CCE-CE-060.1 - GP Exams

CASE INFORMATION

Case ID: CCE-ENT-020
Case Name: James Carter
Age: 34
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: H70 – Otitis Externa

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages the patient 1.2 Explores the patient’s concerns, ideas, and expectations 1.3 Provides clear and structured explanations about diagnosis, prognosis, and management
2. Clinical Information Gathering and Interpretation	2.1 Takes a structured history, including symptom onset, risk factors, and previous treatments 2.2 Identifies red flags for complications (e.g., malignant otitis externa)
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between bacterial, fungal, and other causes of otitis externa 3.2 Identifies when further investigations or specialist referral is required
4. Clinical Management and Therapeutic Reasoning	4.1 Provides an evidence-based treatment plan, including topical therapy and symptom relief 4.2 Educates the patient on proper ear care and prevention of recurrence
5. Preventive and Population Health	5.1 Identifies risk factors for recurrent otitis externa (e.g., water exposure, hearing aids, excessive ear cleaning) 5.2 Advises on lifestyle modifications to reduce recurrence risk
6. Professionalism	6.1 Demonstrates empathy and a patient-centred approach
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and follow-up if symptoms persist
8. Procedural Skills	8.1 Recognises when ear canal cleaning or wick placement is required
9. Managing Uncertainty	9.1 Recognises when a lack of response to treatment warrants further investigation
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and appropriately manages severe or complicated otitis externa

CASE FEATURES

Need for appropriate treatment, education, and prevention advice
Painful ear with discharge and itching for four days
History of recent swimming
Concern about hearing loss and worsening symptoms

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 an appropriate history, including symptom onset, aggravating factors, and previous treatments.
Differentiate between bacterial, fungal, and other causes of otitis externa, identifying any red flags for complications.
Provide a diagnosis and discuss an initial management plan.
Educate the patient on treatment options, self-care, prevention, and when to seek further medical attention.

SCENARIO

James Carter, a 34-year-old swimming instructor, presents with a painful left ear and some discharge for the past four days. He describes itching in the ear before the pain started, and now it hurts to touch the outer ear. He has noticed some muffled hearing and is worried about an ear infection affecting his ability to work.

He has no history of ear infections but admits to cleaning his ears regularly with cotton buds. He has not had a recent cold or upper respiratory infection.

His main concerns are:

“Why does my ear hurt so much?”
“Do I need antibiotics?”
“Will this affect my hearing permanently?”
“Can I keep working as a swimming instructor?”

PATIENT RECORD SUMMARY

Patient Details

Name: James Carter
Age: 34
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

None known

Medications

Nil regular medications

Past History

No history of recurrent ear infections or skin conditions
No diabetes or immunosuppression

Social History

Swimming instructor, frequently in chlorinated pools
Uses cotton buds to clean ears regularly
No recent travel

Family History

No significant ENT conditions in the family

Vaccination and Preventative Activities

Up to date with all vaccinations, including influenza vaccine

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 ear has been really sore for the last few days, and it feels blocked. I think I might have an infection.”

General Information

James Carter is a 34-year-old swimming instructor presenting with a painful left ear, discharge, and a blocked sensation for four days.

Symptoms began with mild itching, which progressed to pain and a feeling of fullness.
Yesterday, he noticed some clear discharge coming from the ear.
Outer ear is extremely tender to touch, making it difficult to sleep on that side.
Hearing is muffled in the affected ear, but he can still hear slightly.
No fever, dizziness, nausea, or facial weakness.

His main concerns are:

“Why does my ear hurt so much?”
“Do I need antibiotics?”
“Will this affect my hearing permanently?”
“Can I keep working as a swimming instructor?”

Specific Information (To be revealed only when asked)

Symptoms and Progression

Started four days ago with itching, then became increasingly painful.
Pain worsens when touching or moving the ear.
Muffled hearing due to swelling and blockage in the ear canal.
No recent colds or upper respiratory infections.
No ringing in the ear or balance issues.

Risk Factors and Exposures

Works as a swimming instructor, spends several hours per day in the pool.
Frequently cleans ears with cotton buds, sometimes pushes them deep into the canal.
No recent ear trauma or foreign object insertion.

Concerns About Treatment and Work

Worried about needing oral antibiotics and whether he can continue swimming.
Anxious about permanent hearing loss.
Curious if ear drops are better than tablets.
Wants to know how quickly it will heal.

Impact on Daily Life

Struggles to sleep on the affected side due to pain.
Finds it hard to focus at work due to discomfort.
Avoids loud places because the blocked ear makes it difficult to hear properly.

Emotional Cues

James is frustrated and in discomfort but open to solutions.

Frustrated with ear pain: “I can’t even touch my ear without it hurting.”
Concerned about his job: “I can’t afford to miss work. Do I need to stop swimming?”
Seeking reassurance: “Is this serious? Will it go away soon?”

If the candidate provides a structured explanation and treatment plan, James will be reassured and willing to follow recommendations.

If the candidate is vague or dismissive, James may become more anxious and push for unnecessary oral antibiotics.

