CCE-CE-037

CASE INFORMATION

Case ID: CCE-2025-001
Case Name: Liam O’Connor
Age: 28
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L92 (Laceration of Hand/Finger), L99 (Other Musculoskeletal Injury)

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to understand their ideas, concerns, and expectations
1.2 Communicates effectively in an empathetic and patient-centred manner
1.4 Provides clear explanations and checks for understanding
2. Clinical Information Gathering and Interpretation2.1 Takes a comprehensive and hypothesis-driven history
2.2 Interprets findings to assess severity and functional impact
3. Diagnosis, Decision-Making and Reasoning3.1 Identifies likely diagnoses based on history and presentation
3.2 Recognises red flags requiring urgent referral
4. Clinical Management and Therapeutic Reasoning4.1 Develops an evidence-based management plan
4.4 Provides appropriate treatment and referral for procedural intervention
5. Preventive and Population Health5.1 Provides education on injury prevention and safe practices
6. Professionalism6.1 Maintains a professional and respectful approach
6.2 Ensures medicolegal considerations, including documentation and consent
7. General Practice Systems and Regulatory Requirements7.1 Demonstrates knowledge of referral pathways for specialist care
8. Procedural Skills8.1 Describes appropriate initial wound care and immobilisation
9. Managing Uncertainty9.1 Develops a structured approach for managing uncertainty in prognosis
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies complications such as tendon rupture or infection

CASE FEATURES

  • Communication challenges around prognosis, treatment options, and career concerns.
  • A young professional musician with a hand injury.
  • Functional implications for livelihood.
  • Requires assessment for tendon involvement and appropriate management.

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
  2. Outline your differential diagnosis
  3. Explain your proposed management plan
  4. Address the patient’s concerns

SCENARIO

Liam O’Connor, a 28-year-old professional guitarist, presents with a laceration to his right index finger after an accident while setting up equipment at a live performance. He reports immediate pain and an inability to fully extend the finger. He is highly concerned about the impact on his ability to perform, as he has upcoming shows.

The laceration occurred approximately 6 hours ago and is located over the dorsal aspect of the proximal phalanx of the index finger. He reports mild bleeding, which has since stopped with compression, but he notices difficulty straightening the finger at the knuckle.

PATIENT RECORD SUMMARY

Patient Details

Name: Liam O’Connor
Age: 28
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • No known allergies

Medications

  • Nil

Past History

  • Nil significant

Social History

  • Professional musician (guitarist)

Family History

  • Nil

Smoking

  • Nil

Alcohol

  • Occasional

Vaccination and Preventative Activities

  • None recorded

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.

Opening Line

“Doctor, I cut my finger setting up my guitar gear, and now I can’t straighten it properly. This is a disaster!”

General Information

  • You were setting up for a live gig earlier today when you accidentally sliced the back of your right index finger on a sharp metal edge while adjusting your equipment.
  • You felt immediate pain and saw some bleeding but managed to control it with a clean cloth.
  • Since then, you have noticed that you cannot fully straighten the finger, and it feels weak when you try to move it.
  • You have never injured this hand before, and you have never had any hand surgeries.
  • You are right-handed, and this is your dominant hand.

Specific Information

(To be revealed only when asked)

Injury Details

  • The wound is about 1.5 cm long, located on the dorsal aspect of your index finger, just above the knuckle.
  • There was a brief period of bleeding, but it has now stopped with compression.
  • You initially had some throbbing pain, but it has settled to a dull ache, around 3-4/10 on the pain scale.
  • You have tried to move the finger, but it won’t fully straighten at the knuckle.
  • You can bend the finger fine, but when you try to extend it, it just won’t move properly.
  • No numbness or tingling, but it feels weak when you try to use it.
  • No excessive swelling or bruising yet.
  • You haven’t taken any painkillers or applied ice.
  • You don’t recall having any immunisations since school.

Functional Concerns

  • You are a professional guitarist and perform multiple times a week.
  • You have a major tour starting in six weeks, and you are extremely anxious about whether you will be able to play.
  • Your guitar playing style is very intricate, involving fast finger movements and delicate control, so even a small functional loss could be devastating.
  • You feel panicked at the thought of needing surgery or a long recovery time.
  • You are already thinking about what happens if you can’t play at full capacity again.

Emotional Response

  • Initially worried and frustrated but trying to stay composed.
  • If the doctor suggests a long recovery time, you will become more anxious and impatient.
  • If surgery is mentioned, you will push for alternatives and ask multiple questions about risks, outcomes, and possible complications.
  • If the doctor seems too dismissive, you will escalate in frustration, saying things like, “This isn’t just some minor cut—I need my hands to work perfectly!”
  • If the doctor acknowledges your concerns and provides a clear plan, you will calm down slightly but still be worried.

Questions for the Candidate

(Ask these questions throughout the consultation, especially if the candidate has not addressed them.)

  1. “Do I need surgery? I really don’t want surgery.”
  2. “Will I be able to play guitar again at the same level?”
  3. “How long will it take to recover? Can I still do my tour in six weeks?”
  4. “If I don’t get full function back, what are my options?”
  5. “Is there anything I can do to speed up my recovery?”
  6. “Could I just tape it up and keep playing, or would that make it worse?”

