CCE-CE-074 - GP Exams

CASE INFORMATION

Case ID: CCE-MSK-034
Case Name: Mark Richards
Age: 55
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: T92 – Gout

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages the patient 1.2 Explores the patient’s concerns, ideas, and expectations 1.3 Provides clear and structured explanations about the diagnosis and management
2. Clinical Information Gathering and Interpretation	2.1 Takes a structured history, including symptom onset, progression, triggers, and impact on function 2.2 Identifies risk factors for gout, including dietary habits, medications, and comorbidities
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates gout from other causes of acute monoarthritis 3.2 Identifies when further investigations (e.g., joint aspiration, blood tests, imaging) are required
4. Clinical Management and Therapeutic Reasoning	4.1 Provides an evidence-based treatment plan, including acute attack management and long-term urate-lowering therapy 4.2 Educates the patient on lifestyle modifications and preventive measures
5. Preventive and Population Health	5.1 Identifies risk factors for recurrent gout attacks and associated metabolic conditions 5.2 Encourages long-term strategies for reducing uric acid levels
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 recurrent or worsening symptoms
8. Procedural Skills	8.1 Identifies when joint aspiration for synovial fluid analysis is indicated
9. Managing Uncertainty	9.1 Recognises when to observe, investigate, or refer for specialist opinion
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and manages severe or atypical gout presentations

CASE FEATURES

Concerns about long-term complications and need for preventive measures
Severe pain, redness, and swelling in the right big toe, onset 24 hours ago
History of previous episodes but never formally diagnosed
Risk factors: obesity, high alcohol intake, and family history of gout

INSTRUCTIONS

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

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

A patient record summary is provided for your information.

Perform the following tasks:

Take an appropriate history.
Outline the differential diagnosis and key investigations required.
Address the patient’s concerns.
Develop a safe and patient-centred management plan.

SCENARIO

Mark Richards, a 55-year-old construction worker, presents with severe pain and swelling in his right big toe that started 24 hours ago.

His symptoms include:

Severe pain, redness, and swelling of the right first metatarsophalangeal (MTP) joint.
Pain started suddenly overnight, now making it difficult to walk or wear shoes.
No preceding trauma or injury.
Has had similar episodes in the past but never sought medical attention.

PATIENT RECORD SUMMARY

Patient Details

Name: Mark Richards
Age: 55
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

None regularly

Past History

Obesity (BMI 32)
Hypertension (controlled with diet and exercise)
No history of diabetes or kidney disease

Social History

Works as a construction labourer, physically active but with poor diet
Drinks alcohol frequently (4-5 beers most nights)
Smoker – 10 cigarettes per day

Family History

Father had gout and was on long-term medication

Vaccination and Preventative Activities

Up to date with general health screenings

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 big toe is killing me. It started last night, and now I can’t even put weight on it.”

General Information

Mark Richards is a 55-year-old construction worker who presents with sudden, severe pain and swelling in his right big toe, which started 24 hours ago.

Woke up with severe pain and swelling in his right big toe.
Pain worsened throughout the day, making it difficult to walk.
Feels like his toe is on fire—can’t even tolerate the bedsheet touching it.

Specific Information

(To be revealed only when asked)

Background Information

No known injury or trauma to the foot.
Has had similar episodes in the past but never sought medical attention.
Took ibuprofen, which helped slightly, but the pain remains intense.

Joint Symptoms

(Mark will describe the following if asked about the nature of his pain.)

Severe pain, swelling, and redness in the right big toe (first metatarsophalangeal joint, MTP).
Pain is worst when touched or moved.
No numbness, tingling, or weakness.
No spreading redness or warmth up the leg.
No pus or open wounds.

Previous Episodes and Triggers

(Mark will provide these details if asked about past episodes.)

Has had 2-3 milder attacks in the past few years.
Each time, the pain resolved on its own after about a week.
Symptoms were not as bad as this time, so he didn’t see a doctor.
Noticed that attacks tend to happen after eating large meals and drinking alcohol.
Had steak, seafood, and several beers last night.

Impact on Work and Daily Life

(Mark will explain how this affects his life if asked.)

Can’t wear his work boots due to swelling.
Struggles to walk, making it impossible to do his job properly.
Concerned about taking time off work and losing income.

Past Medical and Family History

(Mark will share this if asked about medical background.)

Hypertension (controlled with diet and exercise).
No history of diabetes or kidney disease.
Father had gout and was on medication for many years.

Social History and Risk Factors

(Mark will describe his lifestyle if asked.)

Drinks alcohol frequently (4-5 beers most nights).
Diet high in red meat, processed foods, and seafood.
Smokes 10 cigarettes per day.
Physically active at work but does little structured exercise.

Concerns About Long-Term Effects

(Mark will ask about the prognosis and whether he needs long-term treatment.)

“Is this something that will get worse over time?”
“Will I need to be on medication for life?”
“Could this cause permanent damage to my joints?”
“Can I still drink beer, or do I have to give it up completely?”

Emotional Cues

Distressed by the severe pain and inability to work.
Frustrated by repeated episodes and concerned about future attacks.
Worried about long-term impact on his joints and lifestyle.
Seeks clear advice on treatment and prevention.
If the doctor is dismissive, he may insist on stronger pain relief or tests.

Questions for the Candidate

Mark may ask some or all of the following:

“What is causing this pain, and why does it keep happening?”
“Do I need tests to confirm if this is gout?”
“What can I take to make this pain go away quickly?”
“Do I have to stop eating red meat and drinking beer forever?”
“Will this cause permanent joint damage if I don’t treat it?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

Mark will feel reassured and willing to follow recommendations.
He may say: “Alright, I’ll try to cut back on beer and eat better. I just need something to stop the pain now.”

If the candidate is vague or dismissive:

Mark may insist on immediate pain relief without considering lifestyle changes.
He may feel uncertain about whether this is a serious condition.
He may say: “So, do I just have to live with this? What’s the point of coming to the doctor then?”

Key Takeaways for the Candidate

Take a structured history, differentiating gout from other causes of acute monoarthritis.
Explain the diagnosis and triggers, addressing diet, alcohol, and metabolic risk factors.
Provide evidence-based management, including acute treatment and long-term preventive therapy.
Educate on lifestyle modifications and risk reduction strategies.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including onset, severity, risk factors, previous episodes, and impact on daily life.

The competent candidate should:

Obtain a structured history, including:
- Onset and progression (sudden onset, overnight, severe pain).
- Symptoms (severe pain, redness, swelling in the right big toe, no systemic symptoms).
- Previous episodes (similar past episodes, self-resolving).
- Triggers (recent alcohol intake, large meal including steak and seafood).
- Impact on function (difficulty walking, unable to wear work boots).
- Past medical history (obesity, hypertension, family history of gout).
- Social history (frequent alcohol intake, high-purine diet, smoking).
Screen for red flags, including:
- Fever, chills, spreading redness (suggesting septic arthritis).
- Polyarthritis (considering alternative diagnoses like rheumatoid arthritis).

Task 2: Conduct a risk assessment for gout and differentiate from other causes of monoarthritis.

The competent candidate should:

Consider the most likely differential diagnoses:
- Gout (most likely, based on acute onset, severe pain, big toe involvement, risk factors).
- Septic arthritis (considered if fever, systemic signs, or joint aspiration is needed).
- Pseudogout (calcium pyrophosphate deposition, more common in elderly).
- Trauma (rule out injury as cause of joint pain).
Determine if investigations are needed:
- Serum uric acid levels (may be normal during an acute attack, but useful for long-term monitoring).
- Joint aspiration if septic arthritis is suspected (urgent referral if necessary).
- X-ray if concern about joint damage or alternative diagnoses.

Task 3: Provide a diagnosis and discuss an initial management plan, including acute treatment and long-term strategies.

The competent candidate should:

Explain the likely diagnosis:
- “This is most likely a gout flare, which happens when uric acid crystals build up in the joints, causing intense inflammation.”
Acute management:
- NSAIDs (e.g., naproxen, ibuprofen) – first-line for pain relief.
- Colchicine (if NSAIDs contraindicated, lower-dose regimen preferred).
- Prednisolone (if NSAIDs and colchicine not suitable).
- Rest, ice, elevation, and avoiding weight-bearing activities.
Discuss long-term management:
- Urate-lowering therapy (e.g., allopurinol) if recurrent attacks, tophi, or high uric acid levels.
- Lifestyle modifications to reduce recurrence.

Task 4: Educate the patient on triggers, lifestyle modifications, and prevention of future attacks.

The competent candidate should:

Explain key dietary and lifestyle changes:
- Reduce purine-rich foods (red meat, seafood, processed foods).
- Limit alcohol intake, especially beer and spirits.
- Increase hydration to help excrete uric acid.
- Maintain a healthy weight and consider smoking cessation.
Safety-netting advice:
- Return if symptoms worsen or don’t improve within a few days.
- Seek immediate care if fever, severe joint swelling, or systemic illness occurs (septic arthritis concerns).

SUMMARY OF A COMPETENT ANSWER

Takes a comprehensive history, identifying risk factors, triggers, and differential diagnoses.
Explains gout clearly, addressing patient concerns about severity and recurrence.
Provides an effective acute treatment plan, including pain relief and joint care.
Discusses long-term prevention and lifestyle changes.
Provides clear safety-netting instructions for complications or worsening symptoms.

PITFALLS

Failing to consider septic arthritis, especially in a patient with severe joint pain.
Not addressing lifestyle factors, missing an opportunity for preventive education.
Overprescribing NSAIDs without considering contraindications (e.g., hypertension, renal disease).
Not explaining long-term management, leading to poor patient adherence and recurrence.
Dismissing patient concerns about work impact, which may lead to non-compliance.

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 symptom onset, progression, and impact on function.
2.2 Identifies risk factors for gout, including dietary habits, medications, and comorbidities.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates gout from other causes of acute monoarthritis.
3.2 Identifies when further investigations (e.g., joint aspiration, blood tests, imaging) are required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides an evidence-based treatment plan, including acute attack management and long-term urate-lowering therapy.
4.2 Educates the patient on lifestyle modifications and preventive measures.

5. Preventive and Population Health

5.1 Identifies risk factors for recurrent gout attacks and associated metabolic conditions.
5.2 Encourages long-term strategies for reducing uric acid levels.

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 recurrent or worsening symptoms.

8. Procedural Skills

8.1 Identifies when joint aspiration for synovial fluid analysis is indicated.

9. Managing Uncertainty

9.1 Recognises when to observe, investigate, or refer for specialist opinion.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and manages severe or atypical gout presentations.

Competency at Fellowship Level

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