CCE-CE-066.1

CASE INFORMATION

Case ID: CCE-RHEUM-026
Case Name: David Reynolds
Age: 38
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L88 – Arthritis (excluding osteoarthritis and rheumatoid arthritis)

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Establishes rapport and engages the patient
1.2 Explores the patient’s concerns, ideas, and expectations
1.3 Provides clear and structured explanations about diagnosis, prognosis, and management
2. Clinical Information Gathering and Interpretation2.1 Takes a structured history, including joint symptoms, risk factors, and extra-articular manifestations
2.2 Identifies red flags and indications for further investigation
3. Diagnosis, Decision-Making and Reasoning3.1 Differentiates between different types of inflammatory arthritis (e.g., psoriatic, reactive, or seronegative arthritis)
3.2 Identifies when further investigations or specialist referral is required
4. Clinical Management and Therapeutic Reasoning4.1 Provides an evidence-based treatment plan, including pharmacological and non-pharmacological strategies
4.2 Educates the patient on the chronic nature of inflammatory arthritis and the importance of ongoing care
5. Preventive and Population Health5.1 Identifies risk factors for inflammatory arthritis and associated comorbidities
5.2 Advises on long-term health monitoring, including cardiovascular risk
6. Professionalism6.1 Demonstrates empathy and a patient-centred approach
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate documentation and follow-up of arthritis management
8. Procedural Skills8.1 Orders and interprets relevant investigations (e.g., inflammatory markers, autoimmune serology, joint imaging)
9. Managing Uncertainty9.1 Recognises when symptoms require urgent intervention versus ongoing monitoring
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies and appropriately manages complications of inflammatory arthritis (e.g., uveitis, enthesitis)

CASE FEATURES

  • Need for appropriate investigation, early management, and potential rheumatology referral
  • Persistent joint pain, swelling, and morning stiffness lasting >1 hour
  • History of psoriasis, suggesting possible psoriatic arthritis
  • Recent gastrointestinal illness before onset of symptoms, raising possibility of reactive arthritis

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:

  1. Take an appropriate history, including joint symptoms, associated features, medical history, and risk factors for inflammatory arthritis.
  2. Differentiate between types of inflammatory arthritis and identify red flags requiring urgent referral.
  3. Provide a diagnosis and discuss an initial management plan, including investigations and symptom control.
  4. Educate the patient on chronic disease management, lifestyle factors, and the need for follow-up.

SCENARIO

David Reynolds, a 38-year-old construction worker, presents with joint pain, swelling, and stiffness affecting his fingers, wrists, and ankles for the past two months.

His symptoms include:

  • Morning stiffness lasting over an hour.
  • Joint pain improving slightly with movement but worsening after rest.
  • Some episodes of joint redness and warmth.
  • Mild fatigue and intermittent lower back pain.

His main concerns are:

  • “Why are my joints so stiff and painful? Is this arthritis?”
  • “Will this get worse? Will I still be able to work?”
  • “Do I need strong medication for this?”
  • “What tests do I need, and do I have to see a specialist?”

PATIENT RECORD SUMMARY

Patient Details

Name: David Reynolds
Age: 38
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • No known drug allergies

Medications

  • Paracetamol as needed for pain relief
  • Occasional ibuprofen

Past History

  • Psoriasis (diagnosed five years ago, mild, treated with topical steroids)
  • Gastroenteritis six weeks ago (self-limited, no antibiotics required)

Social History

  • Works in construction, physically active but limited by joint pain recently.
  • Smokes 5–10 cigarettes per day, social alcohol consumption.
  • Married, has two children, enjoys playing football on weekends.

Family History

  • No known autoimmune diseases.
  • Father had osteoarthritis in later life.

Vaccination and Preventative Activities

  • No recent blood tests.
  • Up to date with vaccinations.

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, my joints have been really stiff and painful for weeks now, especially in the morning. I’m worried I have arthritis.”

General Information

David Reynolds is a 38-year-old construction worker presenting with persistent joint pain, stiffness, and swelling for the past two months.

  • Symptoms started gradually and have been getting worse.
  • Pain mainly affects fingers, wrists, and ankles, making it hard to grip tools at work.
  • Morning stiffness lasts over an hour but improves slightly with movement.
  • Feels fatigued but no fevers, night sweats, or weight loss.
  • Occasional lower back stiffness, particularly in the morning.

