CASE INFORMATION

Case ID: CCE-HIP-001
Case Name: Michael Thompson
Age: 67
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L18 – Hip symptom/complaint

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Communicates appropriately to the person and sociocultural context. 1.2 Engages the patient to gather information about symptoms, concerns, expectations, and impact on daily life. 1.4 Communicates effectively in routine and difficult situations.
2. Clinical Information Gathering and Interpretation	2.1 Gathers relevant history, including risk factors and functional impact. 2.2 Identifies key symptoms and red flags for serious pathology.
3. Diagnosis, Decision-Making and Reasoning	3.1 Formulates a differential diagnosis. 3.3 Uses clinical reasoning to determine the likely cause of symptoms.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a patient-centred management plan. 4.2 Provides education about condition and treatment options.
5. Preventive and Population Health	5.1 Provides appropriate education on falls prevention and bone health.
6. Professionalism	6.1 Ensures patient autonomy and informed decision-making.
7. General Practice Systems and Regulatory Requirements	7.1 Arranges appropriate investigations and referrals.
9. Managing Uncertainty	9.1 Addresses diagnostic uncertainty and provides a safety-netting approach.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies red flags such as septic arthritis, hip fracture, or malignancy.

CASE FEATURES

Concerned about needing a hip replacement.
67-year-old male with progressive right hip pain over six months.
Intermittent stiffness and worsening mobility.
Difficulty with prolonged walking and stair climbing.
Reports no recent trauma or falls.
Background of hypertension, type 2 diabetes, and osteopenia.

INSTRUCTIONS

You have 15 minutes to complete 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 a focused history from the patient, including symptoms, functional impact, and risk factors.
Formulate a differential diagnosis and explain the likely cause of his symptoms.
Develop a management plan, including investigations, treatment options, and lifestyle advice.
Address the patient’s concerns and discuss long-term prognosis.

SCENARIO

Michael Thompson, a 67-year-old retired carpenter, presents with right hip pain that has gradually worsened over six months. He describes dull, aching pain in the groin and outer thigh, worsening with prolonged standing and walking. Stiffness is particularly noticeable in the morning and after sitting for long periods.

He has not had any falls or acute injuries. He denies fever, night pain, or weight loss. His main concern is whether he will need a hip replacement.

Michael has a history of hypertension, type 2 diabetes, and osteopenia. He takes metformin, amlodipine, and vitamin D.

He is an ex-smoker and drinks 1-2 glasses of wine per night. He lives independently but struggles with household tasks due to his symptoms.

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Thompson
Age: 67
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Metformin 500 mg BD
Amlodipine 5 mg OD
Vitamin D 1000 IU OD

Past History

Hypertension
Type 2 Diabetes Mellitus (diet-controlled)
Osteopenia (diagnosed 3 years ago)

Social History

Retired carpenter
Lives alone, independent with ADLs
Ex-smoker, quit 10 years ago
Drinks 1-2 glasses of wine per night

Family History

Father had hip osteoarthritis requiring surgery
Mother had osteoporosis

Smoking & Alcohol

Ex-smoker, quit 10 years ago
Drinks socially, 1-2 glasses of wine per night

Vaccination and Preventive Activities

Has not had a DEXA scan since osteopenia diagnosis
Up to date with flu and COVID 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.

ROLE-PLAYER SCRIPT – HIP PAIN (OSTEOARTHRITIS VS OTHER CAUSES)

Opening Line

“Doctor, my right hip has been aching for months now. It’s getting harder to move around.”

General Information

You are a 67-year-old retired carpenter who has been experiencing gradually worsening right hip pain over the past six months. The pain started as a mild ache but has progressively become more constant and limiting. You have noticed morning stiffness, which lasts for about 30 minutes, and discomfort when you get up after sitting for a long period.

You have not had any falls, injuries, or sudden onset of pain. The discomfort is primarily in your groin and outer thigh, and you sometimes feel like your hip is “locking up”. You worry that this might mean you will need a hip replacement.

You live alone in a single-story home and are mostly independent, but you struggle with walking long distances and climbing stairs.

Your past medical history includes:

Hypertension – managed with amlodipine.
Type 2 Diabetes – diet-controlled, no medications.
Osteopenia – diagnosed three years ago, but no fractures so far.

Your father had hip osteoarthritis and needed a hip replacement at 72, which makes you wonder if you are following the same path.

You are an ex-smoker (quit 10 years ago) and drink 1-2 glasses of wine per night.

Specific Information (Revealed Only If Asked)

Pain Characteristics:

Worse with activity – especially walking, standing for too long, and climbing stairs.
Relieved by rest – you occasionally take paracetamol, which helps a little.
No sharp pain, numbness, tingling, or weakness in the leg.
No radiating pain down to the foot, but sometimes discomfort reaches your knee.

