CCE-CBD-135

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. Take a focused history from John regarding his shoulder complaint.

• Prompt: Elicit information about the onset, duration, and progression of the pain.
• Prompt: Explore any previous injuries, work factors, and impact on daily activities and sleep.
• Prompt: Ask about red flag symptoms (e.g., night sweats, weight loss, neurological symptoms).
• Prompt: Understand John’s ideas, concerns, and expectations, particularly about his work.

Q2. Perform a focused physical examination to assess John’s shoulder.

• Prompt: Describe the key components: inspection, palpation, range of motion, strength testing, and special tests (e.g., Hawkins-Kennedy, Neer test).
• Prompt: Explain the significance of findings like painful arc and weakness.

Q3. Explain the diagnosis to John in a way he can understand.

• Prompt: Use lay terms to describe rotator cuff tendinopathy and partial tear.
• Prompt: Address his concerns about long-term outcomes and work.
• Prompt: Provide reassurance while being realistic about recovery times.

Q4. Outline your initial management plan for John.

• Prompt: Discuss analgesia options, activity modification, and physiotherapy.
• Prompt: Explore strategies for rural patients with limited access to allied health services (e.g., telehealth, home exercise programs).
• Prompt: Consider a referral to a specialist if symptoms persist despite conservative management.

Q5. Discuss prevention strategies and long-term care for shoulder health.

• Prompt: Recommend ergonomic adjustments at work, strengthening exercises, and avoiding overhead strain.
• Prompt: Consider preventive measures to reduce further injury risk.
• Prompt: Discuss regular follow-ups and monitoring of chronic conditions impacting musculoskeletal health.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: Take a focused history from John regarding his shoulder complaint.

Detailed Answer for Marking Guidance:

• Introduction and Rapport:
  • Greet John, confirm his identity, and establish rapport.
  • Explain the purpose of the consultation and gain consent.
• History of Presenting Complaint:
  • Onset and Duration: Establish when the pain started (6 weeks ago), whether it was gradual or sudden (gradual).
  • Location: Clarify the location (right shoulder, lateral aspect).
  • Character and Severity: Ask about the type of pain (dull ache with sharp exacerbations) and rate on a scale of 1-10.
  • Radiation: Confirm absence of radiation (none reported).
  • Aggravating and Relieving Factors: Activities that worsen the pain (overhead activities, lifting, sleeping on the side), medications tried (paracetamol and ibuprofen, partial relief).
  • Functional Impact: Difficulty with work tasks (carpentry) and activities of daily living, disturbed sleep.
• Red Flag Symptoms:
  • Inquire about systemic symptoms: fevers, night sweats, weight loss (none reported).
  • Neurological symptoms: numbness, tingling, weakness in hands/fingers (none reported).
• Associated Symptoms:
  • Neck pain or referred pain? (No)
  • History of trauma? (None)
• Past History:
  • Previous shoulder problems? (No)
  • General musculoskeletal health? (Osteoarthritis in family, none in John).
• Social History and Psychosocial Impact:
  • Work concerns (carpentry impacted, worried about income).
  • Stress related to the injury and limited access to physiotherapy in his rural area.
• Ideas, Concerns, and Expectations (ICE):
  • John is concerned about long-term damage, expectations of needing surgery, and hopes for relief through exercises or therapy.

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Q2: Perform a focused physical examination to assess John’s shoulder.

Detailed Answer for Marking Guidance:

• Inspection:
  • Look for asymmetry, swelling, muscle wasting, scars (none noted).
• Palpation:
  • Tenderness over the greater tuberosity of the humerus and subacromial space.
• Range of Motion:
  • Active ROM: Limited abduction (painful arc 70-120 degrees), external rotation reduced.
  • Passive ROM: Largely preserved, indicating non-capsular pathology.
• Strength Testing:
  • Weakness in external rotation (suggesting supraspinatus involvement).
  • Pain with resisted movements, especially abduction.
• Special Tests:
  • Hawkins-Kennedy Test: Positive (impingement).
  • Neer Test: Positive (subacromial impingement).
  • Empty Can Test: Weakness and pain (supraspinatus involvement).
• Neurovascular Examination:
  • Normal power, reflexes, and sensation in the upper limb.
• Interpretation:
  • Findings consistent with rotator cuff tendinopathy and partial supraspinatus tear.

