CCE-CE-063.1

CASE INFORMATION

Case ID: CCE-DERM-023
Case Name: Daniel Wright
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S74 – Skin Infection, Post-Traumatic

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 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 Interpretation2.1 Takes a structured history, including onset, wound mechanism, and risk factors for infection
2.2 Identifies red flags for serious infection (e.g., cellulitis, necrotising fasciitis)
3. Diagnosis, Decision-Making and Reasoning3.1 Differentiates between localised and systemic skin infections
3.2 Identifies when further investigations or specialist referral is required
4. Clinical Management and Therapeutic Reasoning4.1 Provides an evidence-based treatment plan, including wound care, antibiotics, and symptom relief
4.2 Educates the patient on wound monitoring and infection prevention
5. Preventive and Population Health5.1 Identifies risk factors for wound infections (e.g., diabetes, immunosuppression, poor wound hygiene)
5.2 Advises on wound care and lifestyle modifications to prevent recurrence
6. Professionalism6.1 Demonstrates empathy and a patient-centred approach
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate documentation and follow-up of wound healing and infection resolution
8. Procedural Skills8.1 Assesses the need for wound drainage or debridement
8.2 Orders and interprets relevant investigations (e.g., wound swab, blood cultures if sepsis suspected)
9. Managing Uncertainty9.1 Recognises when symptoms require urgent intervention versus monitoring
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies and appropriately manages complications of wound infections, such as cellulitis or abscess formation

CASE FEATURES

  • Need for appropriate wound management, infection control, and patient education
  • Worsening redness, swelling, and pain in a wound after a minor injury
  • Patient reports fever and feeling generally unwell
  • History of diabetes, increasing risk of infection

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, including wound mechanism, symptoms, and risk factors for infection.
  2. Identify red flags for serious skin infections and assess the need for urgent intervention or escalation of care.
  3. Provide a diagnosis and discuss an initial management plan.
  4. Educate the patient on wound care, signs of worsening infection, and when to seek further medical attention.

SCENARIO

Daniel Wright, a 45-year-old warehouse worker, presents with worsening redness, swelling, and pain in his right lower leg over the past three days. The symptoms started after a minor scrape at work last week. Initially, he cleaned the wound himself, but now the area is swollen, warm, and increasingly painful.

He also reports feeling feverish and more tired than usual. He has a history of type 2 diabetes, which he manages with metformin but admits that his blood sugar levels have been “a bit high” recently.

His main concerns are:

  • “It’s getting worse every day—should I be worried?”
  • “Do I need antibiotics?”
  • “Will this affect my diabetes?”
  • “What should I do if it gets worse?”

PATIENT RECORD SUMMARY

Patient Details

Name: Daniel Wright
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • No known drug allergies

Medications

  • Metformin 1000mg twice daily (for type 2 diabetes)
  • Paracetamol as needed for mild pain relief

Past History

  • Type 2 diabetes mellitus (diagnosed five years ago)
  • Mild hypertension (diet-controlled)

Social History

  • Works in a warehouse, frequently handles heavy objects.
  • Smoker, about 10 cigarettes per day.
  • Drinks alcohol occasionally.
  • Lives alone, independent in daily activities.

Family History

  • Father had diabetes and heart disease.

Vaccination and Preventative Activities

  • Up to date with vaccinations, including tetanus booster two years ago.

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 leg is getting really red and swollen, and it hurts more every day. I think it’s infected.”

General Information

Daniel Wright is a 45-year-old warehouse worker presenting with increasing redness, swelling, and pain in his right lower leg over the past three days.

  • Injured his right shin at work five days ago, scraping it against a pallet while moving stock.
  • Cleaned it himself with water and antiseptic, then covered it with a bandage.
  • Initially, it looked like a minor scrape, but now the area is swollen, red, and warm.
  • Pain has been worsening, making it hard to walk or stand for long periods.
  • Noticed his leg feeling stiff, and the redness appears to be spreading upwards.

His main concerns are:

  • “It’s getting worse every day—should I be worried?”
  • “Do I need antibiotics?”
  • “Will this affect my diabetes?”
  • “What should I do if it gets worse?”

Specific Information (To be revealed only when asked)

Symptoms and Progression

  • Started feeling more pain and tightness three days ago.
  • Pain worsens with movement, especially when walking.
  • Skin is warm and tender to touch.
  • Has been feeling feverish and more tired than usual.
  • Has not checked his temperature but has had some chills.
  • No nausea or vomiting.

Diabetes and Risk Factors

  • Diagnosed with type 2 diabetes five years ago, takes metformin but does not always check blood sugar levels.
  • Admits his diet has been “off” recently, with higher sugar intake and some skipped meals.
  • Notices that cuts and scrapes take longer to heal than they used to.
  • Smokes about 10 cigarettes per day, knows it isn’t great for healing but hasn’t tried to quit.

Wound Care and Medications

  • Has been using paracetamol for pain relief, but it’s not very effective.
  • Not using any antibiotic ointments or specific wound care dressings.
  • Continues to work, but limping more due to pain.

Concerns About Treatment

  • Worried about needing hospitalisation.
  • Doesn’t want to take time off work unless absolutely necessary.
  • Curious whether he can keep working if he’s on antibiotics.
  • Wants to know how long this will take to heal.

Emotional Cues

Daniel is concerned but trying to stay practical.

  • Frustrated with worsening symptoms: “I thought it would just heal on its own.”
  • Worried about work: “If I need antibiotics, can I still go to work?”
  • Seeking reassurance: “How do I know if this is serious?”

