CCE-CE-070

CASE INFORMATION

Case ID: CCE-DERM-030
Case Name: Daniel Roberts
Age: 34
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S77 – Boil/Carbuncle

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 dermatological history, including symptom onset, risk factors, and systemic symptoms
2.2 Identifies red flags for severe skin infections, including systemic involvement
3. Diagnosis, Decision-Making and Reasoning3.1 Differentiates between simple and complicated skin infections (e.g., abscess, cellulitis, MRSA infection)
3.2 Identifies when further investigations (e.g., swabs, blood tests) or hospital referral is required
4. Clinical Management and Therapeutic Reasoning4.1 Provides an evidence-based treatment plan, including incision and drainage if indicated
4.2 Educates the patient on wound care, infection control, and signs of worsening infection
5. Preventive and Population Health5.1 Identifies risk factors for recurrent boils (e.g., diabetes, hygiene, skin conditions)
5.2 Advises on strategies to prevent recurrence, including decolonisation for recurrent staphylococcal infections
6. Professionalism6.1 Demonstrates empathy and a patient-centred approach
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate documentation and follow-up for skin infections
8. Procedural Skills8.1 Identifies when incision and drainage (I&D) is indicated
8.2 Orders and interprets wound swabs and blood tests if necessary
9. Managing Uncertainty9.1 Recognises when symptoms require urgent intervention versus conservative management
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies severe or systemic infections requiring hospital referral

CASE FEATURES

  • Need for incision and drainage, antibiotics if required, and prevention advice
  • Painful, red, swollen lump on the thigh for five days
  • Increasing size and tenderness with central pus formation
  • No systemic symptoms but mild surrounding redness
  • Concerns about treatment options and recurrence

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.
  2. Outline the differential diagnosis and key investigations required.
  3. Address the patient’s concerns.
  4. Develop a safe and patient-centred management plan.

SCENARIO

Daniel Roberts, a 34-year-old warehouse worker, presents with a painful, swollen lump on his left thigh that has been worsening over five days.

His symptoms include:

  • Tender, red swelling with a central pus-filled area.
  • Gradually increasing in size and pain over the past few days.
  • No fever, chills, or systemic symptoms.
  • Mild redness extending slightly beyond the lump but no spreading streaks.

PATIENT RECORD SUMMARY

Patient Details

Name: Daniel Roberts
Age: 34
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • No known drug allergies

Medications

  • None regularly

Past History

  • Had a similar boil six months ago, resolved with antibiotics.
  • No history of diabetes or immune suppression.

Social History

  • Works in a warehouse, wears tight work pants for long hours.

Family History

  • No known skin conditions or recurrent infections in the family.

Vaccination and Preventative Activities

  • 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, I’ve got this painful lump on my leg, and it’s just getting worse.”

General Information

Daniel Roberts is a 34-year-old warehouse worker who presents with a painful, swollen lump on his left thigh that has been worsening over five days.

  • Started as a small, red bump five days ago, which has gradually become larger and more painful.
  • Now has a visible yellow-white head in the centre, feels warm to the touch.
  • Pain is increasing and worsens when walking, touching, or putting pressure on it.

Specific Information

(To be revealed only when asked)

Background Information

  • Has been using warm compresses, which provide mild relief, but the lump is not improving.
  • No systemic symptoms such as fever, chills, or fatigue.
  • Mild redness around the lump but no red streaks moving up the leg.

His main concerns are:

  • “This thing is really painful, and I don’t know if it’ll go away on its own.”
  • “Do I need antibiotics, or will it burst by itself?”
  • “Can I still go to work, or should I take time off?”
  • “Is this going to keep coming back?”

Progression of Symptoms

(Daniel will describe the following when prompted about how the lump developed.)

  • Started as a firm, red bump about five days ago.
  • Over the last two days, it has become larger, more swollen, and painful.
  • Now has a visible pus-filled centre, but it hasn’t drained on its own yet.
  • No spreading redness or heat beyond the lump itself.

Pain and Functional Impact

(Daniel will mention these details if asked about the effect on his daily life.)

