CASE INFORMATION

Case ID: IF-001
Case Name: Mark Reynolds
Age: 36
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Code: S97 – Local Infection of the Skin/Subcutaneous Tissue

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their concerns and expectations. 1.2 Demonstrates active listening and empathy. 1.4 Explains diagnosis and management in a patient-centred manner.
2. Clinical Information Gathering and Interpretation	2.1 Takes a comprehensive history, including onset, progression, and risk factors for infection. 2.2 Identifies red flags requiring further investigation.
3. Diagnosis, Decision-Making and Reasoning	3.1 Establishes a working diagnosis based on history and examination findings. 3.2 Differentiates between common causes of finger/toe infections (e.g., paronychia, felon, cellulitis).
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan. 4.5 Provides pharmacological and non-pharmacological recommendations. 4.7 Uses shared decision-making to address patient concerns.
5. Preventive and Population Health	5.1 Provides education on wound care and infection prevention. 5.2 Identifies risk factors for recurrent infections and addresses them.
6. Professionalism	6.2 Provides reassurance and addresses patient concerns sensitively.
7. General Practice Systems and Regulatory Requirements	7.1 Documents history, examination findings, and management plan appropriately.
8. Procedural Skills	8.1 Identifies when incision and drainage are required for abscesses or paronychia.
9. Managing Uncertainty	9.3 Recognises when specialist referral or further investigations are required.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises signs of severe infection requiring escalation (e.g., deep space infection, flexor tenosynovitis).

CASE FEATURES

Acute finger infection following a nail injury.
Mild but worsening swelling, redness, and pain.
Unclear if abscess formation is present, requiring assessment of need for incision and drainage.
Patient is concerned about needing antibiotics or a procedure.
Requires discussion on infection prevention and follow-up care.

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

SCENARIO

Mark Reynolds, a 36-year-old construction worker, presents with a painful, swollen finger on his right hand. He reports that four days ago, he accidentally tore the skin next to his fingernail while removing a splinter. Since then, the area has become increasingly red, swollen, and tender, with mild throbbing pain.

His observations today are:

BP: 124/78 mmHg
HR: 72 bpm, regular
Temp: 36.8°C
RR: 16 breaths/min
Oxygen saturation: 99% on room air

PATIENT RECORD SUMMARY

Patient Details

Name: Mark Reynolds
Age: 36
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular

Past History

No history of diabetes or immunosuppression
No previous hand infections

Social History

Occupation: Construction worker – frequent use of tools, minor cuts common
Smoking: No
Alcohol: Occasional social drinking

Family History

Father: Hypertension
Mother: No significant conditions

Vaccination and Preventative Activities

Tetanus vaccination 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.

ROLE-PLAYER SCRIPTS

Opening Line

“Doctor, my finger has been swollen and painful for a few days now, and I’m worried it’s getting infected.”

General Information

You are a 36-year-old construction worker and usually in good health.
Four days ago, you accidentally tore the skin next to your fingernail while removing a splinter.
You rinsed it with water but didn’t use antiseptic or cover it.

Specific Information

(Only Provide If Asked)

Background Information

Over the last few days, the area has become red, swollen, and more painful.
The pain is throbbing and getting worse, especially when you press on the area or try to grip things.
You think the swelling is spreading slightly, but you’re not sure.
You have never had a finger infection before, and you’re worried about it getting worse.
You haven’t taken any antibiotics yet.

Symptoms and Red Flags

The redness is limited to the fingertip and hasn’t spread up the hand.
There is no pus visible, but the skin looks tight and shiny.
You feel a bit of warmth in the area, but you don’t have a fever, chills, or sweats.
You can still move your finger, but it feels stiff and sore when bending.
You haven’t noticed red streaks going up your hand.
You have no numbness or tingling in the finger.

