Case ID: 002
Case Name: Michael Thompson
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L75 (Fracture; femur)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to gather information about their symptoms, concerns, and expectations. 1.2 Communicates effectively in a patient-centred manner. 1.4 Provides clear and appropriate explanations to support patient understanding.
2. Clinical Information Gathering and Interpretation	2.1 Elicits a focused history related to the injury, mechanism, and risk factors. 2.3 Identifies red flag symptoms suggestive of complications.
3. Diagnosis, Decision-Making and Reasoning	3.1 Forms an initial differential diagnosis based on history and presentation. 3.3 Uses clinical reasoning to determine the severity of the injury and need for further investigation.
4. Clinical Management and Therapeutic Reasoning	4.2 Develops an appropriate management plan considering analgesia, immobilisation, and retrieval to a higher level of care. 4.4 Provides clear safety-netting advice regarding complications.
5. Preventive and Population Health	5.3 Identifies modifiable risk factors for fractures (e.g., smoking, occupational hazards, osteoporosis screening).
6. Professionalism	6.2 Demonstrates patient advocacy in accessing timely care, particularly in a rural setting.
7. General Practice Systems and Regulatory Requirements	7.2 Ensures appropriate documentation, referral pathways, and coordination with retrieval services.
8. Procedural Skills	8.1 Recognises the need for and applies principles of fracture immobilisation.
9. Managing Uncertainty	9.3 Develops an approach to undifferentiated presentations of limb pain and swelling.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises potential complications of fractures, such as compartment syndrome or deep vein thrombosis (DVT).
11. Rural Health Context (RH)	RH1.1.1 Appropriately triages and stabilises the patient in a resource-limited setting. RH1.2.1 Recognises the challenges of emergency retrieval in rural and remote areas. RH1.3.1 Works effectively with available resources and community networks to facilitate care.

CASE FEATURES

Middle-aged male presenting with a suspected femur fracture after falling from a ladder.
Remote rural setting with limited immediate medical resources.
Need for effective pain management and urgent retrieval.
Coordination with emergency services for hospital transfer.

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:

Take any further history required
Outline your differential diagnosis and immediate management plan
Explain the diagnosis and next steps to the patient

SCENARIO

Michael Thompson, a 45-year-old construction worker, presents to your rural general practice with severe right thigh pain and inability to walk after falling from a ladder at a local farm.

Due to the lack of immediate ambulance availability, his workmates transported him to your clinic on the back of a ute, using makeshift padding to stabilise him during the journey.

On initial assessment, his leg was swollen, deformed, and tender in the lower thigh and knee region.

His foot pulses are intact, pulse rate is 95, and capillary refill is 2 seconds.

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Thompson
Age: 45
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Amlodipine 5 mg daily

Past History

Hypertension (well controlled)

Social History

Occupation: Construction worker
Smoker: 10 cigarettes/day
Alcohol: Social drinker (6-8 beers on weekends)

Family History

No known osteoporosis
Father had a myocardial infarction at 58

Vaccination and Preventive Activities

Up to date with routine vaccinations

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, this pain is unbearable! I had to be carried onto the back of a ute just to get here!”

General Information

You are Michael Thompson, a 45-year-old construction worker who was helping a mate repair a shed roof on a remote farm.
You fell from a ladder, about two metres high, landing awkwardly on your right leg.
You heard a loud “crack” and immediately felt excruciating pain in your right thigh.
Your workmates had no choice but to load you onto the back of a ute, using a rolled-up swag and some work jackets to support your leg because the ambulance was at least 90 minutes away.

Specific Information

(Only Provide if Asked)

Background Information

The drive to the clinic was rough, and every bump sent shooting pain through your leg.
You are sweaty, pale, and visibly in distress, but you are not aggressive—just in a lot of pain.
You are stressed about work and worried about how serious this is.
You have had two Panadol but they have done nothing for the pain.

Pain and Symptoms

The pain started immediately and has been constant and severe ever since.
You describe the pain as 9/10, deep and throbbing, with sharp stabs of pain when the leg moves.
It’s worse with movement or pressure.
You can wiggle your toes but cannot lift your leg.
Your foot feels a bit colder than usual but not numb.
No pins and needles or numbness.

Mechanism of Injury

You were on a ladder, fixing part of a shed roof on a cattle station.
You lost balance, tried to grab onto something, but fell straight down onto your right leg.
You heard a crack and immediately collapsed.
Your workmates had to carry you, and there was no other transport available except the ute.
There was no head injury, loss of consciousness, or chest pain.

Past Medical History

Hypertension (high blood pressure), managed with amlodipine 5 mg daily.
No previous fractures or bone conditions.
No clotting disorders.
Smokes 10 cigarettes a day.
Social drinker (6-8 beers on weekends).

Family and Social History

Lives in a rural area with wife and two kids (10 and 12 years old).
Works as a construction worker, does heavy labour, and depends on his job for income.
No history of osteoporosis or fractures in the family.
Father had a heart attack at 58.

Expectations from the Doctor

You want immediate pain relief because you are in agony.
You expect to be sent to a hospital—you just don’t know how you’ll get there.
You want to know how serious the injury is.
You prefer not to have surgery, but you will listen to the doctor’s advice.
You want to know exactly what will happen next—you don’t want uncertainty.