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

If the candidate is vague or dismissive, Daniel may become anxious and push for stronger medications or immediate hospital admission.

Questions for the Candidate

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

  1. “Do I need antibiotics?”
  2. “Is this going to get worse?”
  3. “Could this affect my diabetes?”
  4. “How do I know if I need to go to hospital?”
  5. “When will it start getting better?”
  6. “What should I do to stop this from happening again?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

  • Daniel will feel reassured and willing to follow wound care instructions.
  • He will understand the importance of controlling his diabetes for healing.
  • He may say, “Okay, I’ll take the antibiotics and keep an eye on it.”

If the candidate is vague or dismissive:

  • Daniel may push for unnecessary treatments or become more anxious about hospitalisation.
  • He may say, “So, am I just supposed to wait and hope it gets better?”

Key Takeaways for the Candidate

  • Take a structured wound history, assessing infection risk factors and red flags.
  • Differentiate between local and systemic infection.
  • Provide an appropriate treatment plan, including antibiotics, wound care, and diabetes optimisation.
  • Ensure clear safety-netting advice, including signs of worsening infection.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including wound mechanism, symptoms, and risk factors for infection.

The competent candidate should:

  • Elicit a structured history, including:
    • Mechanism of injury (scraped shin at work five days ago).
    • Progression of symptoms (worsening redness, swelling, and pain over the past three days).
    • Signs of systemic involvement (fever, chills, fatigue).
    • Self-care measures taken (cleaned wound, applied antiseptic, no antibiotic use).
  • Identify risk factors for wound infection, including:
    • Type 2 diabetes (poor glycaemic control delaying healing).
    • Smoking history (impairs wound healing).
    • Delayed presentation with increasing systemic symptoms.

Task 2: Identify red flags for serious skin infections and assess the need for urgent intervention or escalation of care.

The competent candidate should:

  • Recognise signs of severe infection:
    • Expanding erythema and warmth.
    • Pain out of proportion to wound size.
    • Fever, chills, systemic symptoms (suggesting possible cellulitis or sepsis).
    • Crepitus, skin necrosis, or bullae (concern for necrotising fasciitis—requires emergency referral).
  • Determine need for escalation:
    • Moderate infection (localised cellulitis) → Oral antibiotics and monitoring.
    • Severe infection (systemic signs, extensive spread) → Hospital referral for IV antibiotics.
    • Concern for deep infection → Urgent imaging (ultrasound or MRI if necrotising infection suspected).

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

The competent candidate should:

  • Explain the likely diagnosis:
    • Cellulitis secondary to post-traumatic skin infection, with possible early systemic involvement.
    • Worsening symptoms in the context of diabetes require careful monitoring.
  • Outline the management plan:
    • Oral antibiotics (flucloxacillin or cephalexin first-line; clindamycin if penicillin allergy).
    • Analgesia (paracetamol, NSAIDs if tolerated, considering gastrointestinal risk).
    • Local wound care (cleaning, dressing, elevation of leg to reduce swelling).
    • Monitoring blood sugar levels closely to optimise healing.
    • Smoking cessation advice to improve healing and long-term health.

Task 4: Educate the patient on wound care, signs of worsening infection, and when to seek further medical attention.

The competent candidate should:

  • Explain wound care techniques:
    • Keep the wound clean and dry.
    • Change dressings regularly and avoid excessive handling.
    • Elevate the leg to reduce swelling.
  • Discuss warning signs that require urgent review:
    • Increasing redness, pain, or spreading infection.
    • Development of fever, chills, or malaise.
    • Any signs of tissue necrosis (blackening of the skin, blisters, or discharge).
  • Ensure follow-up in 48–72 hours to assess response to antibiotics and determine need for escalation.

SUMMARY OF A COMPETENT ANSWER

  • Takes a structured wound history, identifying risk factors, symptoms, and systemic signs.
  • Differentiates between localised and severe infection, recognising red flags for complications.
  • Provides a structured management plan, including antibiotics, wound care, and glycaemic control.
  • Educates the patient on signs of worsening infection and when to seek urgent care.
  • Arranges follow-up to assess response to treatment and determine further intervention if needed.

PITFALLS

  • Failing to assess severity adequately, leading to delayed referral for systemic infection.
  • Prescribing antibiotics without addressing underlying risk factors, such as diabetes control and smoking.
  • Overlooking red flags for necrotising fasciitis, risking serious complications or delayed escalation.
  • Not providing clear wound care instructions, leading to poor compliance and prolonged recovery.
  • Lack of follow-up planning, increasing the risk of missed treatment failure or worsening infection.

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 wound mechanism, symptoms, and risk factors for infection.
2.2 Identifies red flags for serious infection (e.g., cellulitis, necrotising fasciitis).

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between localised and systemic skin infections.
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 wound care, antibiotics, and symptom relief.
4.2 Educates the patient on wound monitoring and infection prevention.

5. Preventive and Population Health

5.1 Identifies risk factors for wound infections (e.g., diabetes, immunosuppression, poor wound hygiene).
5.2 Advises on wound care and lifestyle modifications to prevent recurrence.

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 of wound healing and infection resolution.

8. Procedural Skills

8.1 Assesses the need for wound drainage or debridement.
8.2 Orders and interprets relevant investigations (e.g., wound swab, blood cultures if sepsis suspected).

9. Managing Uncertainty

9.1 Recognises when symptoms require urgent intervention versus monitoring.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and appropriately manages complications of wound infections, such as cellulitis or abscess formation.

Competency at Fellowship Level

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