CCE-CE-033

Case ID: MUS-2025-005
Case Name: Peter Collins
Age: 55
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L92 – Bursitis/Tendonitis/Synovitis NOS​

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to understand their symptoms, ideas, concerns, and expectations.
1.4 Explains the diagnosis and management plan clearly.
2. Clinical Information Gathering and Interpretation2.1 Takes a comprehensive musculoskeletal history, including occupation and functional limitations.
2.2 Performs clinical reasoning to differentiate between bursitis, tendonitis, and synovitis.
3. Diagnosis, Decision-Making and Reasoning3.1 Uses structured reasoning to assess inflammatory versus mechanical causes.
3.3 Identifies red flags that require further imaging or specialist referral.
4. Clinical Management and Therapeutic Reasoning4.2 Develops an appropriate stepwise management plan, including conservative and pharmacological options.
4.5 Advises on rehabilitation, physiotherapy, and injury prevention strategies.
5. Preventive and Population Health5.1 Provides patient education on ergonomic and activity modifications.
6. Professionalism6.3 Engages in shared decision-making, respecting patient preferences and health literacy.
7. General Practice Systems and Regulatory Requirements7.1 Understands Medicare requirements for imaging and referrals.
9. Managing Uncertainty9.2 Recognises when further investigation (e.g., imaging, blood tests) is warranted to exclude other conditions.

CASE FEATURES

  • Discussion of imaging indications and red flags.
  • Middle-aged male presenting with progressive elbow pain over several months.
  • Mechanism suggests overuse rather than acute injury.
  • Work-related factors contributing to symptoms (manual labour).
  • Clinical reasoning required to differentiate bursitis, tendonitis, and synovitis.
  • Management includes conservative treatment, pain relief, and physiotherapy.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

  1. Take an appropriate history from Peter
  2. Explain the differential diagnosis
  3. Provide a management plan
  4. Address Peter’s concerns

SCENARIO

Peter Collins, a 55-year-old carpenter, presents with progressive pain in his right elbow over the past four months. He denies any acute injury but reports that the pain started gradually and has worsened with work activities, particularly repetitive hammering and lifting.

He describes the pain as dull and aching, located around the outer elbow and occasionally radiating down the forearm. The pain is worse at the end of the workday and improves slightly with rest and ice packs.

PATIENT RECORD SUMMARY

Patient Details

Name: Peter Collins
Age: 55
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Occasional ibuprofen for pain

Past History

  • No previous joint injuries
  • No history of rheumatoid arthritis or inflammatory conditions

Social History

  • Works as a carpenter
  • No smoking history
  • Alcohol: 2-3 standard drinks per week

Family History

  • Father had osteoarthritis
  • No known history of arthritis or gout

Vaccination and Preventative Activities

  • Up to date

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, my elbow has been aching for months, and I’m worried it’s getting worse. Do you think I need surgery?”

General Information

  • You have been experiencing gradually worsening right elbow pain for the past four months.
  • You don’t remember any specific injury, but you first noticed discomfort after a long workweek.
  • The pain started as a mild ache but has become more persistent and intense, especially after work.
  • You use hand tools, including hammers and screwdrivers, daily as a carpenter, and gripping them has become painful.
  • You enjoy playing golf on weekends, but now swinging the club aggravates the pain.

Specific Information

(To be provided only when asked relevant questions)

Pain Characteristics

  • Location: The pain is mostly on the outer side of the elbow, near the bony prominence.
  • Radiation: Occasionally, the pain extends down the forearm but does not reach the fingers.
  • Severity: 6-7/10 after work, 3/10 at rest, and it disturbs your sleep some nights.
  • Aggravating factors:
    • Hammering, gripping tools, lifting heavy objects.
    • Opening jars or turning a doorknob.
    • Playing golf, especially swinging the club.
  • Relieving factors:
    • Rest, ice packs, and ibuprofen help somewhat but do not completely relieve the pain.
    • You have tried wearing an elbow brace, which provides some support but does not resolve the pain.

Impact on Daily Life

  • You are struggling to complete full workdays as pain worsens throughout the day.
  • Gripping objects feels weak, and you worry about dropping tools.
  • You can still do most tasks, but you compensate by using your left arm more, which is tiring.
  • You enjoy playing golf and are frustrated that you can’t play without pain.

Concerns & Emotional Reactions

  • You are worried that this might be permanent and that you may have to stop working.
  • You fear surgery might be the only solution and want to know what other treatments exist.
  • You want to avoid taking strong painkillers, but you need something more effective than ibuprofen.
  • You wonder if this is arthritis and if it will worsen with age.
  • You think an X-ray or scan might be needed to check for any damage.

Questions for the Doctor

  1. “Is this something serious? Could I have arthritis or a torn tendon?”
  2. “Do I need an X-ray or MRI to check what’s wrong?”
  3. “Is there anything I can do to stop it from getting worse?”
  4. “What’s the best treatment? Do I need injections or surgery?”
  5. “How long will this take to improve? Will I be able to go back to normal?”

Emotional Cues & Body Language

  • You appear concerned and frustrated, rubbing your elbow occasionally.
  • You lean forward slightly, wanting clear answers.
  • You relax a little if the doctor provides a clear explanation of what’s happening.
  • If surgery is mentioned too quickly, you look worried and hesitant.
  • If conservative management is suggested, you seem receptive but cautious.

Expected Outcome

  • If the doctor explains the diagnosis clearly, you feel relieved that it’s not something more serious.
  • If a stepwise treatment plan (physiotherapy, NSAIDs, lifestyle modifications) is provided, you are open to trying it.
  • If imaging is explained as unnecessary unless red flags are present, you accept it but may ask again for reassurance.
  • If long-term prognosis is discussed, you feel less anxious about recovery.

Additional Information for Role-Player Flexibility

If the candidate does not address your concerns about arthritis, ask:

  • “Could this be arthritis? My father had osteoarthritis in his hands—am I at risk for that?”

If the candidate does not explain why imaging may not be needed, ask:

  • “Should I get an X-ray or MRI just to make sure?”

If the candidate does not discuss activity modifications, ask:

  • “Do I need to stop working? Should I stop playing golf?”

If the candidate does not provide a clear recovery timeline, ask:

  • “How long do you think this will take to heal?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from Peter, focusing on the onset, exacerbating factors, and functional limitations.

The competent candidate should:

  • Use open-ended questions to explore Peter’s symptoms, functional limitations, and expectations.
  • Take a comprehensive musculoskeletal history, including:
    • Onset and progression: Gradual worsening over months, no acute injury.
    • Pain characteristics: Location (lateral elbow), severity (6-7/10 at worst), radiation (forearm), night pain.
    • Aggravating factors: Work activities (hammering, gripping), golf, lifting objects.
    • Relieving factors: Rest, ice, NSAIDs, use of an elbow brace.
  • Assess functional impact:
    • Work limitations due to pain, difficulty gripping tools.
    • Hobbies affected, such as playing golf.
  • Explore red flag symptoms (numbness, weakness, systemic symptoms, fever).
  • Address patient concerns, particularly regarding arthritis, surgery, and work limitations.

Task 2: Explain the differential diagnosis, distinguishing bursitis, tendonitis, and synovitis.

The competent candidate should:

  • Explain that the most likely diagnoses are:
    • Lateral epicondylitis (tennis elbow/tendonitis): Overuse injury of the extensor tendons, common in repetitive hand movements.
    • Olecranon bursitis: Less likely due to location of pain and lack of swelling.
    • Synovitis or early osteoarthritis: Less likely due to absence of joint stiffness, swelling, or systemic symptoms.
  • Differentiate based on clinical presentation:
    • Tendonitis: Pain worsens with wrist extension and gripping.
    • Bursitis: Localised swelling over the olecranon.
    • Synovitis: Persistent stiffness and swelling, possibly with systemic symptoms.
  • Discuss why imaging is not needed unless red flags are present (e.g., trauma, severe functional loss, suspected inflammatory arthritis).

