, as this is a key part of the Ottawa Ankle Rules assessment.
Assess for red flag symptoms, such as severe pain, numbness, tingling, or inability to move toes, which may indicate a more serious injury.
Explore previous injuries, any history of ankle instability, or any predisposing factors such as ligament laxity.
Assess impact on daily activities and work, given Michael’s physically demanding occupation.
Address Michael’s concerns about long-term recovery and return to sport/work.
Provide empathetic communication while reassuring the patient that a structured assessment will guide appropriate management.

Task 2: Explain your differential diagnosis and the application of the Ottawa Ankle Rules to determine if imaging is needed.

The competent candidate should:

Explain that the most likely diagnosis is an ankle sprain, but other possibilities include:
- Lateral malleolus fracture
- Syndesmosis injury
- Avulsion fracture
- Midfoot injury (if pain extends beyond the ankle)
Use the Ottawa Ankle Rules to determine the need for an X-ray, explaining that imaging is recommended if:
- Tenderness over the posterior edge or tip of the lateral or medial malleolus
- Inability to bear weight for four steps both immediately after the injury and during examination
- Tenderness over the navicular bone or base of the 5th metatarsal
If Michael does not meet the Ottawa criteria, explain that an X-ray is unlikely to change management and can be avoided.
Check for patient understanding and address any concerns about missed fractures or long-term complications.

Task 3: Provide a clear management plan, including pain relief, activity modification, and rehabilitation strategies.

The competent candidate should:

Reassure Michael that his injury is most likely a sprain and explain expected healing times.
Manage pain appropriately, advising on:
- Paracetamol and NSAIDs if no contraindications.
- Rest, Ice, Compression, Elevation (RICE) for the first 48-72 hours.
Discuss early mobilisation, avoiding complete immobilisation unless a fracture is present.
Encourage gentle range-of-motion exercises once acute pain subsides.
Discuss the use of a brace or supportive strapping for stability.
Provide clear return-to-work and sport guidance, explaining that gradual weight-bearing and strengthening exercises will help prevent re-injury.

Task 4: Address Michael’s concerns about long-term recovery and future injury prevention.

The competent candidate should:

Acknowledge Michael’s concerns about long-term recovery and reassure him that most ankle sprains recover well with proper rehabilitation.
Explain that ligament damage can lead to chronic instability if not properly rehabilitated.
Provide injury prevention advice, including:
- Balance and proprioception exercises to improve ankle stability.
- Strengthening exercises for the lower limb to support the ankle joint.
- Wearing appropriate footwear during sports and work.
If Michael has persistent pain or repeated sprains, discuss the possibility of physiotherapy referral.
Provide a clear follow-up plan, ensuring he understands when to seek medical review if symptoms persist.

SUMMARY OF A COMPETENT ANSWER

Takes a thorough history, including mechanism of injury, pain, and weight-bearing ability.
Uses Ottawa Ankle Rules correctly to determine the need for imaging.
Explains the differential diagnosis clearly and logically.
Provides an evidence-based management plan, including RICE, pain relief, and rehabilitation.
Addresses patient concerns about long-term recovery and recurrence prevention.
Provides clear return-to-work and sport advice tailored to the patient’s occupation.

PITFALLS

Failing to assess weight-bearing ability, missing a key part of the Ottawa Ankle Rules.
Ordering unnecessary imaging when the Ottawa Ankle Rules suggest it is not required.
Not providing a structured rehabilitation plan, leading to prolonged recovery.
Over-reassuring without explaining injury prevention, missing an opportunity for education.
Not discussing return-to-work strategies, given the patient’s physically demanding job.
Failing to check patient understanding and not addressing concerns about long-term function.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency Assessment

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.4 Communicates examination findings and management plan effectively.

2. Clinical Information Gathering and Interpretation

2.1 Gathers a focused musculoskeletal history, including mechanism of injury.
2.2 Applies the Ottawa Ankle Rules to determine the need for imaging.

3. Diagnosis, Decision-Making and Reasoning

3.1 Demonstrates structured clinical reasoning in assessing ankle injuries.
3.3 Differentiates between ankle sprain, fracture, and other causes of ankle pain.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops an appropriate management plan, considering pain relief and functional recovery.
4.5 Advises on rehabilitation and injury prevention strategies.

5. Preventive and Population Health

5.1 Provides patient education on ankle strengthening and future injury prevention.

6. Professionalism

6.3 Ensures patient safety by correctly applying clinical guidelines (Ottawa Ankle Rules).

8. Procedural Skills

8.1 Performs an appropriate musculoskeletal examination, including weight-bearing assessment.

9. Managing Uncertainty

9.2 Safely manages the patient with an unclear diagnosis and provides a follow-up plan.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD