CCE-CE-063

CASE INFORMATION

Case ID:2025-0A2
Case Name: David Thompson
Age: 42
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S72 – Skin Infection/Post-Traumatic

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to gather relevant information about symptoms and concerns
1.2 Provides clear and empathetic explanations regarding the diagnosis and treatment plan
2. Clinical Information Gathering and Interpretation2.1 Takes a comprehensive history, including mechanism of injury and risk factors for infection
2.2 Assesses for local and systemic signs of infection
3. Diagnosis, Decision-Making and Reasoning3.1 Identifies clinical features of skin infection and differentiates between cellulitis, abscess, and necrotising infection
3.2 Recognises red flags requiring urgent intervention, such as systemic illness or deep tissue involvement
4. Clinical Management and Therapeutic Reasoning4.1 Develops an evidence-based management plan, including wound care, antibiotics, and possible drainage
4.2 Identifies when hospital referral is necessary
5. Preventive and Population Health5.1 Provides advice on wound care and infection prevention strategies
6. Professionalism6.1 Demonstrates patient-centred care and acknowledges the impact of the infection on daily life
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate documentation and follow-up
8. Procedural Skills8.1 Demonstrates appropriate wound assessment and dressing techniques
9. Managing Uncertainty9.1 Recognises when symptoms require further investigation, including ruling out deeper infections
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies cases requiring escalation of care, including septic presentations

CASE FEATURES

  • Middle-aged man with an infected leg wound following a minor trauma (cut on shin from gardening).
  • Delayed presentation (initially managed with home dressings but worsening over a few days).
  • Features of cellulitis (erythema, warmth, pain, mild swelling).
  • No systemic symptoms yet, but concern for progression.
  • Needs assessment for deeper infection, appropriate antibiotics, and wound care education.

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 the differential diagnosis and key investigations required.
  3. Address the patient’s concerns.
  4. Develop a safe and patient-centred management plan.

SCENARIO

David Thompson, a 42-year-old construction worker, presents with a red, painful, swollen wound on his right shin. Five days ago, while gardening, he accidentally scraped his leg on a metal edge. He initially cleaned it at home and applied a bandage, but over the past 3 days, the redness has spread, and the area has become more painful and warm.

He wants to know if he needs antibiotics and whether he should be worried about the infection spreading.

PATIENT RECORD SUMMARY

Patient Details

Name: David Thompson
Age: 42
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Nil regular medications

Past History

  • No history of diabetes, vascular disease, or immunosuppression

Social History

  • Works as a construction worker

Family History

  • No family history of diabetes or immune disorders

Smoking

  • Non-smoker

Alcohol

  • Drinks socially (1-2 beers on weekends)

Vaccination and Preventative Activities

  • Tetanus vaccination 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.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, I scraped my leg a few days ago, and now it’s really red and painful. I thought it would get better on its own, but it seems to be getting worse.”

General Information

You are David Thompson, a 42-year-old construction worker. Five days ago, while doing some gardening at home, you scraped your right shin on the edge of a metal garden bed. At the time, it was just a small cut, so you rinsed it with water, applied antiseptic cream, and covered it with a bandage.

For the first two days, it seemed fine, but by day three, you noticed the skin around the wound had become red, warm, and swollen. The pain has been getting worse, and you now feel a constant throbbing sensation in your shin. You also notice the redness is spreading further up your leg.

Specific Information

(Reveal only when asked)

Background Information

You have been trying to manage it at home by keeping it covered and applying antiseptic cream, but it doesn’t seem to be improving.

You don’t have a fever, but you are starting to worry because the pain is increasing, and the redness is spreading rather than going away.

You are here today because you want to know if this is an infection and if you need antibiotics. You’re also worried about whether it could spread further or become something serious.

History of the Injury

  • You were gardening at home five days ago when you scraped your shin on a metal garden bed.
  • It was a small superficial wound, not very deep.
  • You rinsed it with water, applied antiseptic, and covered it with a bandage.

Current Symptoms

  • Pain: Started as mild discomfort but is now throbbing and constant.
  • Redness and swelling: Initially around the cut but now spreading upwards.
  • Warmth: The area feels hot to touch.
  • No pus or drainage so far.
  • No numbness, no tingling, and no loss of sensation in the leg.
  • No joint pain or difficulty moving the leg.

Systemic Symptoms

  • No fever or chills.
  • No nausea or vomiting.
  • No dizziness or feeling unwell.

Medical History and Risk Factors

  • No history of diabetes, vascular disease, or immunosuppression.
  • Tetanus vaccination is up to date.
  • No history of skin infections in the past.
  • No known allergies to medications.

Concerns and Expectations

  • You are worried about the redness spreading.
  • You want to know if this is an infection and whether it will go away on its own or if you need antibiotics.
  • You don’t want to go to hospital, but you’re willing to if necessary.
  • You want advice on how to prevent infections in the future.

Emotional Cues & Body Language

  • You appear mildly concerned but not in distress.
  • You occasionally touch your shin when talking about the pain.
  • You lean forward slightly when asking if this could spread further.
  • If the doctor explains things well, you nod and seem reassured.
  • If the doctor is vague or dismissive, you become more anxious and push for clear answers.

