CASE INFORMATION

Case ID: CCE-2025-002
Case Name: David Williams
Age: 58 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L16 (Leg/thigh symptom/complaint), K92 (Peripheral vascular disease), L87 (Sciatica)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their ideas, concerns, and expectations. 1.2 Develops a respectful and empathetic doctor-patient relationship. 1.4 Provides appropriate patient-centred explanations.
2. Clinical Information Gathering and Interpretation	2.1 Gathers relevant history, including systemic and red flag symptoms. 2.2 Selects and interprets appropriate investigations.
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis based on clinical findings. 3.5 Identifies red flag symptoms requiring urgent referral.
4. Clinical Management and Therapeutic Reasoning	4.1 Formulates a safe and evidence-based management plan. 4.3 Provides appropriate follow-up and monitoring.
5. Preventive and Population Health	5.2 Addresses modifiable risk factors for vascular disease and neuropathic conditions.
6. Professionalism	6.1 Maintains patient confidentiality and professional integrity.
7. General Practice Systems and Regulatory Requirements	7.1 Orders appropriate tests in accordance with MBS guidelines.
9. Managing Uncertainty	9.2 Develops a plan for a patient with an unclear diagnosis.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and acts on life-threatening conditions.

CASE FEATURES

Middle-aged male presenting with a three-month history of intermittent right thigh pain.
Describes the pain as a dull ache, worsening with walking but relieved by rest.
Increasing difficulty walking long distances due to leg discomfort.
Past medical history of hypertension, hyperlipidaemia, and type 2 diabetes.
Concerned about potential circulation problems or nerve issues.
Requires clinical reasoning to differentiate between vascular, neurological, musculoskeletal, and referred pain causes.

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

David Williams, a 58-year-old male, presents to your clinic complaining of right thigh pain that started three months ago. He describes it as a dull, cramping ache that worsens with walking and improves with rest. Over the past month, he has noticed that he can’t walk as far as he used to without stopping due to the discomfort.

He has a history of hypertension, hyperlipidaemia, and type 2 diabetes, all managed with medication. He is a former smoker (quit 5 years ago after 20 pack-years). His BMI is 32, and he leads a mostly sedentary lifestyle.

PATIENT RECORD SUMMARY

Patient Details

Name: David Williams
Age: 58 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Ramipril 5 mg daily (Hypertension)
Atorvastatin 20 mg daily (Hyperlipidaemia)
Metformin 1000 mg BD (Type 2 Diabetes)

Past History

Hypertension (diagnosed 10 years ago)
Type 2 Diabetes (diagnosed 8 years ago)
Hyperlipidaemia (diagnosed 8 years ago)
Former smoker (quit 5 years ago, 20 pack-year history)

Social History

Works as a retired electrician.

Family History

Father: Died at 65 from a heart attack.
Mother: Alive, hypertension and osteoarthritis.
No family history of neuromuscular or autoimmune diseases.

Smoking & Alcohol

Former smoker (quit 5 years ago, 20 pack-year history).
Drinks 2-3 standard drinks per week.

Vaccination and Preventative Activities

Up to date with vaccinations.
Last health check 1 year ago.

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 been having this aching pain in my right thigh for a few months now, and it’s getting worse when I walk. I have to stop more often. I’m really worried this might be something serious, like a circulation problem.”

General Information

(Freely Shared if Asked Open-Ended Questions)

The pain started gradually about three months ago.
It feels like a deep cramping or aching sensation in the middle of your right thigh.
The pain worsens with walking, especially after about 5-10 minutes, and eases when you rest.
You haven’t noticed any swelling, redness, or warmth in the leg.

Specific Information

(Only Revealed if the Candidate Asks Targeted Questions)

Background Information

The pain is always in the same spot—mid-thigh.
You can predict when it will start, depending on how far you walk.
You feel mild pins and needles in your foot sometimes, but it goes away after you stop walking.
You have no lower back pain, just mild stiffness in the mornings.
No recent injuries or trauma to the leg.
You’re worried because you read that leg pain while walking could mean blocked arteries.
You’re not sure if this is a nerve issue, a muscle problem, or something else.

