CCE-CBD-168

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your assessment of Jack’s wound and what factors guide your decision to suture?

• Prompt: Discuss wound location, depth, contamination risk.
• Prompt: Discuss criteria for primary closure vs. delayed closure.

Q2. Describe the procedural steps you would follow to suture Jack’s wound.

• Prompt: Include anaesthesia, aseptic technique, choice of suture material, and aftercare.
• Prompt: How would you ensure Jack’s comfort and safety?

Q3. How would you manage Jack’s tetanus risk and infection prevention?

• Prompt: Address need for tetanus booster.
• Prompt: Discuss wound care, antibiotics if necessary, and patient education.

Q4. What follow-up and safety-netting advice would you give Jack?

• Prompt: When should he return for suture removal?
• Prompt: What signs of complications should he be aware of?
• Prompt: Discuss work restrictions and hand function monitoring.

Q5. How would you document and code this encounter in your practice software?

• Prompt: Ensure proper coding for billing and clinical records.
• Prompt: Include procedure details, patient consent, and follow-up plan.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your assessment of Jack’s wound and what factors guide your decision to suture?

Answer:

Jack Wilson presents with a 4 cm clean linear laceration on the left palm, exposing subcutaneous tissue but without tendon involvement or neurovascular compromise. There is no evidence of foreign bodies or contamination.

Factors guiding the decision to suture include:

• Wound characteristics:
  • Clean wound edges.
  • Less than 6 hours since injury, reducing infection risk.
  • Location on the palm, where healing by secondary intention would risk impaired function and cosmetic outcomes.
• Depth and tissue involvement:
  • The wound extends to the subcutaneous layer, necessitating closure to promote healing and prevent infection.
• Absence of contraindications:
  • No signs of infection.
  • No significant contamination requiring delayed closure.

The decision to perform primary closure is appropriate to promote optimal wound healing, reduce scarring, and restore hand function.

Q2: Describe the procedural steps you would follow to suture Jack’s wound.

Answer:

Preparation:

• Obtain informed consent, explaining the procedure, risks, and aftercare.
• Ensure aseptic technique, including hand hygiene, gloves, and sterile field.
• Gather equipment: suture kit, 4-0 non-absorbable sutures, local anaesthetic (1% lignocaine without adrenaline).

Procedure:

• Clean the wound with normal saline and inspect for foreign bodies.
• Infiltrate lignocaine for anaesthesia.
• Debride devitalised tissue if necessary.
• Use simple interrupted sutures to approximate wound edges.
• Avoid excessive tension to minimise scarring.
• Apply a sterile dressing.

Post-procedure:

• Provide analgesia as required.
• Educate on wound care and signs of infection.
• Document procedure and consent.

Q3: How would you manage Jack’s tetanus risk and infection prevention?

Answer:

• Tetanus prophylaxis:
  • Last tetanus booster was 8 years ago.
  • Administer ADT (Adult Diphtheria-Tetanus vaccine) as a booster dose.
• Infection prevention:
  • Clean wound thoroughly.
  • No need for prophylactic antibiotics in a clean, uncomplicated wound.
  • Educate on keeping the wound clean and dry.
• Advice on signs of infection:
  • Redness, swelling, discharge, or increasing pain.
  • Fever or systemic symptoms.

Q4: What follow-up and safety-netting advice would you give Jack?

Answer:

• Follow-up: Review in 7-10 days for suture removal.
• Earlier review if there are signs of infection or wound dehiscence.
• Activity restrictions:
  • Minimise use of the affected hand for at least 48 hours.
  • Avoid heavy lifting or strenuous activity until the wound heals.
• Signs of complications:
  • Educate on recognising infection and when to seek urgent care.
  • Discuss potential complications: scarring, wound reopening, infection.

Q5: How would you document and code this encounter in your practice software?

Answer:

• Document patient details, history, and examination findings.
• Include informed consent, tetanus immunisation, and procedural details (number and type of sutures, anaesthetic used).
• Code using ICPC-2 Codes:
  • S18 (Laceration/cut).
  • A21 (Wound care).
• Billing: Medicare item number for suturing (e.g., 30023 for superficial wound repair).
• Include post-procedure advice and follow-up plan.

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SUMMARY OF A COMPETENT ANSWER

• Demonstrates structured wound assessment and rationale for suturing.
• Describes aseptic technique and step-by-step procedural competence.
• Addresses infection prevention, tetanus management, and post-care.
• Provides comprehensive safety netting and follow-up advice.
• Ensures accurate documentation and appropriate coding.

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PITFALLS

• Failure to check or document tetanus status and update if required.
• Inadequate aseptic technique, risking infection.
• Overlooking wound depth or tendon injury.
• Incomplete patient education on wound care and complications.
• Poor documentation, missing critical details like consent and procedural notes.

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REFERENCES

• RACGP Guidelines on Wound Management
• Australian Immunisation Handbook on Tetanus
• Murtagh’s General Practice, 8th Edition

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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 findings accurately and comprehensively.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses about health problems.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans collaboratively.

5. Preventive and Population Health

5.1 Provides care that addresses prevention and early detection of disease.

6. Professionalism

6.1 Adopts a patient-centred approach to care.

7. General Practice Systems and Regulatory Requirements

7.1 Uses practice systems effectively and safely.

8. Procedural Skills

8.1 Demonstrates proficiency in common procedural skills performed in general practice.

9. Managing Uncertainty

9.1 Manages diagnostic uncertainty effectively.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages patients with potentially life-threatening conditions.

Competency at Fellowship Level

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