Lifestyle and Functional Impact

You work in construction, so you use your hands a lot, often handling tools and materials.
You get minor cuts and scrapes often, but they usually heal on their own.
You don’t usually wear gloves unless handling hazardous materials.
You can still work, but gripping tools is painful, and you worry it might get worse.
You don’t want to take time off work unless absolutely necessary.

Emotional and Psychological State

You feel frustrated that such a small injury has caused so much discomfort.
You’re worried about needing antibiotics or having to take time off work.
You’re especially anxious about needing a procedure, as you’ve heard about abscesses needing to be drained.
You want to know if this will heal on its own or if it will get worse.
You’re also concerned about whether you’ve done something wrong by not treating it earlier.

Concerns & Expectations

You want to know if you need antibiotics or if the infection will clear up on its own.
You’re worried about needing a procedure—you don’t want the doctor to cut into it unless absolutely necessary.
You want to get back to work quickly and avoid long recovery times.
You want to know how to prevent this from happening again in the future.

Possible Questions for the Candidate

“Is this going to get worse if I don’t take antibiotics?”
“Do I need a procedure, or will it go away on its own?”
“What’s the difference between this and cellulitis?”
“If it’s an abscess, do you have to cut it open?”
“How do I stop this from happening again?”
“Can I still go to work, or should I rest my hand?”
“How long will this take to heal?”

How to Respond to the Candidate’s Explanations

If the Candidate Explains That This Is Likely a Paronychia (Early Infection Near the Nail):

“So does that mean it’s not serious?”
“How do you know it won’t turn into something worse?”

If the Candidate Recommends Conservative Management (e.g., Warm Soaks, Topical Antibiotics):

“Will just soaking it in warm water really be enough?”
“Do I need to keep it covered, or should I leave it open?”

If the Candidate Suggests Antibiotics:

“How long would I need to take them?”
“Are there any side effects?”
“Will I need a follow-up appointment?”

If the Candidate Suggests Drainage of an Abscess:

“How do you know if an abscess is forming?”
“Does that mean you have to cut it open?”
“Will that hurt? Do I need stitches?”

If the Candidate Talks About Prevention Strategies:

“Should I wear gloves all the time at work?”
“What should I do if I get another small cut?”

Role-Playing Tips for the Candidate Assessment

You are concerned but not overly anxious. You just want clear answers and practical solutions.
You don’t want antibiotics or procedures unless absolutely necessary. The candidate must explain why they are or aren’t needed.
If the candidate dismisses your concerns too quickly, push back. Ask, “So you’re saying this isn’t a real infection?”
If the candidate recommends lifestyle changes, express some doubt. Ask, “Will wearing gloves actually prevent infections?”
If the candidate doesn’t explain things well, ask for clarification. “Can you explain exactly what’s happening under my skin?”

Final Line (If the Candidate Handles the Case Well)

“Thanks, Doctor. I feel better knowing what’s going on. I’ll try the warm soaks and keep an eye on it. If it gets worse, I’ll come back in.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including onset, progression, and risk factors for infection.

The competent candidate should:

Engage the patient with an open-ended approach, ensuring their concerns are addressed.
Take a detailed history of the infection, including:
- Onset and progression of redness, swelling, and pain.
- Previous trauma or injury, such as splinter removal or a cut.
- Changes over time, including worsening pain, spreading redness, or pus formation.
Identify red flags suggesting severe infection:
- Severe pain with passive movement (suggesting deep infection).
- Spreading erythema beyond the finger/toe.
- Systemic symptoms (fever, chills, malaise).
- Restricted movement or numbness.
Assess risk factors for poor healing or recurrent infection:
- Occupation (construction worker, manual labour).
- Diabetes, immunosuppression, or vascular disease.
- Frequent exposure to contaminants (e.g., working without gloves).
Address the patient’s concerns about treatment, recovery time, and prevention.

Task 2: Discuss your differential diagnosis and outline an initial management plan.