His main concerns are:

  • “Why are my joints so stiff and painful? Is this arthritis?”
  • “Will this get worse? Will I still be able to work?”
  • “Do I need strong medication for this?”
  • “What tests do I need, and do I have to see a specialist?”

Specific Information (To be revealed only when asked)

Joint Symptoms and Progression

  • Pain is worse after rest and improves slightly with activity.
  • Some episodes of joint redness and warmth.
  • Pain is symmetrical, mainly in the hands and feet, but ankles are also affected.
  • Occasional lower back pain but not severe.

Impact on Daily Life

  • Can still work but is struggling with fine motor tasks like gripping tools.
  • Pain worsens by the end of the day but is worst in the mornings.
  • Occasionally wakes up at night due to joint discomfort.
  • Stopped playing football with his friends due to joint pain.

Medical and Family History

  • Mild psoriasis on elbows and scalp for five years, managed with topical steroids.
  • Had a stomach bug about six weeks ago, with diarrhoea for a few days but fully recovered.
  • No known autoimmune conditions in the family.
  • Father had osteoarthritis later in life.
  • No previous joint injuries or fractures.

Lifestyle Factors

  • Works in construction, physically demanding job.
  • Smokes 5–10 cigarettes per day.
  • Drinks alcohol socially on weekends.
  • Generally healthy diet but eats takeaway a few times a week due to long work hours.

Concerns About Diagnosis and Treatment

  • Worried about needing long-term medication: “Will I have to take tablets forever?”
  • Concerned about being unable to work: “Is this going to affect my job?”
  • Wants to know if there’s a cure: “Can this be reversed, or will it keep getting worse?”
  • Asks about strong pain relief: “Do I need something stronger than ibuprofen?”

Emotional Cues

David is concerned but practical.

  • Frustrated by ongoing pain: “I can’t grip things properly, and it’s affecting my work.”
  • Anxious about the future: “Is this going to get worse? Will I still be able to work?”
  • Seeking reassurance: “What’s the best way to manage this?”

If the candidate provides a structured explanation and management plan, David will be reassured and willing to follow advice.

If the candidate is vague or dismissive, David may become frustrated and insist on immediate referral or stronger medications.

Questions for the Candidate

David will ask some of the following questions, especially if the doctor does not address them directly:

  1. “What type of arthritis do I have?”
  2. “Do I need blood tests or scans?”
  3. “Is this related to my psoriasis or my stomach infection?”
  4. “What are my treatment options? Do I need strong medication?”
  5. “Will this get worse over time?”
  6. “Can I still work and do normal activities?”
  7. “Could this be something serious like an autoimmune disease?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

  • David will feel reassured and open to investigations and treatment.
  • He will understand that his condition is manageable with proper care.
  • He may say, “I understand now. I’ll do the tests and follow your advice.”

If the candidate is vague or dismissive:

  • David may insist on stronger painkillers or immediate referral.
  • He may say, “So, are you saying there’s nothing we can do?”

Key Takeaways for the Candidate

  • Take a structured inflammatory arthritis history, identifying patterns, triggers, and red flags.
  • Differentiate between psoriatic arthritis, reactive arthritis, and other inflammatory conditions.
  • Provide an evidence-based management plan, including NSAIDs, lifestyle advice, and rheumatology referral if needed.
  • Educate on long-term disease monitoring and follow-up.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including joint symptoms, associated features, medical history, and risk factors for inflammatory arthritis.

The competent candidate should:

  • Elicit a structured history, including:
    • Onset and progression (symptoms over two months, worsening).
    • Pattern of joint involvement (fingers, wrists, ankles, possible axial involvement).
    • Morning stiffness duration (>1 hour, improving with movement).
    • Associated features (fatigue, mild back pain, no fevers, weight loss, or neurological symptoms).
    • Triggers and risk factors (history of psoriasis, recent gastrointestinal infection).
  • Identify red flags that may require urgent referral:
    • Severe functional limitation affecting daily activities.
    • Signs of systemic involvement (e.g., uveitis, unexplained fever, cardiac or pulmonary symptoms).

Task 2: Differentiate between types of inflammatory arthritis and identify red flags requiring urgent referral.

