CCE-CE-073

CASE INFORMATION

Case ID: CCE-MSK-033
Case Name: David Peterson
Age: 47
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L99 – Musculoskeletal Disease, Other

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 the diagnosis, prognosis, and management
2. Clinical Information Gathering and Interpretation2.1 Takes a structured history, including symptom onset, progression, and impact on function
2.2 Identifies red flags for serious musculoskeletal conditions (e.g., infection, inflammatory disease, malignancy)
3. Diagnosis, Decision-Making and Reasoning3.1 Differentiates between mechanical and inflammatory musculoskeletal conditions
3.2 Identifies when further investigations (e.g., imaging, blood tests, specialist referral) are required
4. Clinical Management and Therapeutic Reasoning4.1 Provides an evidence-based treatment plan, including pain management, physiotherapy, and lifestyle modifications
4.2 Educates the patient on prognosis, recovery expectations, and self-management strategies
5. Preventive and Population Health5.1 Identifies risk factors for chronic musculoskeletal conditions (e.g., occupational strain, obesity, sedentary lifestyle)
5.2 Encourages strategies to prevent recurrence and long-term complications
6. Professionalism6.1 Demonstrates empathy and a patient-centred approach
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate documentation and follow-up for unresolved symptoms
8. Procedural Skills8.1 Identifies when joint aspiration, corticosteroid injection, or other procedures may be indicated
9. Managing Uncertainty9.1 Recognises when to observe, investigate, or refer for specialist opinion
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies serious musculoskeletal conditions requiring urgent intervention

CASE FEATURES

  • Need for appropriate assessment, management, and lifestyle modification advice
  • Chronic, intermittent joint pain in hands and knees, worse in the morning
  • Progressive stiffness and swelling, with occasional flare-ups
  • Concerned about whether this is arthritis or another chronic condition

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face to face.

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 Peterson, a 47-year-old office worker, presents with chronic joint pain in his hands and knees that has gradually worsened over the past year.

His symptoms include:

  • Intermittent pain and stiffness, worse in the mornings and after prolonged inactivity.
  • Occasional swelling, particularly in the fingers and knees.
  • Pain improves with movement but worsens after heavy activity.
  • Some days are worse than others, with occasional flare-ups lasting a few days.

PATIENT RECORD SUMMARY

Patient Details

Name: David Peterson
Age: 47
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • No known drug allergies

Medications

  • Occasionally takes ibuprofen for joint pain

Past History

  • No previous diagnosis of arthritis or other musculoskeletal conditions
  • No history of significant joint injury

Social History

  • Works as an office manager, mostly sedentary with some typing-related strain
  • Ex-smoker, quit 10 years ago
  • Occasional alcohol use, no illicit drugs

Family History

  • Mother had rheumatoid arthritis
  • No known history of osteoarthritis or autoimmune conditions in other family members

Vaccination and Preventative Activities

  • Overdue for a check-up on cardiovascular risk factors
  • Up to date with general health screenings

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, I’ve been having joint pain for a while now, and I’m worried it could be arthritis.”

General Information

David Peterson is a 47-year-old office manager presenting with chronic joint pain affecting his hands and knees over the past 12 months.

  • Initially mild, but gradually worsening.
  • Pain is intermittent, with flare-ups lasting a few days at a time.
  • Stiffness is most noticeable in the morning and after sitting for long periods.
  • No major limitations in movement, but some activities—especially typing and prolonged walking—are becoming more difficult.

Specific Information

(To be revealed only when asked)

Background Information

His main concerns are:

  • “I wake up feeling stiff every morning, and it takes a while before I can move comfortably.”
  • “Could this be arthritis? My mother had rheumatoid arthritis.”
  • “Is this something that’s going to keep getting worse?”
  • “Do I need to stop playing tennis to protect my joints?”

Joint Symptoms

(David will describe the following if asked about the nature and location of his pain.)

  • Pain mainly affects his fingers (especially the knuckles) and both knees.
  • Pain is symmetrical in his hands but varies in intensity.
  • He experiences swelling in his fingers and knees, particularly after long workdays.
  • No redness or warmth over the joints.
  • No locking, instability, or giving way in the knees.
  • No major issues in the hips, spine, or shoulders.

