CCE-CE-095

CASE INFORMATION

Case ID: CCE-2025-03
Case Name: Mark Reynolds
Age: 67
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S18 (Contusion/Haematoma), B78 (Coagulation Disorder), K99 (Cardiovascular Disease – other)

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Establishes rapport and engages with the patient empathetically.
1.2 Uses clear, non-judgemental language to explore concerns about bruising.
1.4 Elicits patient’s ideas, concerns, and expectations.
2. Clinical Information Gathering and Interpretation2.1 Takes a detailed history of bruising, medical conditions, and medications.
2.2 Identifies potential causes, including trauma, medication side effects, or systemic disease.
2.3 Screens for bleeding disorders, malignancy, or elder abuse.
3. Diagnosis, Decision-Making and Reasoning3.1 Differentiates between benign vs. pathological causes of bruising.
3.3 Determines when further investigation (e.g., blood tests, imaging) is warranted.
4. Clinical Management and Therapeutic Reasoning4.1 Develops a safe and evidence-based management plan.
4.3 Provides patient-centred education on bruising causes and monitoring.
4.5 Refers for specialist assessment if indicated.
5. Preventive and Population Health5.2 Screens for falls risk, medication safety, and elder abuse.
6. Professionalism6.1 Ensures empathetic and respectful communication.
7. General Practice Systems and Regulatory Requirements7.2 Understands when to escalate concerns (e.g., haematology, safeguarding authorities).
9. Managing Uncertainty9.1 Recognises when observation vs. investigation is appropriate.
10. Identifying and Managing the Patient with Significant Illness10.1 Recognises potential serious underlying conditions (e.g., thrombocytopenia, malignancy).

CASE FEATURES

  • Elderly man presenting with unexplained bruising.
  • Assessment of medication side effects, bleeding disorders, and elder abuse.
  • Decision-making regarding investigations vs. reassurance.
  • Patient concerns about a serious underlying cause (e.g., cancer, blood disorder).
  • Preventive approach for falls and medication safety.

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

Mark Reynolds, a 67-year-old retired teacher, presents to your general practice clinic with multiple bruises on his arms and legs over the past month. He does not recall any significant trauma, though he occasionally bumps into furniture at home. His wife has noticed more bruises lately, which has made him worried about a blood disorder or cancer.

He has a history of atrial fibrillation, for which he takes apixaban. He is also on amlodipine for hypertension.

PATIENT RECORD SUMMARY

Patient Details

Name: Mark Reynolds
Age: 67
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Apixaban 5 mg BD (for atrial fibrillation)
  • Amlodipine 5 mg OD (for hypertension)

Past History

  • Atrial fibrillation (diagnosed 5 years ago)
  • Hypertension

Social History

  • Retired schoolteacher, lives with wife
  • No smoking, occasional alcohol use
  • No history of illicit drug use

Family History

  • Father had ischaemic stroke at 72
  • No known family history of bleeding disorders or malignancy

Smoking and Alcohol

  • Non-smoker
  • Drinks alcohol occasionally (1–2 drinks per week)

Vaccination and Preventative Activities

  • Routine vaccinations 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, my wife and I have noticed I’ve been getting more bruises lately, and I’m worried something serious might be going on.”

General Information

You are Mark Reynolds, a 67-year-old retired schoolteacher. Over the past four weeks, you have noticed increasing bruises on your arms and legs. You don’t recall any significant trauma, though you sometimes bump into furniture at home. Your wife has also noticed these bruises, and she is getting concerned.

Specific Information

(Revealed When Asked)

Background Information

You take apixaban for atrial fibrillation, and you know it can cause bruising, but this seems more than usual. You also take amlodipine for high blood pressure. You are worried about a serious medical condition, such as cancer or a blood disorder, as you read online that unexplained bruising could be a sign of leukaemia.

You have not had nosebleeds, gum bleeding, blood in urine, or prolonged bleeding from cuts. You also haven’t experienced any major weight loss, night sweats, or prolonged fevers. However, you do feel slightly unsteady on your feet at times, though you haven’t had any major falls.

You haven’t spoken to a doctor about this yet, but your wife has insisted you come in today.

Bruising Characteristics:

  • The bruises appear mainly on your arms and legs, particularly on your forearms and shins.
  • They start as dark purple, then turn yellow before fading over a few days.
  • They are not painful unless pressed firmly.
  • You haven’t had any large or spreading bruises.

Bleeding Symptoms:

  • No nosebleeds, gum bleeding, or prolonged bleeding from minor cuts.
  • No blood in urine or stools.
  • No excessive bleeding after shaving or brushing teeth.

Falls and Injury History:

  • You occasionally bump into furniture but don’t recall any major falls or injuries.
  • You sometimes feel slightly unsteady, particularly when getting up from a chair or walking in dim lighting.

Concerns and Expectations:

  • You are worried about a serious condition like cancer, blood disorders, or internal bleeding.
  • You are wondering if you need blood tests or imaging.
  • You are unsure if this means your medication is harming you.
  • You want to know how to prevent this from worsening.

Emotional Cues and Body Language

  • Anxious and slightly tense, especially when discussing serious conditions like cancer.
  • Looks at the doctor attentively, wanting clear answers.
  • Reassured if the doctor explains things well, but will ask follow-up questions if something is unclear.
  • Becomes more concerned if the doctor mentions needing tests without providing proper explanation.

Patient Concerns and Questions

1. “Why am I bruising so easily?”

  • You want a clear, logical explanation.
  • If the doctor says it’s due to medication, you might ask, “But I’ve been on it for years. Why is this happening now?”
  • If the doctor says it could be something else, you will ask, “So, what tests do I need?”