Impact on Daily Life:

You have stopped walking as much because of the pain.
Getting up from a chair or bed is difficult due to stiffness.
You find it hard to bend down to tie your shoes or pick up objects from the ground.
You avoid long drives because sitting in one position for too long makes your hip stiff.

Red Flags (Absent unless candidate asks specifically):

No recent falls, trauma, or acute injuries.
No fever, weight loss, night sweats, or unexplained fatigue.
No history of cancer, steroid use, or recent infections.
No loss of bowel or bladder control.

Emotional Cues & Concerns

Anxiety about needing surgery
- “I really don’t want a hip replacement. Is there any way to avoid it?”
Frustration with declining mobility
- “I used to go on long walks every day, now I can barely do half of what I used to.”
Fear of losing independence
- “Will I still be able to live on my own if this gets worse?”
Concerns about diabetes and osteopenia
- “Could my diabetes or bone issues be making my hip worse?”

Questions for the Candidate

“Do you think I’ll need a hip replacement?”
“What can I do to keep my hip from getting worse?”
“Is this related to my diabetes or my osteopenia?”
“Will exercise make it better or worse?”
“Do I need any tests or scans?”

Suggested Role-Playing Tone and Behaviour

Mildly anxious – You are worried about surgery and frustrated about your decreasing mobility.
Slightly cautious – You are open to treatment suggestions, but skeptical about strong painkillers.
Realistic and cooperative – You follow medical advice but need reassurance.
Mildly emotional when discussing independence – You don’t want to rely on others and fear that your condition may worsen.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient regarding their hip pain.

The competent candidate should:

Use open-ended questions to explore the onset, duration, location, severity, and nature of the pain.
Ask about aggravating and relieving factors, including impact on daily activities and mobility.
Explore morning stiffness, association with activity, and pain radiating to other areas.
Assess for red flags: history of trauma, unexplained weight loss, night pain, fever, or neurological symptoms.
Take a past medical history (especially diabetes, osteopenia, arthritis, previous injuries).
Obtain a medication history, including use of analgesics, anti-inflammatory drugs, and supplements.
Explore social history, including living arrangements, functional independence, and mobility limitations.
Address patient concerns, particularly regarding the need for surgery and impact on independence.

Task 2: Discuss your differential diagnosis with the patient.

The competent candidate should:

Explain common causes of hip pain, including:
- Osteoarthritis (most likely, given gradual onset, stiffness, and age).
- Trochanteric bursitis (if lateral pain and tenderness).
- Hip labral tear (less likely but possible in physically active individuals).
- Referred pain from spine (lumbar radiculopathy or spinal stenosis).
- Avascular necrosis of the hip (if risk factors such as steroid use or alcohol excess).
- Inflammatory arthritis (if systemic symptoms or other joint involvement).
Provide simple, layman’s explanations to improve patient understanding.
Address patient concerns (e.g., “Do I need surgery?”).

Task 3: Develop a management plan and explain it to the patient.

The competent candidate should:

Provide a multimodal approach, considering lifestyle modifications, physiotherapy, pharmacological treatment, and possible referrals.
Recommend weight management, strengthening exercises, and physiotherapy.
Discuss analgesia options (paracetamol, NSAIDs if appropriate, topical agents).
Consider intra-articular steroid injections if symptoms persist.
Outline indications for referral to an orthopaedic specialist (severe pain, loss of function, failure of conservative management).
Provide reassurance and education on the prognosis of hip osteoarthritis.

SUMMARY OF A COMPETENT ANSWER

Comprehensive history-taking, including pain characteristics, functional impact, and red flags.
Systematic approach to differential diagnosis, explaining conditions in lay terms.
Holistic management plan including non-pharmacological and pharmacological treatments.
Patient-centred approach, addressing concerns about surgery, mobility, and independence.
Appropriate use of guidelines for osteoarthritis management.

PITFALLS

Failing to screen for red flags, such as infection, malignancy, or fractures.
Over-reliance on imaging without a strong clinical indication.
Ignoring non-pharmacological management (e.g., physiotherapy, exercise).
Not addressing the patient’s concerns (e.g., fear of surgery, loss of independence).
Using medical jargon instead of layman’s terms.

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.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers relevant clinical information.

3. Diagnosis, Decision-Making and Reasoning

3.1 Demonstrates sound clinical reasoning.

4. Clinical Management and Therapeutic Reasoning

4.2 Manages common conditions in general practice.

5. Preventive and Population Health

5.1 Provides lifestyle advice relevant to the patient’s condition.

6. Professionalism

6.3 Maintains professional standards in patient-centred care.

9. Managing Uncertainty

9.1 Deals with clinical uncertainty appropriately.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies significant illness early and manages appropriately.

Competency at Fellowship Level

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