Questions for the Candidate (Ask Naturally During the Consultation)

  1. “Do you think this is infected? Do I need antibiotics?”
  2. “How do I know if this is serious? Could it spread further?”
  3. “Will I need to go to hospital?”
  4. “How should I take care of this at home?”
  5. “What can I do to stop this from happening again?”
  6. “If I start antibiotics, how long will it take to get better?”
  7. “Is there anything I should watch out for that means it’s getting worse?”

Response to Advice Given by the Candidate

  • If the candidate explains cellulitis clearly, you feel reassured.
  • If they suggest oral antibiotics, you ask how long it will take to improve.
  • If they recommend wound care, you ask what type of dressing to use.
  • If they mention warning signs to watch for, you pay close attention and may ask for clarification on when to seek urgent care.
  • If the doctor fails to provide clear instructions, you ask for more specifics about treatment, monitoring, and follow-up.

Final Thought

If the candidate explains the infection well, reassures you, and provides a clear treatment plan, you feel confident about managing the wound. If they are vague, dismissive, or fail to address your concerns, you remain worried and dissatisfied with the consultation.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including mechanism of injury, wound progression, and signs of infection.

The competent candidate should:

  • Elicit a clear history of the initial injury:
    • Mechanism: When and how the wound occurred.
    • Initial management: Cleaning, dressing, or use of antiseptic.
    • Timeline of symptom progression: Worsening pain, spreading redness, swelling.
  • Assess signs of infection:
    • Local symptoms: Erythema, warmth, tenderness, swelling, presence of pus.
    • Systemic symptoms: Fever, chills, malaise (suggestive of deeper infection).
  • Identify risk factors for poor healing:
    • Diabetes, immunosuppression, vascular disease.
    • High-risk exposure (e.g., soil contamination, animal bites).
  • Address patient concerns: Fear of worsening infection, need for hospitalisation.

Task 2: Identify key clinical features and assess for complications, such as abscess formation or systemic involvement.

The competent candidate should:

  • Differentiate between common skin infections:
    • Cellulitis: Spreading erythema, warmth, pain, swelling.
    • Abscess: Fluctuant mass, pus collection, pain.
    • Necrotising infection: Rapid progression, severe pain, systemic toxicity.
  • Recognise red flags for deeper infection:
    • Rapidly spreading erythema, intense pain, skin necrosis.
    • Systemic illness: fever, hypotension, confusion.
  • Assess for complications requiring escalation:
    • Sepsis, osteomyelitis, deep tissue involvement.
  • Decide on need for further imaging or specialist referral.

Task 3: Explain the likely diagnosis, treatment options, and when urgent care is needed.

The competent candidate should:

  • Explain the diagnosis in simple terms:
    • Likely cellulitis, a bacterial infection of the skin.
    • Infection is spreading, so treatment is needed to prevent complications.
  • Discuss treatment options:
    • Oral antibiotics: Flucloxacillin or cephalexin (first-line).
    • Pain management: Paracetamol or NSAIDs as appropriate.
    • Wound care: Cleaning, dressing changes.
  • Provide red flag warnings:
    • Worsening pain, fever, spreading redness → seek urgent care.
    • Signs of an abscess → may need drainage.

Task 4: Develop a safe, evidence-based management plan, including antibiotics, wound care, and follow-up.

The competent candidate should:

  • Start oral antibiotics:
    • Flucloxacillin 500 mg QID for 7 days (or cephalexin if allergic).
  • Provide wound care instructions:
    • Keep wound clean, change dressings daily.
    • Avoid excessive moisture (e.g., bathing, swimming).
  • Educate on infection prevention:
    • Proper wound care, early signs of infection.
    • If recurrent infections occur, consider investigating for underlying conditions.
  • Arrange follow-up in 2–3 days:
    • Assess response to antibiotics.
    • Escalate if no improvement or worsening symptoms.

SUMMARY OF A COMPETENT ANSWER

  • Takes a thorough history, including mechanism of injury and infection progression.
  • Identifies features of cellulitis, differentiating from deeper infections.
  • Explains the diagnosis clearly, reassuring the patient while discussing risks.
  • Provides a structured management plan, including antibiotics, wound care, and follow-up.
  • Recognises when referral is needed, ensuring timely escalation for complications.

PITFALLS

  • Failing to assess for deeper infection (e.g., necrotising fasciitis, osteomyelitis).
  • Overlooking systemic symptoms, delaying escalation of care.
  • Prescribing antibiotics without clear wound care instructions.
  • Not educating the patient on red flag symptoms, leading to potential deterioration.
  • Lack of structured follow-up, missing 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 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 comprehensive history, including mechanism of injury and risk factors for infection.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies clinical features of skin infection and differentiates between cellulitis, abscess, and necrotising infection.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan, including wound care, antibiotics, and possible drainage.

5. Preventive and Population Health

5.1 Provides advice on wound care and infection prevention strategies.

6. Professionalism

6.1 Demonstrates patient-centred care and acknowledges the impact of the infection on daily life.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up.

8. Procedural Skills

8.1 Demonstrates appropriate wound assessment and dressing techniques.

9. Managing Uncertainty

9.1 Recognises when symptoms require further investigation, including ruling out deeper infections.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies cases requiring escalation of care, including septic presentations.

Competency at Fellowship Level

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