  • Pain worsens when moving or putting pressure on the area.
  • Struggles to bend his leg comfortably due to tenderness.
  • Can still walk but avoids prolonged standing or heavy lifting.
  • Has been wearing looser pants to avoid irritating the lump further.

Previous Treatment Attempts

(Daniel will share these details if asked about what he has tried so far.)

  • Using warm compresses twice daily, but no significant improvement.
  • Tried applying antiseptic cream but no noticeable change.
  • Has not taken any painkillers or antibiotics yet.
  • Has not attempted to squeeze or pop it himself but is considering doing so.

Risk Factors and Hygiene Practices

(Daniel will provide the following details if asked about his activities and possible triggers.)

  • Works in a hot, humid warehouse and wears tight-fitting work pants.
  • Sweats a lot during work and showers at the gym afterward.
  • Occasionally borrows gym towels when he forgets his own.
  • Shaves his legs sometimes and has had small cuts from shaving before.
  • Had a similar boil on his back six months ago, which went away with antibiotics.
  • No history of diabetes or immune disorders.

Concerns About Treatment and Work

(Daniel is looking for guidance on the best way to treat this.)

  • “Do I need antibiotics, or can I just drain it myself?”
  • “Can you drain it today?”
  • “How long will it take to heal?”
  • “Can I still go to work, or should I rest?”
  • “Is this going to spread?”
  • “Why do I keep getting these?”

Emotional Cues

Daniel is frustrated by the pain and inconvenience of the boil.

  • Mildly embarrassed about the location of the lump.
  • Concerned about recurrence and whether it means something serious.
  • Wants a quick solution so he can continue working.
  • Reassured by clear explanations and a structured treatment plan.

Questions for the Candidate

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

  1. “What is this lump, and why did I get it?”
  2. “Do I need antibiotics, or will it go away on its own?”
  3. “Can you drain it today?”
  4. “How can I stop this from coming back?”
  5. “Is this contagious?”
  6. “Do I need any tests to check my immune system?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

  • Daniel will feel reassured and agree to treatment recommendations.
  • He may say: “Alright, I’ll follow the advice and keep the area clean.”

If the candidate is vague or dismissive:

  • Daniel may insist on antibiotics even if not indicated.
  • He may say: “So, you’re saying I just have to wait it out?”
  • He may attempt to self-drain the boil at home if not given clear instructions.

Key Takeaways for the Candidate

  • Take a structured dermatological history, assessing onset, progression, and risk factors.
  • Differentiate between a simple boil, carbuncle, or more severe infection (e.g., cellulitis, abscess).
  • Provide a clear management plan, including:
    • Incision and drainage (I&D) if the boil is fluctuant and ready to drain.
    • Antibiotics only if indicated (e.g., spreading infection, immunosuppression, systemic signs).
    • Pain relief and wound care advice.
    • Instructions on hygiene and prevention to avoid recurrence.
  • Discuss when to seek further medical attention (e.g., worsening pain, increasing redness, fever).

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including onset, progression, associated symptoms, previous treatments, and risk factors for recurrent boils.

The competent candidate should:

  • Obtain a structured dermatological history, including:
    • Onset and progression (five-day history of a painful lump that has enlarged).
    • Symptoms (tender, red swelling with a central pus-filled area).
    • Previous treatments (warm compresses, antiseptic cream, no antibiotics or incision and drainage).
    • Impact on daily life (pain affecting movement, concerns about work).
  • Identify risk factors, including:
    • Work environment (tight clothing, sweating in a warm warehouse).
    • Hygiene factors (shared gym showers, borrowing towels).
    • Skin trauma (shaving, minor cuts).
    • History of previous boils (suggests recurrent infection risk).
    • Medical history (diabetes, immune function).
  • Screen for signs of systemic infection or complications, including:
    • Fever, chills, malaise, or lymphadenopathy (abscess requiring urgent drainage).
    • Expanding redness or streaking (suggestive of cellulitis).

Task 2: Differentiate between a simple boil, a carbuncle, cellulitis, or a more severe skin infection.

