CCE-CBD-075

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. Take a focused history and discuss your differential diagnoses

• Prompt: Explore the history of presenting complaint
• Prompt: Discuss red flags you would exclude
• Prompt: Discuss your provisional diagnosis and differentials

Q2. Explain your management plan, including non-surgical options

• Prompt: Discuss conservative management
• Prompt: Explain the role of physiotherapy and analgesia
• Prompt: Discuss when to consider further referral

Q3. What lifestyle modifications and preventive strategies would you recommend?

• Prompt: Ergonomic advice for work
• Prompt: Exercise program tailored to his condition
• Prompt: Weight management and diabetes control

Q4. How would you address John’s concerns about prognosis and recovery?

• Prompt: Discuss expected outcomes with conservative management
• Prompt: Explain red flags for deterioration
• Prompt: Provide reassurance and set realistic expectations

Q5. When and why would you refer for surgical consideration?

• Prompt: Indications for surgical referral
• Prompt: Discuss timeframes and response to conservative therapy
• Prompt: Address John’s reluctance to consider surgery

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: Take a focused history and discuss your differential diagnoses

The competent candidate should begin by exploring the history of presenting complaint in a structured manner:

• Onset and duration: Insidious onset over 3 months.
• Character and location: Lateral shoulder pain, worsens with overhead activities.
• Aggravating/relieving factors: Exacerbated by overhead movements; relieved slightly by rest.
• Impact on daily activities: Difficulty dressing, reaching overhead, and sleep disturbance when lying on the affected side.
• Functional limitations: Impacting work performance, particularly prolonged computer use.

Screen for red flags:

• No history of trauma or dislocation.
• No systemic symptoms (fever, weight loss) suggesting infection or malignancy.
• No neurological symptoms such as weakness or paraesthesia.

Discuss the differential diagnoses:

• Rotator cuff tendinopathy/impingement syndrome: Most likely based on history and examination.
• Adhesive capsulitis (frozen shoulder): Less likely due to preserved passive movement.
• Calcific tendinitis: Could be considered but not supported by imaging.
• Glenohumeral osteoarthritis: Less likely in the absence of crepitus and relatively preserved joint function.
• Cervical radiculopathy: Unlikely as there is no neck pain or radicular symptoms.

Provisional diagnosis: Rotator cuff tendinopathy with secondary impingement.

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Q2: Explain your management plan, including non-surgical options

The competent candidate should outline a stepwise, evidence-based management plan.

• Education and reassurance: Explain that rotator cuff tendinopathy is common and often responds well to conservative treatment.
• Pain management:
  • Simple analgesia (paracetamol).
  • NSAIDs for short-term use if no contraindications (consider diabetes).
  • Discuss potential risks of NSAIDs in diabetic patients.
• Physiotherapy referral:
  • Focus on supervised rotator cuff strengthening and scapular stabilisation exercises.
  • Address postural issues due to prolonged desk work.
• Activity modification:
  • Avoid aggravating activities, but encourage movement within the pain-free range.
  • Ergonomic adjustments at work (keyboard height, posture).
• Injection therapy:
  • Subacromial corticosteroid injection if pain remains poorly controlled despite initial conservative measures.
• Follow-up:
  • Review in 4-6 weeks to assess response to physiotherapy and pain control.

Explain that most cases improve over 6-12 weeks. Surgery is rarely required unless there is a full-thickness tear or failure of conservative management.

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Q3: What lifestyle modifications and preventive strategies would you recommend?

The competent candidate should promote holistic management.

• Exercise and physiotherapy: Continue home exercise program to maintain flexibility and strength.
• Posture and ergonomics:
  • Regular breaks from sitting.
  • Ensure ergonomic workspace setup.
• Weight management:
  • Encourage gradual weight loss; BMI currently 29 kg/m².
  • Explain benefits on shoulder health and overall joint load.
• Diabetes control:
  • Optimise glycaemic control (HbA1c 7% currently reasonable).
  • Better control may improve tendon healing.
• Smoking and alcohol:
  • Non-smoker and light alcohol use, maintain these healthy behaviours.
• General physical activity:
  • Encourage low-impact activities (e.g., swimming, walking).

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Q4: How would you address John’s concerns about prognosis and recovery?

The competent candidate should provide realistic and supportive counselling.

• Prognosis:
  • Explain that rotator cuff tendinopathy is often self-limiting with appropriate treatment.
  • Most patients improve within 3-6 months of conservative care.
• Recovery expectations:
  • Emphasise adherence to physiotherapy and home exercises is key.
  • Pain relief may take several weeks.
• Warning signs/red flags:
  • Worsening pain, sudden weakness, or loss of range of motion may suggest a tear.
  • Advise to return sooner if these occur.
• Encouragement:
  • Empathise with his concerns about work and function.
  • Discuss options for temporary work modification to reduce strain.
• Avoid surgery for now:
  • Most patients improve without surgery.
  • Surgery considered only if conservative management fails after 6 months.

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Q5: When and why would you refer for surgical consideration?

The competent candidate should outline clear indications for referral.

• Indications:
  • Persistent pain despite 6 months of appropriate conservative management.
  • Functional limitations impacting work or daily life.
  • Evidence of a rotator cuff tear on imaging that is full-thickness and symptomatic.
  • Failed response to corticosteroid injections and physiotherapy.
• Type of referral:
  • Orthopaedic referral for consideration of arthroscopic subacromial decompression or rotator cuff repair.
• Addressing reluctance:
  • Provide information on surgical options.
  • Discuss outcomes and risks of surgery.
  • Emphasise that surgery is not urgent and focus on non-surgical options initially.

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SUMMARY OF A COMPETENT ANSWER

• Clear history gathering focusing on onset, function, and red flags.
• Accurate differential diagnoses based on history and examination.
• Stepwise management with conservative treatment first.
• Holistic lifestyle advice including exercise, weight loss, and diabetes management.
• Supportive counselling with realistic expectations.
• Appropriate referral indications explained clearly.

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PITFALLS

• Failure to consider red flags like adhesive capsulitis or full-thickness tear.
• Over-reliance on imaging rather than clinical diagnosis.
• Neglecting to address diabetes as a contributing factor.
• Underestimating ergonomic and lifestyle factors in prevention.
• Inadequate counselling on recovery expectations and prognosis.

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REFERENCES

• RACGP Guidelines for Musculoskeletal Conditions
• Therapeutic Guidelines: Rheumatology
• Australian Government Diabetes Guidelines

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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 an appropriate history informed by the patient’s context.
2.2 Performs a relevant physical examination and assessment, identifies abnormal findings.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates hypotheses and establishes a provisional diagnosis.
3.2 Demonstrates diagnostic reasoning with consideration of differentials.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a management plan with appropriate investigations, treatments and referrals.
4.2 Explains therapeutic options and engages in shared decision making.

5. Preventive and Population Health

5.1 Provides advice on ergonomic strategies and exercise to prevent recurrence.

6. Professionalism

6.1 Provides respectful care, taking into account the patient’s values and preferences.

7. General Practice Systems and Regulatory Requirements

7.1 Refers appropriately to allied health and specialist services.
7.2 Documents care appropriately.

9. Managing Uncertainty

9.1 Recognises when further investigation is needed (e.g., imaging, specialist referral).

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises red flags (e.g., rotator cuff tear, adhesive capsulitis) requiring urgent management.

Competency at Fellowship Level

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