CASE INFORMATION

Case ID: CE-SUM-01
Case Name: Daniel Hughes
Age: 28
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L88 – Arthritis (Excluding Osteoarthritis and Rheumatoid Arthritis)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to gather relevant information about symptoms and concerns 1.2 Provides clear and empathetic explanations regarding the diagnosis and management plan
2. Clinical Information Gathering and Interpretation	2.1 Takes a comprehensive history, including risk factors for inflammatory arthritis 2.2 Orders and interprets appropriate investigations for suspected inflammatory or reactive arthritis
3. Diagnosis, Decision-Making and Reasoning	3.1 Identifies clinical features suggestive of a systemic inflammatory condition 3.2 Recognises red flags requiring urgent referral (e.g., septic arthritis, systemic autoimmune disease)
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan, including pharmacological and non-pharmacological interventions 4.2 Identifies when referral to a rheumatologist is required
5. Preventive and Population Health	5.1 Provides education on joint health, physical activity, and lifestyle modifications
6. Professionalism	6.1 Demonstrates patient-centred care and acknowledges the impact of arthritis on quality of life
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate monitoring and follow-up, including specialist referrals
8. Procedural Skills	8.1 Performs appropriate joint examination and orders relevant imaging if indicated
9. Managing Uncertainty	9.1 Recognises when symptoms require further investigation or specialist input
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies cases requiring urgent intervention, such as septic arthritis or autoimmune flare

CASE FEATURES

Young man presenting with persistent joint pain and swelling in multiple joints.
Recent history of a gastrointestinal infection two weeks prior to symptom onset.
Morning stiffness lasting more than 30 minutes, affecting daily activities.
Likely reactive arthritis (ReA), but differential includes seronegative spondyloarthritis or autoimmune causes.
Needs assessment for infection-associated arthritis, autoimmune markers, and inflammatory joint disease.
Requires education on prognosis, symptom management, and potential need for specialist referral.

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

SCENARIO

Daniel Hughes, a 28-year-old construction worker, presents with persistent joint pain and swelling for the past three weeks. He first noticed pain in his left knee, but over time, his right ankle and a few fingers also became swollen and stiff. The symptoms are worst in the morning and improve slightly with movement.

Two weeks before the joint pain started, he had a short bout of diarrhoea that lasted three days, but he did not seek medical treatment at the time.

PATIENT RECORD SUMMARY

Patient Details

Name: Daniel Hughes
Age: 28
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular medications

Past History

No previous history of arthritis, autoimmune disease, or inflammatory bowel disease
No history of sexually transmitted infections (STIs) or uveitis

Social History

Works in construction, physically demanding job

Smoking

Non-smoker

Alcohol

Drinks socially on weekends

Vaccination and Preventative 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.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, my joints have been hurting and swollen for a few weeks now, and I don’t know why. I can’t work properly because of it.”

General Information

You are Daniel Hughes, a 28-year-old construction worker. Over the past three weeks, you have noticed persistent joint pain and swelling. It started in your left knee but has since spread to your right ankle and a few fingers. The joints feel stiff and swollen, and the pain is worst in the morning, taking a while to ease up once you start moving.

You have been struggling to do your job properly because your joints feel weak and painful. You work in construction, so you need to be physically active, and this is making it difficult to lift materials, bend, or walk long distances.

Specific Information

(Reveal only when asked)

Background Information

Two weeks before the joint pain started, you had a stomach bug with diarrhoea for about three days. You didn’t think much of it at the time because it went away on its own, but now you are wondering if it could be related.

You feel more tired than usual, and by the end of the day, you feel exhausted. However, you haven’t had a fever, chills, or major weight loss.

You have never had anything like this before and are worried about what’s happening. You’re concerned that this might be some kind of infection or an autoimmune disease, and you want to know what tests you need and whether there’s treatment to make it go away.

Symptoms

The pain started gradually, first in your left knee, then spread to the right ankle and fingers.
Your joints feel swollen, warm, and stiff in the mornings.
The stiffness lasts more than 30 minutes but improves somewhat with activity.
You don’t recall any injuries or accidents that might have caused this.
You haven’t noticed any rashes, eye redness, or mouth ulcers.
You haven’t had any recent tick bites or travelled overseas.

Gastrointestinal History

Two weeks before the joint pain, you had diarrhoea for three days, but no vomiting or fever.
You didn’t see a doctor at the time because it resolved on its own.

Sexual History

You are sexually active, with inconsistent condom use.
No history of sexually transmitted infections (STIs), but haven’t been tested recently.

Family History

No known family history of arthritis, autoimmune diseases, or inflammatory bowel disease.

Concerns and Expectations

You are worried this could be an infection in your joints.
You are concerned about whether this is something serious like an autoimmune disease.
You want to know if this could affect your long-term health or ability to work.
You want to understand the cause and get treatment that will help.

Emotional Cues & Body Language

You look concerned and frustrated, rubbing your knee or wrist occasionally when talking about the pain.
You frown slightly when discussing your work difficulties, as this is affecting your ability to earn a living.
You seem relieved when the doctor reassures you, but push for more information if answers seem vague.
If the doctor does not give clear next steps or a structured plan, you become frustrated and ask about referrals or specialist input.

Questions for the Candidate (Ask Naturally During the Consultation)

“Could this be an infection in my joints?”
“Is this something serious like an autoimmune disease?”
“Do I need tests or a scan to find out what’s going on?”
“What medication can I take to make this go away?”
“Can I keep working, or do I need to rest?”
“Will this come back again, or is it just a one-time thing?”
“Is there anything I can do to stop this from happening again?”