Morning Stiffness and Functionality

(David will describe these symptoms if asked about how his condition affects his daily life.)

  • Stiffness lasts about 30-45 minutes each morning, easing with movement.
  • After prolonged sitting (e.g., long meetings), he feels stiff when standing up.
  • Can still do most daily activities, but typing at work for long hours is becoming uncomfortable.
  • Can play tennis but notices knee pain afterward.

Impact on Work and Activities

(David will elaborate on how his symptoms interfere with work and hobbies if asked.)

  • Works at a desk for most of the day, using a keyboard and mouse.
  • Noticed that his fingers ache more after a full day of typing.
  • Plays recreational tennis once a week but worries that it might be worsening his knee pain.

Self-Management Attempts

(David will share what he has tried so far if asked about any treatments or medications.)

  • Occasionally takes ibuprofen, which helps but doesn’t completely relieve the pain.
  • Tried using a wrist brace while typing but found it uncomfortable.
  • Has not seen a physiotherapist or done specific exercises.
  • Hasn’t noticed any improvement with heat or cold therapy.

Family and Medical History

(David will reveal these details if asked about family history or underlying conditions.)

  • Mother had rheumatoid arthritis, diagnosed in her 50s.
  • No known osteoarthritis or autoimmune diseases in other family members.
  • Ex-smoker (quit 10 years ago), occasional alcohol use.
  • No previous fractures or significant joint injuries.
  • No history of psoriasis, bowel disease, or unexplained skin rashes.

Concerns About Arthritis and Long-Term Effects

(David will ask about his future prognosis and management.)

  • “Do I need tests to confirm if this is arthritis?”
  • “Will this eventually stop me from working or playing sports?”
  • “What can I do to slow this down or prevent it from getting worse?”
  • “Are there any medications I should take now to protect my joints?”

Emotional Cues

  • Mild anxiety about the possibility of arthritis and its long-term consequences.
  • Concerned about whether this will progress to severe joint damage.
  • Wants a structured plan for symptom management and prevention.
  • If the candidate is dismissive, David may push for further testing or seek a second opinion.

Questions for the Candidate

David may ask some or all of the following:

  1. “Is this arthritis, and what type?”
  2. “Do I need blood tests or X-rays?”
  3. “Should I stop playing tennis to protect my joints?”
  4. “What can I do to prevent this from getting worse?”
  5. “Will I need to take medication for this long-term?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

  • David will feel reassured and follow the management recommendations.
  • He may say: “That makes sense. I’ll try those exercises and see how it goes.”

If the candidate is vague or dismissive:

  • David may push for further testing or seek a second opinion.
  • He may feel uncertain about how to manage his symptoms.

Key Takeaways for the Candidate

  • Take a structured musculoskeletal history, identifying inflammatory versus mechanical joint disease.
  • Differentiate between osteoarthritis, inflammatory arthritis, and overuse syndromes.
  • Provide evidence-based management, including exercise, physiotherapy, and pain relief.
  • Educate the patient on prognosis, lifestyle modifications, and when to seek further review.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including onset, progression, impact on daily life, past medical history, and red flags for systemic illness.

The competent candidate should:

  • Obtain a structured musculoskeletal history, including:
    • Onset and duration (12 months of progressive joint pain).
    • Pain characteristics (symmetrical, intermittent, affects fingers and knees, no redness or warmth).
    • Stiffness and functional impact (morning stiffness for 30-45 minutes, difficulty typing and prolonged sitting).
    • Flare-ups and triggers (worse after long workdays, relieved by movement).
    • Family history (mother had rheumatoid arthritis).
    • Past injuries or joint conditions (no significant joint trauma).
    • Systemic symptoms (no weight loss, fevers, night sweats, or rashes).
  • Screen for red flags, including:
    • Unexplained weight loss, persistent night pain, systemic symptoms.
    • Rapidly progressive joint deformity or signs of inflammatory arthritis.
  • Assess risk factors for inflammatory versus degenerative joint disease.

Task 2: Conduct a risk assessment for inflammatory versus mechanical musculoskeletal conditions and determine whether further investigations are required.