Questions for the Candidate

James will ask some of the following questions, especially if the doctor does not address them directly:

“Why does my ear hurt so much?”
“Do I need antibiotics?”
“Will this affect my hearing permanently?”
“How can I stop this from happening again?”
“When can I get back in the pool?”
“Can I use cotton buds to clean my ears once this clears up?”
“How long will it take for my ear to feel better?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

James will feel reassured and motivated to follow ear care advice.
He will accept topical treatment and the need to avoid swimming temporarily.
He may say, “I’ll stop using cotton buds and try the ear drops instead.”

If the candidate is vague or dismissive:

James may push for unnecessary oral antibiotics or be reluctant to stop swimming.
He may say, “So, I just have to wait and hope it gets better?”

Key Takeaways for the Candidate

Take a structured otitis externa history, identifying risk factors and symptom progression.
Differentiate bacterial from fungal otitis externa.
Provide an evidence-based treatment plan, including topical ear drops, analgesia, and ear protection advice.
Educate on prevention, including avoiding excessive ear cleaning and prolonged moisture exposure.
Plan follow-up if symptoms persist or worsen.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including symptom onset, aggravating factors, and previous treatments.

The competent candidate should:

Elicit a structured history of symptoms, including:
- Onset (four days ago, started with itching and progressed to pain and discharge).
- Nature of pain (worse on touching or moving the ear, throbbing in character).
- Associated symptoms (muffled hearing, tenderness, discharge, no fever or dizziness).
- Presence of aggravating factors (frequent swimming, cotton bud use).
Identify risk factors for otitis externa, including:
- Water exposure from swimming.
- Mechanical trauma from cotton buds.
- No history of skin conditions, diabetes, or immunosuppression.
Assess previous treatments, including:
- No prior treatment with ear drops or antibiotics.

Task 2: Differentiate between bacterial, fungal, and other causes of otitis externa, identifying any red flags for complications.

The competent candidate should:

Differentiate common causes:
- Bacterial otitis externa (most likely in this case) – painful, swollen ear canal, discharge, tenderness, history of moisture exposure.
- Fungal otitis externa – itching, thick white or black debris, less pain, history of prolonged antibiotic use.
- Other conditions (e.g., otomycosis, foreign body, dermatological conditions) should be considered if symptoms persist.
Identify red flags for complications:
- Malignant otitis externa (severe pain, fever, cranial nerve involvement, common in diabetics).
- Extensive swelling causing complete ear canal obstruction.
- Spreading cellulitis or systemic symptoms.

Task 3: Provide a diagnosis and discuss an initial management plan.

The competent candidate should:

Explain the diagnosis:
- Bacterial otitis externa due to excessive moisture exposure and ear trauma.
- Not a middle ear infection (otitis media), which presents differently.
Outline the treatment plan:
- Topical antibiotic and corticosteroid drops (e.g., ciprofloxacin + hydrocortisone or framycetin + dexamethasone + gramicidin).
- Pain relief with oral analgesia (paracetamol or ibuprofen).
- Avoidance of water exposure (ear plugs or cotton wool with Vaseline when showering).
Discuss follow-up:
- Review in 3–5 days if symptoms persist or worsen.

Task 4: Educate the patient on treatment options, self-care, prevention, and when to seek further medical attention.

The competent candidate should:

Provide self-care advice:
- Stop using cotton buds as they cause microtrauma.
- Keep ears dry while healing.
- Do not insert any foreign objects into the ear.
Discuss prevention strategies:
- Use alcohol-based ear drops (e.g., acetic acid) after swimming to prevent recurrence.
- Avoid excessive ear cleaning.
Explain when to seek medical attention:
- Worsening pain, fever, spreading redness, persistent symptoms despite treatment.

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, identifying symptom progression, risk factors, and previous treatments.
Differentiates bacterial otitis externa from other causes, such as fungal infections or otitis media.
Recognises red flags requiring urgent referral, such as malignant otitis externa in high-risk individuals.
Provides an evidence-based management plan, including topical antibiotic/steroid drops, analgesia, and prevention strategies.
Educates the patient on self-care, prevention, and when to seek medical attention.

PITFALLS

Failing to differentiate otitis externa from otitis media, leading to inappropriate systemic antibiotics.
Not recognising red flags for malignant otitis externa, delaying urgent referral in high-risk cases.
Overprescribing oral antibiotics when topical treatment is the first-line therapy.
Not advising on prevention measures, increasing the risk of recurrence.
Failing to address the patient’s concerns about work and hearing loss, leading to anxiety and reduced adherence to treatment.

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.
1.3 Provides clear and structured explanations about diagnosis, prognosis, and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured history, including symptom onset, risk factors, and previous treatments.
2.2 Identifies red flags for complications (e.g., malignant otitis externa).

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between bacterial, fungal, and other causes of otitis externa.
3.2 Identifies when further investigations or specialist referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides an evidence-based treatment plan, including topical therapy and symptom relief.
4.2 Educates the patient on proper ear care and prevention of recurrence.

5. Preventive and Population Health

5.1 Identifies risk factors for recurrent otitis externa (e.g., water exposure, hearing aids, excessive ear cleaning).
5.2 Advises on lifestyle modifications to reduce recurrence risk.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up if symptoms persist.

8. Procedural Skills

8.1 Recognises when ear canal cleaning or wick placement is required.

9. Managing Uncertainty

9.1 Recognises when a lack of response to treatment warrants further investigation.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and appropriately manages severe or complicated otitis externa.

Competency at Fellowship Level

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