Response to Advice Given by the Candidate

If the candidate explains the likely diagnosis clearly, you feel relieved but still ask what the next steps are.
If they suggest reactive arthritis as a possibility, you ask how long it will last and what can be done to manage it.
If they recommend blood tests and investigations, you agree but ask how long the results will take and if it will show the exact cause.
If they discuss medications like NSAIDs, you ask if there are stronger options and how long you’ll need to take them.
If they don’t provide a clear explanation or plan, you push for more answers and ask if you should see a specialist.

Final Thought

If the candidate explains the likely diagnosis well, reassures you, and provides a structured management plan, you feel more confident about managing your symptoms and are willing to follow their advice. If they are vague, dismissive, or fail to address your concerns about work and long-term health, you leave feeling frustrated and unsure about what to do next.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including symptom onset, joint involvement, and associated systemic symptoms.

The competent candidate should:

Clarify the onset and progression of joint symptoms:
- First affected joint (left knee), followed by right ankle and fingers.
- Morning stiffness lasting more than 30 minutes.
- Pattern of joint involvement (asymmetrical, oligoarthritis).
Identify preceding triggers:
- History of diarrhoea two weeks prior (suggestive of post-infectious aetiology).
- Sexual history (inconsistent condom use, potential for sexually transmitted reactive arthritis).
Assess systemic symptoms:
- Fatigue and reduced energy but no fever or weight loss.
- No rashes, eye redness, or mouth ulcers (reducing likelihood of lupus or psoriatic arthritis).
Explore functional impact:
- Work difficulties due to pain and swelling.
- Limitations in mobility and hand function.

Task 2: Identify key clinical features and order appropriate investigations to determine the underlying cause.

The competent candidate should:

Recognise features suggestive of reactive arthritis (ReA):
- Preceding gastrointestinal infection.
- Asymmetrical oligoarthritis (large and small joints).
- Morning stiffness with gradual improvement with activity.
Consider differential diagnoses:
- Septic arthritis (less likely given multiple joints affected and lack of systemic illness).
- Seronegative spondyloarthritis (e.g., psoriatic arthritis, inflammatory bowel disease-related arthritis).
- Autoimmune conditions (e.g., lupus, rheumatoid arthritis).
Order relevant investigations:
- Inflammatory markers (CRP, ESR) to assess inflammation.
- Rheumatoid factor (RF) and anti-CCP to rule out rheumatoid arthritis.
- HLA-B27 (associated with reactive arthritis and ankylosing spondylitis).
- Urethral swab or first-pass urine for Chlamydia PCR (if suspected post-STI reactive arthritis).
- Faecal cultures if persistent gastrointestinal symptoms.
- Joint aspiration if effusion present (to rule out septic arthritis).

Task 3: Explain the likely diagnosis, management options, and need for follow-up.

The competent candidate should:

Explain the likely diagnosis:
- Reactive arthritis due to previous gastrointestinal infection.
- Inflammatory process that can last weeks to months but often resolves.
Discuss treatment approach:
- NSAIDs as first-line treatment for symptom relief.
- Physiotherapy and exercise to maintain joint mobility.
- Possible short-term corticosteroids if severe inflammation.
Address prognosis and follow-up:
- Most cases resolve in 3–6 months, but some can persist.
- Review in 4 weeks to assess symptom response.
- If persistent or worsening symptoms, consider rheumatology referral.

Task 4: Develop a safe, evidence-based management plan, including pharmacological and non-pharmacological strategies.

The competent candidate should:

Start symptom management:
- NSAIDs (e.g., naproxen, ibuprofen) for pain relief.
- Short-course corticosteroids if symptoms are severe.
Support functional recovery:
- Encourage light physical activity to prevent stiffness.
- Refer to physiotherapy for structured joint exercises.
Educate on prognosis:
- Explain that most cases resolve over time, but monitoring is needed.
- Discuss risk of recurrence, especially with repeated infections.
Arrange follow-up and specialist input:
- Review in 4 weeks to assess response to NSAIDs.
- Consider rheumatology referral if symptoms persist beyond 6 months.

SUMMARY OF A COMPETENT ANSWER

Takes a comprehensive history, identifying preceding infection and joint pattern.
Recognises clinical features of reactive arthritis and differentiates from autoimmune conditions.
Orders relevant investigations, including inflammatory markers, autoimmune screening, and infection testing.
Explains the diagnosis clearly, reassuring the patient while outlining treatment options.
Develops an evidence-based management plan, including NSAIDs, physiotherapy, and follow-up.
Provides guidance on prognosis and when referral to a specialist may be required.

PITFALLS

Failing to consider reactive arthritis, leading to delayed diagnosis.
Not screening for underlying infections, such as Chlamydia or post-gastroenteritis triggers.
Overlooking inflammatory markers and autoimmune tests, missing alternative causes.
Not addressing the impact on work and function, leaving the patient unsure about activity modifications.
Lack of follow-up plan, delaying escalation if symptoms persist.

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 symptom onset and associated infections.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies clinical features suggestive of a systemic inflammatory condition.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan, including pharmacological and non-pharmacological interventions.

5. Preventive and Population Health

5.1 Provides education on joint health, physical activity, and lifestyle modifications.

6. Professionalism

6.1 Demonstrates patient-centred care and acknowledges the impact of arthritis on quality of life.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate monitoring and follow-up, including referrals where necessary.

8. Procedural Skills

8.1 Performs appropriate joint examination and orders relevant imaging if indicated.

9. Managing Uncertainty

9.1 Recognises when symptoms require further investigation or specialist input.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies cases requiring urgent intervention, such as septic arthritis or autoimmune flare.

Competency at Fellowship Level

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