Pain Characteristics

No pain at rest, only with walking or exertion.
The pain goes away within 1-2 minutes of stopping activity.
It’s always in the same location—middle of the right thigh.
No sharp, shooting, or burning pain.
No pain radiating from the back down the leg.
No significant weakness in the leg.
Occasionally, you feel like your right foot is colder than the left, but you haven’t noticed any colour changes or ulcers.

Lifestyle & Risk Factors

You try to walk daily, but lately, you’ve been walking less because of the pain.
Ex-smoker, quit 5 years ago after smoking for about 20 years.
You take medications for blood pressure, cholesterol, and diabetes.
Your weight has increased slightly in the past few years.
You mostly eat home-cooked meals but admit to eating fast food occasionally.
You don’t do any specific exercises aside from walking.
You sit for long periods during the day.
You used to be more active when working, but since retiring, you have become more sedentary.

Medical & Family History

You were diagnosed with type 2 diabetes 8 years ago, but your sugar levels have been stable with metformin.
You have had high cholesterol and high blood pressure for the last 10 years.
Your father died at 65 from a heart attack, and he also had poor circulation in his legs before he passed.
Your mother has hypertension and osteoarthritis but is otherwise well.
No family history of autoimmune disorders or neuromuscular diseases.

Emotional Cues & Concerns

You are anxious about this pain and what it might mean.
You feel frustrated because you want to walk for exercise, but the pain makes it difficult.
You’re worried about circulation problems because of your father’s history of heart disease and poor leg circulation.
You want to know if this means you’ll need surgery or if it can be treated another way.
You’re afraid that if it gets worse, you might not be able to walk properly anymore.
You want to stay active, but you don’t want to make the pain worse.

Questions for the Candidate

(Drop these in naturally throughout the consultation)

“What do you think is causing this pain?”
“Could this be serious? Do I need to worry about losing circulation in my leg?”
“Will I need an ultrasound or other scans?”
“If it’s a circulation problem, what happens next? Do I need surgery?”
“What can I do to improve this?”
“Will I ever be able to walk normally again?”
“What lifestyle changes should I make to prevent this from getting worse?”

How to Respond Based on the Candidate’s Answers

If the Candidate Provides a Clear Explanation and Plan:

You feel relieved but still cautious.
You may ask for clarification:
- “So you think it’s more likely a circulation issue than a nerve problem?”
- “And if I follow the plan you’ve suggested, I should be able to keep walking?”
You agree to the investigations and follow-up plan.

If the Candidate is Unclear or Dismissive:

You become more insistent and anxious.
You might push for a second opinion or request more tests:
- “I just don’t want to take any chances. Can we do all the tests now?”
- “If this gets worse, will I lose mobility?”
- “I need to know for sure what’s going on.”

Ending the Consultation

If the Candidate Has Done Well:

You feel somewhat reassured and agree to the plan.
You might still confirm:
- “So I’ll come back in two weeks unless something changes?”
- “You’ll call me when the test results are in?”
You thank the doctor and leave with a clear idea of what to do next.

If the Candidate Has Not Addressed Your Concerns Well:

You remain doubtful and uneasy.
You may say:
- “I think I might get a second opinion. I just want to be sure.”
- “I’m still not sure if this is something serious.”
You leave feeling frustrated and uncertain about your next steps.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including risk factors and red flag symptoms.

The competent candidate should:

Use open-ended questions to explore the patient’s symptoms, then move to targeted questions to clarify key details.
Identify red flag symptoms such as pain at rest, non-healing ulcers, skin colour changes, weakness, or rapid progression of symptoms.
Clarify the onset, duration, progression, and nature of the pain.
Assess whether the pain is vascular (claudication), neurogenic (sciatica), musculoskeletal, or referred pain.
Explore risk factors for peripheral artery disease (PAD), including smoking history, diabetes, hypertension, and hyperlipidaemia.
Assess for neurological symptoms, including numbness, tingling, or weakness, which may indicate lumbar spinal stenosis or radiculopathy.
Consider musculoskeletal causes by asking about recent injuries, joint pain, or osteoarthritis.
Address psychosocial concerns, including the patient’s worries about disability and quality of life.
Summarise key findings to ensure accuracy and demonstrate active listening.

