CCE-CE-078 - GP Exams

CASE INFORMATION

Case ID: CCE-RA-001
Case Name: Emily Dawson
Age: 42
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L88 – Rheumatoid Arthritis

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 the condition, investigations, and management
2. Clinical Information Gathering and Interpretation	2.1 Takes a structured history, including symptom onset, progression, functional impact, and red flags 2.2 Conducts a clinical assessment for inflammatory arthritis and identifies the need for further investigations
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between inflammatory and non-inflammatory arthritis 3.2 Recognises indications for specialist referral and disease-modifying therapy
4. Clinical Management and Therapeutic Reasoning	4.1 Provides an evidence-based treatment plan, including symptom relief and long-term management 4.2 Advises on lifestyle modifications, physical activity, and occupational adaptations
5. Preventive and Population Health	5.1 Assesses cardiovascular and osteoporosis risk in patients with chronic inflammatory conditions 5.2 Encourages appropriate vaccinations and bone health management
6. Professionalism	6.1 Demonstrates empathy and a patient-centred approach
7. General Practice Systems and Regulatory Requirements	7.1 Documents assessment, referral indications, and shared decision-making appropriately
9. Managing Uncertainty	9.1 Recognises when to monitor, investigate further, or refer for specialist care
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies progressive disease requiring escalation of care

CASE FEATURES

Worried about treatment options, side effects, and lifestyle implications
Middle-aged woman presenting with chronic joint pain and stiffness
Symptoms suggestive of inflammatory arthritis (early morning stiffness, multiple joint involvement, functional impairment)
Concerned about worsening symptoms and long-term disability
Has not previously seen a rheumatologist or been formally diagnosed

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:

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

Emily Dawson, a 42-year-old administrative worker, presents with progressive joint pain and stiffness over the past six months.

Her symptom history includes:

Pain in both hands, wrists, and knees (symmetrical involvement).
Early morning stiffness lasting over an hour.
Swelling in the affected joints.
Difficulty performing daily tasks (e.g., typing, gripping objects).
Fatigue and occasional low-grade fever.

PATIENT RECORD SUMMARY

Patient Details

Name: Emily Dawson
Age: 42
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Occasionally takes ibuprofen for joint pain

Past History

No major medical conditions

Social History

Works as an office administrator (desk job, typing-intensive tasks)
Non-smoker, occasional alcohol use

Family History

Mother diagnosed with rheumatoid arthritis in her 50s

Preventative Activities

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 hands have been stiff and sore every morning for months now, and it seems to be getting worse.”

General Information

Emily Dawson is a 42-year-old office administrator who has been experiencing progressive joint pain and stiffness over the last six months. She has come to the doctor because she is worried that she might have rheumatoid arthritis (RA), like her mother did.

The pain started gradually and has worsened over time.
Initially mild and intermittent, but now it is present daily.
She struggles with daily activities such as typing, opening jars, and buttoning clothes.

Specific Information

(To be revealed only when asked)

Background Information

The stiffness is worst in the morning, lasting over an hour before improving slightly.
She has noticed some swelling in her hands and knees.
She has been taking ibuprofen occasionally, but it is becoming less effective.

Symptoms and Functional Impact

(Emily will describe the following if asked.)

Symmetrical joint pain in both hands, wrists, and knees.
Some warmth and swelling in the affected joints.
Struggles with fine motor tasks such as doing up buttons or gripping objects.
No major issues with weight-bearing joints like hips or ankles.
No significant back pain.
Fatigue and occasional mild fevers.
No recent weight loss or night sweats.

Medical and Family History

(Emily will provide this information when prompted.)

No previous joint diseases or arthritis diagnosis.
No history of psoriasis, irritable bowel disease, or thyroid disease.
No previous inflammatory markers or imaging.
Mother had rheumatoid arthritis, diagnosed in her 50s, and required long-term medication.

Concerns About Diagnosis and Treatment

(Emily will ask about these issues when prompted.)

“What tests do I need?”
“What are my treatment options? Will I have to take medication forever?”
“Can I do anything naturally to help this?”
“What are the side effects of the medications?”
“How soon will I know if this is serious?”

Current Management and Coping Strategies

(Emily will mention these if asked.)

Taking ibuprofen occasionally but doesn’t like relying on it.
Using heat packs in the morning, which help a little.
Avoiding certain tasks at work due to pain.
Has not seen a physiotherapist or tried any formal exercise routine.

Emotional Cues

Emily is anxious but trying to stay composed.

She fears long-term disability and is worried about her future.
She is hesitant about medication but wants to understand her options.
She is concerned about how this might affect her ability to work.
If the candidate is reassuring and provides a clear plan, she will be more receptive to medical advice.
If the candidate is vague or dismissive, she may become frustrated or feel hopeless.

Questions for the Candidate

Emily may ask some or all of the following:

“How do you know if this is rheumatoid arthritis?”
“What tests do I need?”
“Will I need lifelong medication?”
“Are there natural treatments for this?”
“How can I stop this from getting worse?”
“What happens if I don’t take medication?”
“Could this just be from working too much at the computer?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

Emily will feel reassured and more open to specialist referral and early treatment.
She may say: “That makes sense. I’ll do the tests and see what the specialist says.”
She may ask about lifestyle changes she can implement alongside medical treatment.