The competent candidate should:

Explain the most likely diagnosis based on the history:
- Paronychia (early infection of the nail fold) – most likely in this case.
- Felon (pulp space abscess) – if worsening swelling and pain.
- Cellulitis – if spreading erythema and systemic signs.
Differentiate between conservative vs procedural management:
- If no abscess: warm soaks, antiseptic treatment, topical/oral antibiotics if needed.
- If an abscess is forming: incision and drainage (I&D) may be required.
Discuss when antibiotics are needed:
- Mild cases: may resolve with warm soaks and antiseptic care.
- Moderate-severe cases: oral antibiotics such as flucloxacillin (or cephalexin if allergic).
- If associated cellulitis or deeper infection: consider escalation.
Provide wound care advice, including hygiene and monitoring for worsening symptoms.
Arrange follow-up in 48-72 hours if symptoms persist or worsen.

Task 3: Address the patient’s concerns about treatment options, procedures, and prognosis.

The competent candidate should:

Acknowledge and validate the patient’s concerns about pain, treatment, and returning to work.
Explain why antibiotics may or may not be needed based on the severity.
Discuss incision and drainage (if required):
- The procedure is quick, performed under local anaesthetic, and highly effective.
- Delaying drainage can worsen infection and prolong healing.
- Pain management options during and after the procedure.
Reassure the patient about healing time:
- Most cases resolve within a few days to a week with proper care.
- Returning to work depends on pain levels and treatment.
Provide clear safety-netting advice:
- Seek urgent care if worsening redness, severe pain, pus formation, or spreading infection.

Task 4: Develop a comprehensive management plan, including investigations, procedural options, and preventive strategies.

The competent candidate should:

First-line conservative management (for mild cases):
- Warm soaks in antiseptic solution (chlorhexidine/saline).
- Keep the area dry and avoid further trauma.
- Topical antiseptics (e.g., povidone-iodine or mupirocin if bacterial involvement suspected).
Pharmacological treatment (if indicated):
- Oral antibiotics (flucloxacillin 500 mg QID for 5-7 days) if moderate-severe infection.
- Consider alternative antibiotics (e.g., cephalexin, clindamycin for penicillin allergy).
- Analgesia (paracetamol ± NSAIDs) for pain relief.
Procedural intervention (if abscess is present):
- Incision and drainage under local anaesthetic.
- Dressing and wound care education.
Preventive strategies to reduce recurrence:
- Proper wound hygiene at work.
- Use of gloves for manual labour.
- Early intervention if minor cuts or injuries occur.
Follow-up within 48-72 hours to assess response to treatment.

SUMMARY OF A COMPETENT ANSWER

Takes a thorough history, identifying the onset, risk factors, and red flags.
Provides a structured differential diagnosis, distinguishing paronychia, felon, and cellulitis.
Explains treatment options clearly, including conservative vs procedural approaches.
Addresses patient concerns regarding procedures, antibiotics, and return to work.
Ensures safety-netting and follow-up, providing clear monitoring instructions.
Educates the patient on prevention, particularly regarding wound care and workplace precautions.

PITFALLS

Failing to assess red flags, such as spreading erythema, severe pain with movement, or systemic symptoms.
Over-prescribing antibiotics unnecessarily, especially in mild cases where conservative treatment is sufficient.
Not considering the need for incision and drainage, leading to delayed recovery.
Underestimating patient concerns about work, recovery time, and procedural discomfort.
Failing to provide preventive advice, increasing risk of recurrent infections.
Not arranging appropriate follow-up, missing progression to deep infections (e.g., felon, tenosynovitis).

REFERENCES

MARKING

Each competency area is rated 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 Engages the patient to understand their concerns and expectations.
1.2 Demonstrates active listening and empathy.
1.4 Explains diagnosis and management in a patient-centred manner.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history, including onset, progression, and risk factors.
2.2 Identifies red flags requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Establishes a working diagnosis based on history and examination findings.
3.2 Differentiates between common causes of finger/toe infections.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.5 Provides pharmacological and non-pharmacological recommendations.
4.7 Uses shared decision-making to address patient concerns.

Competency at Fellowship Level

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