Additional Concerns

  • You will hesitate if the doctor suggests stopping guitar practice completely, as you feel you can’t afford to stop working.
  • You will resist the idea of a long rehab process unless the doctor clearly explains why it is necessary.
  • If the doctor mentions permanent damage, you will become visibly distressed and ask for a second opinion or other treatment options.
  • You may bring up alternative treatments, such as seeing a hand therapist, chiropractor, or acupuncturist, to see if they could help.

End of Consultation

If the doctor provides a clear management plan that includes realistic timeframes, treatment options, and a discussion about prognosis, you will be more reassured but still somewhat anxious.

If the doctor seems unsure or vague, you will insist on seeing a specialist immediately and may refuse to leave without a clear referral or next step.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including details of the injury, functional impact, and any red flags.

The competent candidate should:

  • Use open-ended questions to explore the mechanism of injury (e.g., “Can you describe exactly how you injured your finger?”).
  • Elicit details about onset, duration, and progression of symptoms (pain, weakness, loss of function).
  • Assess functional impact, particularly regarding the patient’s profession as a guitarist.
  • Screen for red flags, including:
    • Loss of active extension (suggesting extensor tendon injury).
    • Numbness or tingling (suggesting nerve involvement).
    • Signs of infection (redness, warmth, increasing pain).
  • Obtain relevant past medical history (e.g., diabetes, previous injuries/surgeries).
  • Check for recent tetanus booster (5 years if tetanus prone, 10 years if not).
  • Address the patient’s concerns (e.g., prognosis, impact on career).

Task 2: Outline your differential diagnosis and key concerns regarding prognosis.

The competent candidate should:

  • Recognise extensor tendon laceration as the most likely diagnosis.
  • Consider other differentials, including:
    • Partial tendon injury (some preserved function).
    • Mallet finger (terminal extensor tendon rupture).
    • Joint capsule or ligamentous injury.
  • Discuss key prognostic factors, including:
    • Extent of tendon injury (partial vs full thickness).
    • Timeliness of treatment (delayed management risks poor functional recovery).
    • Occupational demands (fine motor recovery crucial for guitar playing).
  • Identify need for urgent specialist input.
  • Identify need for tetanus booster.

Task 3: Explain your proposed management plan, including any investigations, treatment, and referral.

The competent candidate should:

  • Confirm tendon involvement via:
    • Clinical examination (active extension test).
    • Ultrasound or MRI if uncertain.
  • Initial management:
    • Clean and dress the wound.
    • Apply splinting in slight extension to protect the tendon.
    • Provide analgesia (paracetamol ± NSAIDs if not contraindicated).
  • Referral:
    • Immediate hand surgeon review for suspected full-thickness laceration.
    • Flag need for hand physiotherapy referral for rehabilitation.
  • Patient education:
    • Explain the importance of early repair.
    • Outline expected recovery timeline (months).
    • Discuss potential long-term limitations.

Task 4: Address the patient’s concerns regarding his career and long-term function.

The competent candidate should:

  • Acknowledge the patient’s anxiety and validate their concerns.
  • Provide realistic expectations regarding recovery:
    • Surgical vs non-surgical outcomes.
    • Rehabilitation importance and expected time frame.
    • Likelihood of regaining fine motor function.
  • Reassure that hand therapy can optimise recovery.
  • Address psychosocial aspects, including financial or emotional concerns.

SUMMARY OF A COMPETENT ANSWER

  • Uses structured history-taking to assess the mechanism of injury, symptoms, and functional impact.
  • Identifies extensor tendon laceration as the most likely diagnosis and considers other differentials.
  • Recognises urgent referral for suspected full-thickness laceration.
  • Provides appropriate initial management, including wound care, pain control and tetanus booster.
  • Delivers clear, empathetic explanations about prognosis, recovery, and treatment options.
  • Addresses psychosocial and occupational concerns, including return to guitar playing.

PITFALLS

  • Failure to assess functional loss (missing signs of tendon rupture).
  • Overlooking potential red flags such as nerve injury.
  • Inadequate intitial care leading to complications.
  • Delaying referral for a suspected full-thickness tendon injury.
  • Providing unrealistic recovery expectations, failing to consider the impact on fine motor function.
  • Not addressing the patient’s psychological distress and career concerns.

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, 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 Takes a comprehensive and hypothesis-driven history.
2.2 Interprets findings to assess severity and functional impact.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies likely diagnoses based on history and presentation.
3.2 Recognises red flags requiring urgent referral.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.4 Provides appropriate treatment and referral for procedural intervention.

5. Preventive and Population Health

5.1 Provides education on injury prevention and safe practices.

6. Professionalism

6.1 Maintains a professional and respectful approach.
6.2 Ensures medicolegal considerations, including documentation and consent.

7. General Practice Systems and Regulatory Requirements

7.1 Demonstrates knowledge of referral pathways for specialist care.

8. Procedural Skills

8.1 Describes appropriate initial wound care and immobilisation.

9. Managing Uncertainty

9.1 Develops a structured approach for managing uncertainty in prognosis.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies complications such as tendon rupture or infection.

Competency at Fellowship Level

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