If the candidate is vague or dismissive:

Emily may feel lost and hesitant to start treatment.
She may become defensive about medication use and insist on avoiding drug therapy.
She may say: “So, do I just wait and see? What if I get worse?”

Key Takeaways for the Candidate

Take a structured history, identifying symptoms suggestive of inflammatory arthritis.
Order appropriate investigations, including RF, anti-CCP, ESR/CRP, and X-rays of the hands and feet.
Provide a structured management plan, including NSAIDs for symptom relief, early DMARD initiation, and lifestyle advice.
Ensure timely referral to a rheumatologist to prevent joint damage and disability.
Address patient concerns about medication, side effects, and long-term outcomes.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including onset, progression, joint involvement, functional impact, and systemic symptoms.

The competent candidate should:

Obtain a detailed symptom history, including:
- Duration and progression of joint pain (6 months, worsening).
- Pattern of joint involvement (symmetrical, small joints of hands/wrists, knees).
- Morning stiffness duration (>1 hour, improves with movement).
- Presence of swelling, warmth, and functional limitations.
- Systemic symptoms (fatigue, low-grade fevers, weight loss).
Explore risk factors and family history:
- Mother had rheumatoid arthritis.
- No personal or family history of psoriasis or inflammatory bowel disease.
Assess impact on daily life and work function.
Screen for red flags:
- Rapidly progressive symptoms, significant weight loss, or neurological deficits.

Task 2: Conduct a clinical assessment to determine inflammatory vs. non-inflammatory arthritis and need for investigations.

The competent candidate should:

Perform a focused musculoskeletal examination:
- Inspect for swelling, warmth, and deformities in small joints of the hands and knees.
- Assess range of motion and grip strength.
- Check for synovitis or joint effusions.
Order appropriate investigations to confirm inflammatory arthritis:
- Inflammatory markers (ESR, CRP).
- Autoantibody tests (rheumatoid factor, anti-CCP).
- Baseline X-rays of hands, wrists, and feet to assess for erosions.
- FBC and liver/renal function tests before considering treatment options.

Task 3: Provide a management plan, including symptom relief, specialist referral, and lifestyle modifications.

The competent candidate should:

Explain the likely diagnosis and need for early intervention.
Initiate symptom relief measures:
- NSAIDs or short-term corticosteroids for pain and inflammation.
- Hand exercises and splints if joint function is impacted.
Refer to a rheumatologist for confirmation and early disease-modifying therapy (DMARDs).
Discuss lifestyle modifications:
- Encourage regular movement and low-impact exercises (e.g., swimming, yoga).
- Consider referral to a physiotherapist for joint protection strategies.
- Assess and optimise bone health (calcium, vitamin D, weight-bearing exercise).

Task 4: Educate the patient on the nature of rheumatoid arthritis, expected prognosis, and treatment options.

The competent candidate should:

Explain rheumatoid arthritis in simple terms:
- “This is an autoimmune condition where your immune system attacks your joints, causing inflammation and pain.”
Provide reassurance and treatment goals:
- “Early treatment can prevent long-term joint damage and help you maintain function.”
Address concerns about medication:
- “DMARDs help control the disease, but we will monitor for side effects.”
Discuss the role of self-care:
- Importance of smoking cessation, maintaining a healthy weight, and managing stress.
Safety-netting and follow-up:
- “If you develop worsening symptoms, side effects from treatment, or new joint involvement, seek medical review.”

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, identifying hallmark features of inflammatory arthritis.
Performs a targeted musculoskeletal exam, looking for synovitis, swelling, and functional limitations.
Orders appropriate investigations, including RF, anti-CCP, ESR/CRP, and joint X-rays.
Provides a clear management plan, including symptom control, lifestyle advice, and rheumatology referral.
Educates the patient on the chronic nature of RA, the importance of early treatment, and long-term outcomes.

PITFALLS

Failing to differentiate inflammatory vs. mechanical arthritis, leading to delayed referral and treatment.
Not screening for systemic symptoms, missing potential extra-articular manifestations of RA.
Delaying specialist referral, increasing the risk of joint damage and disability.
Over-relying on NSAIDs for symptom relief, without considering early DMARD initiation.
Not addressing patient concerns about medication, leading to treatment hesitancy and poor adherence.

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 RA, investigations, and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured history, including symptom onset, progression, and functional impact.
2.2 Conducts a clinical assessment for inflammatory arthritis and identifies the need for further investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between inflammatory and non-inflammatory arthritis.
3.2 Recognises indications for specialist referral and early treatment initiation.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides an evidence-based treatment plan, including symptom relief and long-term management.
4.2 Advises on lifestyle modifications, physical activity, and occupational adaptations.

5. Preventive and Population Health

5.1 Assesses cardiovascular and osteoporosis risk in patients with chronic inflammatory conditions.
5.2 Encourages appropriate vaccinations and bone health management.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.1 Documents assessment, referral indications, and shared decision-making appropriately.

9. Managing Uncertainty

9.1 Recognises when to monitor, investigate further, or refer for specialist care.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies progressive disease requiring escalation of care.

Competency at Fellowship Level

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