The competent candidate should:

  • Consider key differential diagnoses:
    • Psoriatic arthritis (PsA) – history of psoriasis, small and large joint involvement, dactylitis, enthesitis.
    • Reactive arthritis – post-infectious onset, asymmetric arthritis, history of recent gastroenteritis.
    • Ankylosing spondylitis (Axial SpA) – morning back stiffness, young male, history of enthesitis.
    • Gout or crystal arthritis – sudden onset, episodic, affecting a single joint, tophi in chronic cases.
  • Recognise features requiring further investigation:
    • Severe joint swelling, erythema, fever (concern for septic arthritis).
    • Persistent back pain with morning stiffness and systemic symptoms (suggestive of axial spondyloarthritis).

Task 3: Provide a diagnosis and discuss an initial management plan, including investigations and symptom control.

The competent candidate should:

  • Explain the likely diagnosis:
    • Psoriatic arthritis is highly suspected due to psoriasis history and polyarticular inflammatory symptoms.
    • Reactive arthritis is also possible given prior gastrointestinal infection.
  • Order relevant investigations:
    • Inflammatory markers (CRP, ESR).
    • Rheumatoid factor (RF) and anti-CCP (to rule out rheumatoid arthritis).
    • HLA-B27 testing (if axial involvement is suspected).
    • Joint X-ray/ultrasound (to assess joint damage or enthesitis).
  • Provide symptomatic management:
    • NSAIDs (e.g., naproxen) for pain and inflammation.
    • Paracetamol as needed for additional pain relief.
    • Steroid injection if a single joint is significantly affected.
  • Plan for specialist referral:
    • If persistent symptoms or erosive changes, early referral to rheumatology.
    • If reactive arthritis, monitor for spontaneous resolution within six months.

Task 4: Educate the patient on chronic disease management, lifestyle factors, and the need for follow-up.

The competent candidate should:

  • Discuss the importance of early treatment to prevent joint damage.
  • Address concerns about long-term disease progression and work implications.
  • Encourage lifestyle changes to reduce inflammation:
    • Weight management, smoking cessation, and regular exercise.
    • Reduce alcohol intake (linked to inflammation in arthritis).
  • Explain follow-up plan:
    • Review blood results in 2–4 weeks.
    • Monitor symptoms and adjust treatment based on response.
    • Potential need for disease-modifying antirheumatic drugs (DMARDs) if persistent inflammation is confirmed.

SUMMARY OF A COMPETENT ANSWER

  • Takes a structured history, identifying pattern, triggers, and systemic involvement.
  • Differentiates between psoriatic arthritis, reactive arthritis, and other inflammatory causes.
  • Orders appropriate investigations, including CRP, ESR, RF, and imaging if needed.
  • Provides symptomatic management, including NSAIDs and potential specialist referral.
  • Educates on long-term monitoring, lifestyle changes, and early intervention to prevent joint damage.

PITFALLS

  • Failing to assess for extra-articular manifestations, leading to missed diagnosis of a systemic inflammatory condition.
  • Overlooking red flags, delaying specialist referral in severe or erosive disease.
  • Misdiagnosing inflammatory arthritis as mechanical joint pain, missing early treatment opportunities.
  • Not addressing smoking and lifestyle factors, which are modifiable contributors to disease progression.
  • Lack of clear follow-up plan, increasing the risk of undiagnosed progression and joint deformity.

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

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.3 Provides clear and structured explanations about diagnosis, prognosis, and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured history, including joint symptoms, risk factors, and extra-articular manifestations.
2.2 Identifies red flags and indications for further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between different types of inflammatory arthritis (e.g., psoriatic, reactive, or seronegative arthritis).
3.2 Identifies when further investigations or specialist referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides an evidence-based treatment plan, including pharmacological and non-pharmacological strategies.
4.2 Educates the patient on the chronic nature of inflammatory arthritis and the importance of ongoing care.

5. Preventive and Population Health

5.1 Identifies risk factors for inflammatory arthritis and associated comorbidities.
5.2 Advises on long-term health monitoring, including cardiovascular risk.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up of arthritis management.

8. Procedural Skills

8.1 Orders and interprets relevant investigations (e.g., inflammatory markers, autoimmune serology, joint imaging).

9. Managing Uncertainty

9.1 Recognises when symptoms require urgent intervention versus ongoing monitoring.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and appropriately manages complications of inflammatory arthritis (e.g., uveitis, enthesitis).

Competency at Fellowship Level

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