The competent candidate should:

  • Differentiate between key musculoskeletal conditions:
    • Osteoarthritis (OA) – Age-related wear and tear, worse with activity, improves with rest, minimal swelling.
    • Inflammatory arthritis (e.g., RA) – Symmetrical joint pain, morning stiffness >1 hour, small joint involvement, family history.
    • Other conditions (e.g., gout, psoriatic arthritis, reactive arthritis, lupus) – Consider if risk factors present.
  • Determine if investigations are needed:
    • X-rays if concern about OA or joint damage.
    • Rheumatoid factor (RF), anti-CCP, ESR/CRP if inflammatory arthritis suspected.
    • Uric acid levels if gout is considered.
    • ANA testing if autoimmune disease is suspected.

Task 3: Provide a diagnosis and discuss an initial management plan, including pain relief, physiotherapy, lifestyle modifications, and follow-up.

The competent candidate should:

  • Explain the likely diagnosis:
    • “Your symptoms are suggestive of early osteoarthritis, but we should rule out inflammatory arthritis given your family history.”
  • Management plan for suspected osteoarthritis:
    • Pain relief:
      • First-line: Paracetamol, NSAIDs (topical or oral, as tolerated).
      • Consider trial of glucosamine or chondroitin.
    • Non-pharmacological interventions:
      • Physiotherapy for strengthening and flexibility.
      • Weight management and low-impact exercise (e.g., swimming, cycling).
      • Ergonomic workplace adjustments for typing.
    • Referral to rheumatology if inflammatory arthritis is suspected.

Task 4: Educate the patient on expected prognosis, self-care strategies, and when to seek further medical attention.

The competent candidate should:

  • Explain the nature of osteoarthritis:
    • “OA is a chronic condition that can be managed with lifestyle modifications and targeted treatments.”
    • “Progression varies, but early intervention can help maintain function and reduce pain.”
  • Provide guidance on self-management:
    • Regular exercise and muscle strengthening.
    • Use of joint supports or braces if needed.
    • Heat or cold therapy for symptom relief.
  • Safety-netting and follow-up:
    • “Return for review if symptoms worsen, new joints are affected, or daily activities become difficult.”
    • “If we suspect inflammatory arthritis, early treatment can prevent joint damage.”

SUMMARY OF A COMPETENT ANSWER

  • Takes a detailed history, distinguishing between inflammatory and mechanical joint disease.
  • Identifies red flags requiring further investigation.
  • Explains likely diagnosis, balancing patient concerns and clinical findings.
  • Provides a structured management plan, including pain relief, physiotherapy, and lifestyle modifications.
  • Advises on prognosis, preventive strategies, and when to seek further care.

PITFALLS

  • Failing to assess red flags, such as systemic symptoms or progressive joint deformity.
  • Overlooking inflammatory arthritis, leading to delayed diagnosis and joint damage.
  • Overprescribing NSAIDs without considering lifestyle modifications and non-pharmacological management.
  • Not addressing the patient’s concerns about family history and disease progression.
  • Failing to discuss long-term joint health, prevention strategies, and self-management.

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, progression, and impact on function.
2.2 Identifies red flags for serious musculoskeletal conditions (e.g., infection, inflammatory disease, malignancy).

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between mechanical and inflammatory musculoskeletal conditions.
3.2 Identifies when further investigations (e.g., imaging, blood tests, specialist referral) are required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides an evidence-based treatment plan, including pain management, physiotherapy, and lifestyle modifications.
4.2 Educates the patient on prognosis, recovery expectations, and self-management strategies.

5. Preventive and Population Health

5.1 Identifies risk factors for chronic musculoskeletal conditions (e.g., occupational strain, obesity, sedentary lifestyle).
5.2 Encourages strategies to prevent recurrence and long-term complications.

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 for unresolved symptoms.

8. Procedural Skills

8.1 Identifies when joint aspiration, corticosteroid injection, or other procedures may be indicated.

9. Managing Uncertainty

9.1 Recognises when to observe, investigate, or refer for specialist opinion.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies serious musculoskeletal conditions requiring urgent intervention.

Competency at Fellowship Level

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