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Q3: Explain the diagnosis to John in a way he can understand.

Detailed Answer for Marking Guidance:

• Use lay terms:
  • “John, you have an issue with the tendons in your shoulder. The tendon that helps you lift your arm, called the supraspinatus, is partly torn and inflamed.”
• Explain the mechanics:
  • “This tendon gets irritated, especially when you work overhead or lift things. That’s causing your pain and limiting movement.”
• Address concerns:
  • “The good news is this is common and often improves with the right exercises and treatment. Surgery is rarely needed unless it doesn’t improve after 3-6 months.”
• Reassurance with realism:
  • “Recovery can take weeks to months, but many people do very well with non-surgical treatment.”
• Clarify next steps in management and follow-up.

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Q4: Outline your initial management plan for John.

Detailed Answer for Marking Guidance:

• Pain Management:
  • Continue paracetamol and NSAIDs as needed, ensure safe use (consider his hypertension and renal function).
  • Discuss topical NSAIDs as an option.
• Activity Modification:
  • Advise to avoid overhead activities and lifting heavy objects.
  • Provide strategies for work modifications (lighter duties).
• Physiotherapy Referral:
  • Referral to physiotherapist (telehealth or community-based options if in a rural setting).
  • Emphasise importance of exercise: strengthening rotator cuff and scapular stabilisers.
• Education and Self-Management:
  • Provide printed resources or apps for guided exercises.
• Follow-up:
  • Review in 2-4 weeks to assess progress.
  • If no improvement after 6-12 weeks, consider ultrasound-guided corticosteroid injection or referral to orthopaedic specialist.

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Q5: Discuss prevention strategies and long-term care for shoulder health.

Detailed Answer for Marking Guidance:

• Ergonomic Advice:
  • Modify work techniques: use of scaffolding, reduce overhead work, and alternate tasks.
• Exercise:
  • Long-term commitment to shoulder strengthening and flexibility exercises.
  • Encourage ongoing physiotherapy if available.
• Lifestyle:
  • Weight management to reduce joint load.
  • Manage comorbid conditions (e.g., hypertension, cholesterol).
• Monitoring and Follow-up:
  • Regular reviews to assess function and pain.
  • Early intervention for recurrence of symptoms.

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SUMMARY OF A COMPETENT ANSWER

• Thorough focused history addressing pain onset, aggravating factors, and work impact.
• Comprehensive shoulder examination including range of motion, special tests, and neurovascular assessment.
• Clear explanation of rotator cuff tendinopathy in lay language, addressing concerns about work and recovery.
• Evidence-based management plan including analgesia, physiotherapy, and rural healthcare considerations.
• Preventive strategies with ergonomic advice and long-term exercise planning.

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PITFALLS

• Failing to elicit red flag symptoms, risking missing serious pathology.
• Over-reliance on imaging instead of clinical diagnosis.
• Inadequate explanation of diagnosis and prognosis, increasing patient anxiety.
• Neglecting work and functional implications, particularly in a rural setting.
• Missing comorbidities impact (e.g., hypertension affecting NSAID use).

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REFERENCES

• RACGP Guidelines on Musculoskeletal injuries
• Therapeutic Guidelines on Pain and Analgesia
• Sports Medicine Australia on Shoulder Pain Resources
• HealthPathways on Shoulder Pain Management

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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 an appropriate physical examination.

3. Diagnosis, Decision-Making and Reasoning

3.1 Selects appropriate investigations based on clinical presentation.
3.2 Demonstrates diagnostic reasoning and considers differential diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a management plan, including pharmacological and non-pharmacological strategies.

5. Preventive and Population Health

5.1 Provides appropriate lifestyle advice to promote musculoskeletal health.

6. Professionalism

6.1 Demonstrates respectful and culturally responsive care.

7. General Practice Systems and Regulatory Requirements

7.1 Coordinates care with allied health services, including physiotherapy and radiology.

9. Managing Uncertainty

9.1 Explains limitations of diagnosis and treatment when certainty is not possible.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises red flags and refers when appropriate.

12. Rural Health Context (RH)

RH1.1 Demonstrates resourcefulness in areas with limited access to services.

Competency at Fellowship Level

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