Your Role in the Consultation

Stay cooperative, but let the pain show in your voice and body language.
If the doctor asks about pain, wince and say, “It’s bloody awful, mate. Every bump on the road felt like a knife in my leg.”
If the doctor asks about movement, shake your head and say, “I can’t even lift it, Doc.”
If the doctor reassures you, nod slowly but still look worried about recovery time.
If the doctor talks about retrieval logistics, express concern but trust their judgment.

End of the Consultation

If the doctor explains everything clearly and provides pain relief, you relax slightly and say:

“Alright, Doc. I trust you—just get me to a hospital before this gets any worse.”

If the doctor is uncertain or vague, you look frustrated and say:

“So what happens now? Am I just stuck here waiting?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate, limited history, including the mechanism of injury and symptoms

The competent candidate should:

Elicit a clear mechanism of injury: Identify that the patient fell from a two-metre-high ladder, landed awkwardly on the right leg, and heard a “crack” at the time of impact.
Assess the nature and progression of pain: Establish that the pain is severe (9/10), deep, and throbbing, with sharp exacerbations on movement.
Screen for associated symptoms and complications: Ask about numbness, tingling, loss of sensation, weakness, or changes in distal circulation.
Identify red flag symptoms: Assess for pale, cold extremity, absent pulses, increasing pain, or signs of compartment syndrome.
Understand the emergency medicine concept of an AMPLE history
- Allergies
- Medications currently used
- Past medical history/Pregnancy
- Last meal
- Environment of the injury/event and Events leading to the injury

Task 2: Outline a differential diagnosis and immediate management plan, considering the rural context.

The competent candidate should:

Present a clear differential diagnosis:
- Primary diagnosis: Femoral shaft fracture based on mechanism, deformity, and severe pain.
- Differentials: Knee dislocation, patellar or tibial plateau fracture, vascular injury, compartment syndrome.
Outline initial management:
- IV Access
- Pain control:
  - Use parenteral analgesia (e.g., Fentany Intranasal/IV/IM, IV/IM morphine IM/IV, Penthrox, Ketamine IM)
- Immobilisation:
  - Use a Thomas splint if available.
  - If unavailable, apply improvised traction (e.g., using a wooden board, padding, and bandages).
- Monitor for complications:
  - Assess limb perfusion (colour, temperature, capillary refill, distal pulses).
  - Watch for compartment syndrome (increasing pain, tight swelling, loss of pulses).
- Coordinate retrieval:
  - Arrange urgent transfer to the nearest hospital with orthopaedic capabilities
  - Recognising limited ambulance availability and potential Royal Flying Doctor Service (RFDS) involvement.
- Prepare for extended pre-hospital care:
  - Provide fluid resuscitation, ongoing analgesia, and close monitoring during potential delayed transfer.

Task 3: Explain the diagnosis and next steps to the patient, ensuring their concerns are addressed.

The competent candidate should:

Clearly communicate the likely diagnosis: Explain the suspected femoral fracture in plain language, using reassuring but honest wording.
Address the need for urgent hospital transfer:
- Explain that this cannot be managed in a rural clinic.
- Outline retrieval options (ambulance, RFDS).
- Set expectations regarding timing and delays.
Discuss pain management and ongoing care:
- Reassure that strong pain relief is being given.
- Explain why the leg must be immobilised to prevent further damage.
- Advise on the potential need for surgery.
Acknowledge work and financial concerns:
- Empathise with job-related stress.
- Offer medical certification for work absence.
- Suggest early engagement with local support services.

SUMMARY OF A COMPETENT ANSWER

Elicits a structured history, including mechanism of injury, red flags, and social factors.
Provides a structured differential diagnosis, identifying high-risk complications.
Prioritises pain relief, immobilisation, and retrieval coordination in a rural setting.
Clearly communicates the diagnosis and next steps in a patient-centred way.
Demonstrates awareness of rural challenges and practical solutions for delayed retrieval.

PITFALLS

Failure to recognise a fracture despite clear deformity, pain, and mechanism.
Inadequate pain management, relying solely on oral analgesia instead of parenteral opioids.
Not considering vascular injury or compartment syndrome, leading to potential limb-threatening complications.
Neglecting retrieval logistics, assuming an ambulance is immediately available instead of planning for delays.
Failure to address the patient’s concerns, including work, finances, and emotional distress.
Not recognising the need for prolonged pre-hospital care, given rural delays in transport.

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

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, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured and hypothesis-driven history.
2.3 Identifies red flag symptoms indicating complications.

3. Diagnosis, Decision-Making and Reasoning

3.1 Develops an appropriate differential diagnosis.
3.3 Uses clinical reasoning to determine the severity of the injury.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops an appropriate emergency management plan.
4.4 Provides clear safety-netting advice regarding complications.

5. Preventive and Population Health

5.3 Identifies modifiable risk factors (e.g., smoking, occupational hazards).

6. Professionalism

6.2 Demonstrates patient advocacy in accessing timely care.

7. General Practice Systems and Regulatory Requirements

7.2 Ensures appropriate documentation and retrieval coordination.

8. Procedural Skills

8.1 Recognises the need for and applies fracture immobilisation.

9. Managing Uncertainty

9.3 Develops an approach to undifferentiated limb pain and swelling.

12. Rural Health Context (RH)

RH1.1.1 Appropriately triages and stabilises the patient in a resource-limited setting.
RH1.2.1 Recognises the challenges of emergency retrieval in rural areas.

Competency at Fellowship Level

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