The competent candidate should:

  • Recognise the clinical features of a boil (furuncle):
    • Tender, fluctuant, pus-filled swelling with surrounding redness.
    • No systemic symptoms, no spreading cellulitis.
    • No history of immunosuppression or recurrent infections requiring further testing.
  • Differentiate from other conditions:
    • Carbuncle (multiple interconnected boils, larger area of involvement).
    • Cellulitis (diffuse spreading redness, no focal pus-filled lesion).
    • MRSA-related infection (may require wound swabs, different antibiotic choices).
  • Determine if further investigations are needed:
    • Swab for culture if the patient has recurrent boils, is immunosuppressed, or has suspected antibiotic resistance.
    • Blood glucose testing if recurrent or severe infections.

Task 3: Provide a diagnosis and discuss an initial management plan, including incision and drainage, antibiotics (if required), wound care, and follow-up.

The competent candidate should:

  • Explain the diagnosis:
    • “You have a boil, which is a bacterial infection of a hair follicle. It has formed a collection of pus under the skin.”
  • Outline first-line management:
    • If fluctuant and ready to drain: Incision and drainage (I&D) in a sterile setting.
    • If small and not ready to drain: Continue warm compresses, monitor closely.
    • If extensive surrounding cellulitis, immunosuppression, or systemic symptoms: Consider oral antibiotics (flucloxacillin or cephalexin, or doxycycline if MRSA risk).
    • Pain relief: Paracetamol or ibuprofen as needed.
  • Discuss wound care and hygiene:
    • Keep the area clean and covered.
    • Avoid squeezing or picking at the lesion.
    • Wash hands after touching the affected area.

Task 4: Educate the patient on infection control, prevention strategies, and when to seek further medical attention.

The competent candidate should:

  • Prevent recurrence through hygiene measures:
    • Regular washing with antiseptic soap in affected areas.
    • Avoid sharing towels and gym equipment.
    • Wear loose, breathable clothing at work.
    • Consider decolonisation strategies (e.g., mupirocin nasal ointment, chlorhexidine wash for recurrent infections).
  • Safety-netting advice:
    • Seek urgent care if worsening pain, spreading redness, fever, or new boils develop.
    • Follow-up in 2–3 days if I&D is performed.

SUMMARY OF A COMPETENT ANSWER

  • Takes a structured dermatological history, assessing onset, risk factors, and systemic symptoms.
  • Recognises a simple boil and differentiates it from more serious skin infections.
  • Recommends appropriate management, including incision and drainage, antibiotics if needed, and wound care.
  • Provides patient education on hygiene, prevention strategies, and when to seek further medical review.

PITFALLS

  • Failing to assess red flags, such as spreading cellulitis, fever, or recurrent infections.
  • Overprescribing antibiotics without considering incision and drainage, which is the main treatment for fluctuant abscesses.
  • Not advising proper hygiene measures, increasing the risk of recurrence and transmission.
  • Not addressing patient concerns about work, recurrence, or self-treatment attempts.
  • Failing to provide safety-netting advice, leading to delayed management if infection worsens.

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 dermatological history, including symptom onset, risk factors, and systemic symptoms.
2.2 Identifies red flags for severe skin infections, including systemic involvement.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between simple and complicated skin infections (e.g., abscess, cellulitis, MRSA infection).
3.2 Identifies when further investigations (e.g., swabs, blood tests) or hospital referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides an evidence-based treatment plan, including incision and drainage if indicated.
4.2 Educates the patient on wound care, infection control, and signs of worsening infection.

5. Preventive and Population Health

5.1 Identifies risk factors for recurrent boils (e.g., diabetes, hygiene, skin conditions).
5.2 Advises on strategies to prevent recurrence, including decolonisation for recurrent staphylococcal infections.

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 for skin infections.

8. Procedural Skills

8.1 Identifies when incision and drainage (I&D) is indicated.
8.2 Orders and interprets wound swabs and blood tests if necessary.

9. Managing Uncertainty

9.1 Recognises when symptoms require urgent intervention versus conservative management.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies severe or systemic infections requiring hospital referral.

Competency at Fellowship Level

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