CCE-CBD-157

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your working diagnosis and immediate management plan for Luke?

• Prompt: Discuss both injuries.
• Prompt: What are your priorities in the first 24 hours?
• Prompt: Any referrals required?

Q2. What are the important considerations in Luke’s follow-up care and rehabilitation?

• Prompt: Return to work planning.
• Prompt: Preventing complications.
• Prompt: Multidisciplinary team involvement.

Q3. What preventive health strategies would you recommend for Luke?

• Prompt: Consider vaccination and workplace safety.
• Prompt: Discuss health promotion opportunities relevant to a young rural male.

Q4. How would you address Luke’s concerns about long-term function and employment?

• Prompt: Address his psychosocial and occupational concerns.
• Prompt: How would you support him if complications arise (e.g., chronic pain, delayed healing)?

Q5. Discuss your role in coordinating Luke’s care as a rural GP.

• Prompt: Access to allied health and specialist services.
• Prompt: Communication with his employer.
• Prompt: Follow-up and monitoring responsibilities.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your working diagnosis and immediate management plan for Luke?

Working Diagnosis:

• Minimally displaced distal radial fracture (right wrist)
• Soft tissue injury (sprain/contusion) of the right ankle

Immediate Management Plan:

• Immobilisation:
  • Apply a removable wrist splint for the distal radial fracture.
  • Advise RICE protocol (Rest, Ice, Compression, Elevation) for the ankle.
• Analgesia:
  • Start with regular paracetamol and add NSAIDs if there are no contraindications (e.g., ibuprofen 400 mg every 8 hours).
• Referral:
  • Consider orthopaedic referral for assessment of fracture displacement, if necessary.
  • Arrange physiotherapy input for ankle rehabilitation after acute management.
• Investigations:
  • Repeat imaging may be indicated if there is concern for further injury or delayed healing.
• Tetanus status:
  • Confirm vaccination status. If the booster was over 5 years ago, consider giving a tetanus booster, especially if there are abrasions.
• Work cover and documentation:
  • Complete appropriate WorkCover certificates and provide medical clearance forms.

Priorities in the First 24 Hours:

• Pain control and immobilisation.
• Monitoring for neurovascular compromise (particularly in the wrist).
• Educating Luke on signs of compartment syndrome and red flags (numbness, increased pain).
• Arranging follow-up within 5-7 days to reassess pain, swelling, and function.

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Q2: What are the important considerations in Luke’s follow-up care and rehabilitation?

Follow-Up Care:

• Fracture management:
  • Regular reviews (initially at 5-7 days) to assess pain control, swelling, and function.
  • Repeat X-rays if pain worsens or healing does not progress as expected.
• Rehabilitation:
  • Referral to physiotherapy for wrist mobilisation once pain allows (usually after 3-4 weeks in a splint).
  • Ankle sprain management, including balance and proprioceptive training to prevent recurrence.
• Return to work planning:
  • Light duties for 4-6 weeks depending on pain and function.
  • Close communication with Luke’s employer regarding suitable duties and a graduated return to work plan.

Preventing Complications:

• Educate on signs of complications (non-union, chronic pain, complex regional pain syndrome).
• Emphasise early mobilisation of uninjured joints (e.g., elbow, fingers, toes).

Multidisciplinary Team:

• Engage physiotherapists for both wrist and ankle rehabilitation.
• Consider occupational therapy if concerns about returning to manual work.

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Q3: What preventive health strategies would you recommend for Luke?

Vaccinations:

• Tetanus booster if due (last booster was 8 years ago—recommend updating).

Workplace Safety:

• Review ladder safety practices at the worksite.
• Discuss the importance of occupational health and safety protocols.

Health Promotion:

• Lifestyle factors:
  • Address alcohol consumption—within NHMRC guidelines (<10 standard drinks per week).
  • Promote physical fitness—strength training to prevent future injuries.
• Preventative health checks:
  • Consider CVD risk assessment, even though Luke is young, as a baseline for future.
  • Skin checks and other age-appropriate screenings as per Red Book guidelines.

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Q4: How would you address Luke’s concerns about long-term function and employment?

Addressing Concerns:

• Provide reassurance: Most distal radius fractures heal well with minimal long-term impairment.
• Set realistic expectations: Healing of fractures may take 6-8 weeks, full strength recovery longer.
• Reinforce the importance of physiotherapy and adherence to rehab to optimise outcomes.

Psychosocial Considerations:

• Explore anxiety about employment—acknowledge financial stress and offer WorkCover support.
• Discuss mental health—risk of depression/anxiety in injured workers.
• Offer referral to psychology services if indicated.

If Complications Arise:

• Early detection and management of complex regional pain syndrome.
• Referral to orthopaedics if non-union is suspected.
• Long-term functional capacity evaluation if permanent work restrictions become necessary.

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Q5: Discuss your role in coordinating Luke’s care as a rural GP.

Coordination of Care:

• Act as the primary point of contact for all health needs.
• Facilitate access to physiotherapy and occupational health services (may require telehealth).
• Arrange specialist referral (orthopaedics), mindful of rural access barriers.
• Liaise with WorkCover, providing clear communication about Luke’s capacity for work.

Communication:

• Provide clear documentation to the employer regarding fitness for duties.
• Ensure continuity of care by maintaining comprehensive medical records.

Follow-up Responsibilities:

• Regular monitoring for recovery progress.
• Ensuring completion of rehabilitation goals.
• Long-term management of any chronic issues that arise from the injury.

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SUMMARY OF A COMPETENT ANSWER

• Accurate working diagnosis of wrist fracture and ankle sprain.
• Prioritised immediate management, including immobilisation, analgesia, and referral.
• Appropriate follow-up with an emphasis on rehabilitation and prevention of complications.
• Patient-centred communication addressing psychosocial and occupational concerns.
• Coordinated care, recognising rural challenges and involving a multidisciplinary team.

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PITFALLS

• Failure to assess neurovascular status in the wrist and ankle.
• Inadequate pain management, resulting in poor compliance with rehabilitation.
• Neglecting preventive health strategies, such as tetanus immunisation and workplace safety advice.
• Not involving allied health early, which may delay functional recovery.
• Overlooking psychosocial factors, particularly related to employment and mental health.

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REFERENCES

• RACGP Red Book (9th edition) on Preventive activities in general practice
• Australian and New Zealand Orthopaedic Trauma Society (ANZOTS) guidelines
• NHMRC Guidelines for Alcohol Consumption
• WorkCover Queensland

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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 Gathers and interprets information about health needs and issues.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses and diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Prescribes and monitors therapies appropriately.

5. Preventive and Population Health

5.1 Provides care that includes health promotion and illness prevention activities.

6. Professionalism

6.1 Adopts a patient-centred approach to care.

7. General Practice Systems and Regulatory Requirements

7.1 Practices in accordance with relevant policies and guidelines.

8. Procedural Skills

8.1 Performs procedural skills safely.

9. Managing Uncertainty

9.1 Manages uncertainty in diagnosis and management.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages the patient with potentially serious illness.

12. Rural Health Context (RH)

RH1.1 Provides comprehensive, evidence-based care appropriate to rural settings.

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Competency at Fellowship Level

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