CCE-CBD-073.1

CASE INFORMATION

Case ID: MS-008
Case Name: David Harris
Age: 46
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L87 – Bursitis/Tendonitis/Synovitis

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 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 Interpretation2.1 Elicits a clinical history that is informed by the patient’s context and the presenting problem.
2.2 Performs a clinical examination tailored to the presentation.
2.3 Selects and implements appropriate investigations based on available evidence and best practice.
3. Diagnosis, Decision-Making and Reasoning3.1 Interprets findings to reach a diagnosis.
3.2 Considers differential diagnoses, weighing the probability of each.
4. Clinical Management and Therapeutic Reasoning4.1 Designs and implements appropriate management plans.
4.2 Provides therapeutic reasoning to support treatment choices.
5. Preventive and Population Health5.1 Applies preventive care strategies including patient education on ergonomics and physical activity.
6. Professionalism6.1 Displays ethical behaviour and maintains patient-centred care.
7. General Practice Systems and Regulatory Requirements7.1 Documents care according to medico-legal requirements, including WorkCover certification if required.
9. Managing Uncertainty9.1 Explains prognosis and rationale for treatment, including the approach when diagnosis is uncertain.
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies when specialist input is required for persistent or worsening symptoms.
12. Rural Health Context (RH)RH1.1 Adapts management to limited allied health resources and services in rural settings.

CASE FEATURES

  • Lives in a rural town with limited access to allied health services.
  • 46-year-old male presenting with right shoulder pain.
  • Office worker, recently increased workload, with prolonged desk use.
  • Pain described as aching, worsened by overhead movements and sleeping on the right side.
  • No history of trauma, systemic symptoms, or prior shoulder issues.
  • Concerned about ability to continue working full-time.
  • Exam findings suggestive of rotator cuff tendinopathy.

INSTRUCTIONS

Review the following patient record summary and scenario.

Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.
The time allocation for each question is roughly as follows:

  • Question 1 – 3 minutes
  • Question 2 – 3 minutes
  • Question 3 – 3 minutes
  • Question 4 – 3 minutes
  • Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: David Harris
Age: 46
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Occasional paracetamol

Past History

No significant history

Social History

  • Office worker
  • Lives in rural NSW
  • Married, two children
  • No smoking, occasional alcohol
  • Limited physical activity due to work commitments

Family History

No musculoskeletal or autoimmune conditions

Vaccination and Preventive Activities

Up to date on influenza and tetanus vaccines

SCENARIO

David Harris is a 46-year-old office worker who presents with a three-month history of right shoulder pain. He describes it as a dull ache, worse with overhead movements and while lying on the affected side. He denies any trauma or systemic symptoms. The pain has gradually worsened since he increased his desk work hours due to a recent promotion.

He is concerned about his ability to continue working full-time if the pain persists. He has tried over-the-counter paracetamol, which provides minimal relief. He is open to physiotherapy but lives in a rural area where services are limited.

On examination:

  • Inspection: No swelling or deformity
  • Palpation: Tenderness over the supraspinatus tendon
  • Range of Motion: Painful arc between 60-120 degrees of abduction
  • Strength: Mild weakness on external rotation against resistance
  • Special Tests: Positive Hawkins-Kennedy and Neer impingement tests
  • Neurovascular: Intact
  • No signs of systemic illness

INVESTIGATION FINDINGS

  • Plan for a shoulder ultrasound to assess for rotator cuff pathology.
  • No imaging has been performed yet.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: Take a focused history to assess David’s shoulder pain.

The competent candidate should:

  • Establish rapport and clarify the reason for consultation.
  • Explore the history of presenting complaint, including:
    • Onset, duration, and progression of shoulder pain.
    • Location and radiation of pain.
    • Character of pain (dull ache, sharp).
    • Aggravating (overhead activities, sleep) and relieving factors (rest, medication).
    • Severity using a pain scale (e.g., 0-10).
  • Assess functional limitations (e.g., dressing, grooming, work tasks).
  • Review impact on quality of life, mental health, and work.
  • Explore red flags: night pain, systemic symptoms (fever, weight loss), history of cancer.
  • Enquire about past treatments: analgesia use, physiotherapy, self-care.
  • Elicit expectations and concerns (e.g., about chronicity, ability to work).