Task 3: Provide a clear management plan, including conservative treatments, pain relief, and physiotherapy.

The competent candidate should:

  • Reassure Peter that surgery is rarely needed and most cases improve with conservative management.
  • Recommend first-line management:
    • Activity modification: Reduce repetitive gripping and hammering, avoid exacerbating movements.
    • Pain relief:
      • NSAIDs (e.g., ibuprofen) short-term if no contraindications.
      • Topical NSAIDs (e.g., Voltaren gel) as a safer alternative.
    • Bracing: Elbow counterforce brace may help reduce strain on tendons.
    • Physiotherapy referral for strengthening and stretching exercises.
    • Ice therapy for pain relief post-activity.
  • Set realistic expectations: Recovery may take weeks to months depending on adherence to therapy.
  • Plan follow-up in 4-6 weeks to assess progress and consider further interventions if no improvement.

Task 4: Address Peter’s concerns about long-term work impact, prognosis, and need for further investigations.

The competent candidate should:

  • Acknowledge Peter’s anxiety about work limitations and reassure him that most cases improve with proper management.
  • Explain prognosis:
    • Most cases resolve within 3-6 months with conservative management.
    • Ongoing exercises can prevent recurrence.
  • Address imaging concerns:
    • X-rays are not required unless trauma or suspected arthritis.
    • Ultrasound/MRI only if symptoms persist despite treatment.
  • Discuss work modifications:
    • Adjust workload temporarily to reduce strain.
    • Ergonomic changes (e.g., different grip techniques, wrist positioning).
  • Offer reassurance and a structured management plan to help him regain function while preventing long-term issues.

SUMMARY OF A COMPETENT ANSWER

  • Takes a structured musculoskeletal history, assessing pain characteristics, work impact, and red flags.
  • Differentiates bursitis, tendonitis, and synovitis based on clinical reasoning.
  • Provides a clear, evidence-based management plan, including pain relief, physiotherapy, and bracing.
  • Addresses patient concerns about arthritis, surgery, and ability to work.
  • Explains why imaging is not immediately required, ensuring patient understanding.
  • Provides a follow-up plan, ensuring continuity of care.

PITFALLS

  • Failing to assess functional impact, missing the effect on work and daily activities.
  • Over-relying on imaging instead of using clinical diagnosis.
  • Not addressing patient concerns about surgery, leading to unnecessary anxiety.
  • Providing only symptomatic relief without addressing activity modifications or physiotherapy.
  • Failing to discuss prognosis, leaving the patient uncertain about recovery.
  • Not offering follow-up, which is essential for monitoring progress.

REFERENCES

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

Competency Assessment

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.4 Explains the diagnosis and management plan clearly.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive musculoskeletal history, including occupation and functional limitations.
2.2 Performs clinical reasoning to differentiate between bursitis, tendonitis, and synovitis.

3. Diagnosis, Decision-Making and Reasoning

3.1 Uses structured reasoning to assess inflammatory versus mechanical causes.
3.3 Identifies red flags that require further imaging or specialist referral.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops an appropriate stepwise management plan, including conservative and pharmacological options.
4.5 Advises on rehabilitation, physiotherapy, and injury prevention strategies.

5. Preventive and Population Health

5.1 Provides patient education on ergonomic and activity modifications.

6. Professionalism

6.3 Engages in shared decision-making, respecting patient preferences and health literacy.

7. General Practice Systems and Regulatory Requirements

7.1 Understands Medicare requirements for imaging and referrals.

9. Managing Uncertainty

9.2 Recognises when further investigation (e.g., imaging, blood tests) is warranted to exclude other conditions.

Competency at Fellowship Level

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