Task 2: Discuss your differential diagnosis with the patient.

The competent candidate should:

Explain that the cause of the leg pain could be due to multiple possible conditions.
Discuss the most likely differentials:
- Peripheral artery disease (PAD): Claudication pain due to arterial insufficiency, relieved by rest.
- Neurogenic claudication (lumbar spinal stenosis): Pain worsens with walking, relieved by sitting/flexion.
- Sciatica: Radiating pain from the back down the leg, associated with tingling or weakness.
- Osteoarthritis of the hip/knee: Pain associated with movement, worse at the end of the day.
- Referred pain from the lower back: Pain patterns that follow nerve root distributions.
Address the patient’s concern about circulation problems and explain the need for further assessment.
Explain that investigations will help confirm the diagnosis and guide management.

Task 3: Explain the investigations you will request and why.

The competent candidate should:

Justify initial investigations, including:
- Ankle-Brachial Index (ABI): To assess for peripheral artery disease.
- Doppler ultrasound of the lower limb arteries: To evaluate arterial blood flow.
- Lumbar spine X-ray or MRI (if neurogenic claudication is suspected): To check for spinal stenosis.
- Full blood count (FBC), fasting glucose, HbA1c, lipid profile: To assess cardiovascular risk factors.
- ESR/CRP: To screen for inflammatory or rheumatological conditions.
Explain that if PAD is suspected, referral to a vascular specialist may be necessary for further testing.
Provide clear timeframes for follow-up and test results.

Task 4: Provide an initial management plan and follow-up advice.

The competent candidate should:

Develop a management plan tailored to the likely diagnosis:
- If PAD is suspected: Lifestyle changes (smoking cessation, exercise, weight loss), medication (aspirin, statins), and possible referral.
- If neurogenic claudication is suspected: Physiotherapy, pain management, and possible imaging referral.
- If musculoskeletal causes are suspected: Physiotherapy, analgesia, and weight management.
Address modifiable risk factors, including diabetes control, blood pressure management, and cholesterol reduction.
Advise the patient on symptom monitoring and when to seek urgent care (e.g., worsening pain at rest, ulceration).
Schedule a follow-up appointment to review test results and assess symptom progression.

SUMMARY OF A COMPETENT ANSWER

Conducts a structured, patient-centred history, addressing red flags and differential diagnoses.
Provides a clear and logical differential diagnosis based on clinical reasoning.
Orders appropriate evidence-based investigations to confirm the diagnosis.
Develops a safe, patient-centred management plan with clear follow-up.
Uses empathetic communication to address the patient’s concerns.

PITFALLS

Failure to elicit red flags, such as rest pain or neurological symptoms.
Over-reassurance without appropriate investigations.
Narrow focus on one diagnosis, leading to missed differentials.
Lack of safety-netting, missing worsening vascular compromise.
Failure to address the patient’s concerns about circulation and mobility.

REFERENCES

RACGP Guidelines – Peripheral Artery Disease

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.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets relevant history, including red flags.
2.2 Selects and justifies appropriate investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms a logical differential diagnosis based on history and findings.
3.5 Identifies red flag symptoms requiring urgent referral.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based, patient-centred management plan.
4.3 Provides structured follow-up and safety-netting.

5. Preventive and Population Health

5.2 Addresses modifiable risk factors for vascular and neuropathic disease.

6. Professionalism

6.1 Maintains confidentiality and professional integrity.

7. General Practice Systems and Regulatory Requirements

7.1 Orders appropriate tests in line with MBS guidelines.

9. Managing Uncertainty

9.2 Develops a structured approach to a patient with an unclear diagnosis.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and acts on potentially serious conditions.

Competency at Fellowship Level

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