Q2: Outline the differential diagnoses and justify your provisional diagnosis.

The competent candidate should:

  • List and briefly describe:
    • Rotator cuff tendinopathy (most likely): gradual onset, pain with overhead activity, painful arc, positive impingement tests.
    • Subacromial bursitis: pain with abduction, localised tenderness.
    • Frozen shoulder (adhesive capsulitis): progressive loss of both active and passive movement.
    • Cervical radiculopathy: referred pain, neurological signs.
  • Justify rotator cuff tendinopathy as the provisional diagnosis:
    • Clinical features: painful arc, tender supraspinatus tendon, positive Hawkins-Kennedy/Neer.
    • Absence of red flags or systemic symptoms.

Q3: Develop a management plan suitable for a rural setting.

The competent candidate should:

  • Non-pharmacological:
    • Education on condition, prognosis.
    • Modify activities: avoid overhead work.
    • Home-based exercises focusing on strengthening and flexibility.
    • Ergonomic advice for desk work.
  • Pharmacological:
    • Continue paracetamol.
    • NSAIDs (short course), consider gastroprotection.
  • Investigations:
    • Arrange shoulder ultrasound for structural assessment (rotator cuff tears).
  • Referrals:
    • Local physiotherapy if available; otherwise, online exercise programs or self-management plans.
  • Discuss barriers (access to services) and strategies (telehealth, home programs).

Q4: Educate David on preventive strategies and prognosis.

The competent candidate should:

  • Explain condition: typically self-limiting with conservative management.
  • Emphasise ergonomics: monitor height, keyboard/mouse positioning.
  • Encourage graded return to activity.
  • Provide a home exercise plan or handouts.
  • Discuss weight management and maintaining general fitness.
  • Prognosis: gradual improvement over weeks to months; review if no progress.
  • Red flags warranting review: persistent weakness, severe pain, or functional loss.

Q5: Discuss criteria for referral to specialist services.

The competent candidate should:

  • Refer to orthopaedic surgeon if:
    • Full-thickness rotator cuff tear on imaging.
    • Significant weakness or functional impairment.
    • Failure of conservative management over 3-6 months.
  • Consider sports medicine or pain specialists for complex cases.
  • Early referral if red flags or rapid progression of symptoms.
  • Use WorkCover documentation if injury is work-related and affecting employment.

SUMMARY OF A COMPETENT ANSWER

  • Demonstrates structured history taking, focusing on pain characteristics and functional impact.
  • Identifies rotator cuff tendinopathy as the likely diagnosis, considering differentials.
  • Provides a comprehensive management plan, considering rural limitations.
  • Emphasises patient education, ergonomic advice, and home-based rehabilitation.
  • Discusses appropriate referral pathways based on patient progress and access issues.

PITFALLS

  • Failing to identify red flags requiring urgent referral.
  • Overlooking psychosocial impacts of chronic pain (mental health, work stress).
  • Not considering rural health access issues and practical strategies.
  • Providing incomplete education about home management and prognosis.
  • Inadequate documentation for work-related injuries (e.g., WorkCover).

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.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Elicits a clinical history informed by the patient’s context and presenting problem.
2.2 Performs a targeted musculoskeletal and neurological exam.
2.3 Selects appropriate investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Interprets clinical findings to reach a diagnosis.
3.2 Considers differential diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.1 Designs a management plan appropriate to patient context.
4.2 Provides therapeutic reasoning.

5. Preventive and Population Health

5.1 Provides preventive strategies (ergonomics, exercise).

6. Professionalism

6.1 Maintains a patient-centred approach, respects autonomy.

7. General Practice Systems and Regulatory Requirements

7.1 Documents care appropriately, including WorkCover.

9. Managing Uncertainty

9.1 Explains prognosis and rationale for treatment in uncertain situations.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies when specialist input is required.

12. Rural Health Context (RH)

RH1.1 Adapts management for rural resource limitations.

Competency at Fellowship Level

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