CCE-CBD-177

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you approach Jack’s concerns and gather relevant information?

• Prompt: Explore wound history, mechanism of injury, and initial management
• Prompt: Ask about tetanus immunisation status and systemic symptoms
• Prompt: Explore his ideas, concerns, and expectations

Q2. What are the possible diagnoses, and how would you manage uncertainty in this case?

• Prompt: Discuss likely diagnosis (local wound infection/cellulitis)
• Prompt: Consider differentials (foreign body, deeper infection)
• Prompt: Rationalise investigations or referrals (blood tests not routinely indicated; review timeframe)

Q3. What is your management plan for Jack today?

• Prompt: Wound care (cleaning, dressing, antiseptics)
• Prompt: Antibiotic choice (oral flucloxacillin or cephalexin)
• Prompt: Tetanus immunisation (if >10 years since last booster or uncertain history)

Q4. How would you provide preventive advice and safety-netting?

• Prompt: Educate on wound care (keeping it clean and dry)
• Prompt: Discuss red flag symptoms (fever, worsening redness, lymphangitis)
• Prompt: Plan follow-up in 48 hours to review response to treatment

Q5. What factors should you consider regarding Jack’s occupation and return to work?

• Prompt: Advise on safe work practices and wound protection
• Prompt: Assess fitness for work (risk of worsening wound at work)
• Prompt: Provide certificate if time off is needed

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you approach Jack’s concerns and gather relevant information?

Approach to Concerns & Information Gathering:

• Build rapport and create a safe, non-judgmental environment.
• Begin with open-ended questions: “Can you tell me what happened when you injured your leg?” and “What has been worrying you the most about this wound?”
• Explore the mechanism of injury, including:
  • Time and place of injury (construction site, metal beam exposure).
  • Details of initial wound management—rinsed but not cleaned properly.
• Inquire about progression of symptoms:
  • Redness, swelling, pain, discharge.
  • Systemic features: fevers, chills, fatigue.
• Tetanus immunisation history:
  • Confirm timing of last booster.
  • Note his uncertainty, which may indicate no booster in the last 10 years.
• Explore ideas, concerns, and expectations (ICE):
  • Concern about infection worsening.
  • Fear of missing work or needing hospitalisation.
  • Expectations: possible antibiotics, wound care, return-to-work clearance.
• Psychosocial context:
  • Impact on work (labourer at a construction site).
  • Support systems at home.

Q2: What are the possible diagnoses, and how would you manage uncertainty in this case?

Differential Diagnoses:

• Likely diagnosis: Local wound infection/cellulitis.
• Differentials:
  • Abscess formation (although no fluctuance noted).
  • Foreign body retention in the wound.
  • Tetanus risk (if immunisation is incomplete).
  • Less likely: systemic infection/sepsis.

Managing Uncertainty:

• No need for urgent investigations unless systemic symptoms arise (no fever, no lymphadenopathy).
• Clear explanation to Jack about expected course with antibiotics and wound care.
• Safety net:
  • Explain red flags (fever, spreading erythema, lymphangitis).
  • Provide clear instructions on when to return.
• Arrange follow-up review in 48 hours to reassess.

Q3: What is your management plan for Jack today?

Wound Care:

• Clean with normal saline.
• Apply antiseptic (povidone-iodine or chlorhexidine).
• Dress wound with non-adherent sterile dressing.

Antibiotics:

• Start empirical oral flucloxacillin 500mg QID for 5 days (covers Staphylococcus aureus).
  • If penicillin-allergic: Cephalexin or Clindamycin.

Tetanus Immunisation:

• Provide tetanus booster if last dose >10 years or unclear history.
• Consider tetanus immunoglobulin (TIG) if high-risk wound and incomplete immunisation.

Pain relief:

• Recommend paracetamol/NSAIDs for pain and inflammation.

Q4: How would you provide preventive advice and safety-netting?

Wound Care Education:

• Keep the wound clean and dry.
• Change dressings as advised.
• Monitor for signs of worsening infection.

Red Flags for Review:

• Fever, chills.
• Increased pain, swelling, spreading redness.
• Red streaks up the limb (lymphangitis).

Follow-Up:

• Review in 48 hours or sooner if deterioration occurs.
• Reinforce importance of early review if no improvement.

Prevention Strategies:

• Use of protective clothing at work.
• Early wound care (clean, cover, monitor).

Q5: What factors should you consider regarding Jack’s occupation and return to work?

Assess Fitness for Work:

• High infection risk in dirty environments.
• Potential for exacerbation of infection if physical strain applied.

Work Modifications:

• Consider modified duties or light duties until wound heals.

Certification:

• Provide medical certificate if Jack is unfit for usual duties.
• Include timeframe for return to work and review date.

Ongoing Occupational Advice:

• Importance of PPE (Personal Protective Equipment).
• Educate on early wound care practices.

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SUMMARY OF A COMPETENT ANSWER

• Thorough history-taking, including injury mechanism, wound care, tetanus status.
• Differential diagnoses addressed with focus on infection and tetanus risk.
• Clear management plan, including wound care, antibiotics, immunisation.
• Patient-centred communication, addressing Jack’s concerns about work.
• Preventive health advice and safety-netting emphasised.
• Occupational health considerations integrated into management.

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PITFALLS

• Omitting tetanus booster assessment and immunisation.
• Neglecting safety-netting advice, particularly for signs of systemic infection.
• Failing to discuss work fitness and provide a medical certificate.
• Not arranging follow-up, risking delayed identification of complications.
• Underestimating Jack’s concerns, leading to reduced patient engagement.

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REFERENCES

• RACGP Red Book (9th Edition)
• Therapeutic Guidelines on Antibiotic
• Australian Immunisation Handbook (Tetanus)
• RACGP Clinical Competencies

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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 and health determinants.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and tests hypotheses and makes evidence-based decisions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements appropriate management plans.
4.2 Provides patient-centred management.

5. Preventive and Population Health

5.1 Provides healthcare that anticipates and addresses social determinants of health.

6. Professionalism

6.1 Demonstrates ethical behaviour and professional integrity.

7. General Practice Systems and Regulatory Requirements

7.1 Uses quality and safety systems in practice.

8. Procedural Skills

8.1 Performs procedures safely and effectively.

9. Managing Uncertainty

9.1 Manages uncertainty in clinical practice.

10. Identifying and Managing the Patient with Significant Illness

10.1 Manages patients with chronic and complex health conditions.

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Competency at Fellowship Level

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