2. “Could this be cancer?”

  • You read online that leukaemia and other cancers can cause bruising.
  • You want to hear the doctor explicitly rule it out or explain why further tests are or aren’t needed.
  • If the doctor dismisses your concern too quickly, you might press further: “But you haven’t tested anything yet—how can you be sure?”

3. “Do I need blood tests or a scan?”

  • If the doctor says no testing is needed, you might feel unsatisfied and ask, “But what if we’re missing something?”
  • If the doctor suggests blood tests, you might ask, “What are we looking for?”

4. “Should I stop taking my blood thinner?”

  • You understand that apixaban can cause bruising, but you’re worried about whether you should stop it or switch to something else.
  • If the doctor advises against stopping, you might still ask, “But what if I keep getting more bruises?”

5. “How can I prevent this from getting worse?”

  • You are interested in practical strategies.
  • If the doctor only talks about monitoring, you might ask, “But is there anything I can do to make it better?”

Possible Reactions Based on the Doctor’s Approach

If the doctor reassures you and explains things clearly:

  • You feel relieved and trust the advice.
  • You will be open to monitoring the situation instead of demanding immediate tests.
  • You might say, “That makes sense. I’ll keep an eye on it and let you know if things change.”

If the doctor is dismissive or vague:

  • You become frustrated and push for more tests.
  • You might say, “But how do we know for sure? Shouldn’t we at least check my blood?”
  • If the doctor downplays your concern, you might insist, “I really think we should test for something—what if it’s serious?”

If the doctor suggests unnecessary tests without explanation:

  • You might feel more anxious and say, “Why do I need these tests? Are you worried about something?”

If the doctor recommends stopping apixaban without weighing the risks properly:

  • You become worried about having a stroke.
  • You might say, “But isn’t that dangerous for my heart?”

Your Expectations from This Consultation

  • You want a clear explanation for why you are bruising easily.
  • You need reassurance that nothing serious is being missed.
  • You want to know if tests are necessary and, if not, why.
  • You want practical advice on managing or reducing bruising.
  • You don’t want to be dismissed, but you also don’t want unnecessary tests.

End of Consultation Cues

  • If the doctor provides clear reassurance and explains things well, you accept the advice and feel relieved.
  • If the doctor brushes off your concerns, you push for more tests.
  • If the doctor suggests a review in a few weeks, you are happy with this plan if you feel heard and reassured.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including details of the bruising, medical history, and medication use.

The competent candidate should:

  • Elicit a detailed history of the bruising, including:
    • Onset, duration, and progression of the bruises.
    • Location and distribution (random vs. trauma-prone areas).
    • Associated symptoms (pain, swelling, warmth, fatigue, weight loss, fever).
    • Pattern of healing (does it resolve normally or persist longer than expected?).
  • Assess bleeding symptoms:
    • Nosebleeds, gum bleeding, prolonged bleeding from cuts.
    • Blood in urine or stools, excessive menstrual bleeding.
  • Review medication history, particularly:
    • Anticoagulants (e.g., apixaban, warfarin).
    • Antiplatelets (e.g., aspirin, clopidogrel).
    • Corticosteroids or NSAIDs (can cause skin thinning and bruising).
  • Assess falls risk and trauma history, including:
    • Recent falls or bumping into objects at home.
    • Symptoms of dizziness, postural hypotension, or weakness.
  • Screen for systemic causes, such as:
    • Haematological conditions (leukaemia, thrombocytopenia).
    • Liver disease (history of alcohol use, jaundice).
    • Nutritional deficiencies (vitamin C, vitamin K).
  • Assess for potential elder abuse, if history seems inconsistent.

Task 2: Formulate a differential diagnosis, distinguishing between benign and serious causes of bruising.

The competent candidate should:

  • Differentiate between benign and pathological causes of bruising:
    • Benign causes:
      • Medication-induced (apixaban, aspirin, corticosteroids).
      • Age-related skin fragility (senile purpura).
      • Minor trauma (especially in elderly patients).
    • Pathological causes:
      • Coagulopathies (thrombocytopenia, haemophilia, von Willebrand disease).
      • Haematological malignancies (leukaemia, multiple myeloma).
      • Liver disease (cirrhosis leading to clotting factor deficiencies).
      • Nutritional deficiencies (vitamin K, vitamin C, iron).
  • Consider red flags for serious pathology, such as:
    • Unexplained, recurrent, or spontaneous bruising.
    • Bruising in unusual sites (e.g., trunk, back, face).
    • Concurrent weight loss, fevers, or night sweats.
    • Signs of active bleeding (e.g., epistaxis, haematuria, melaena).

Task 3: Explain the likely diagnosis to the patient in a clear and patient-centred manner.

The competent candidate should:

  • Acknowledge the patient’s concern about serious conditions like cancer or a blood disorder.
  • Explain the most likely cause:
    • “Your bruising is most likely due to your blood thinner (apixaban), which can cause bruising even with minor trauma.”
    • “Your blood vessels may also be more fragile due to age-related changes.”
  • Address why a serious cause is unlikely:
    • “You do not have other signs of a bleeding disorder, such as persistent bleeding, nosebleeds, or blood in your urine or stools.”
    • “There is no history of concerning symptoms like weight loss or night sweats.”
  • Discuss when further testing is needed:
    • “To be thorough, we may check your full blood count, liver function, and clotting profile.”
    • “If the bruising worsens or new symptoms appear, we may refer you to a haematologist.”
  • Ensure patient understanding using teach-back methods.

Task 4: Develop a safe and effective management plan, including investigations and follow-up.

The competent candidate should:

  • Order appropriate investigations if indicated, such as:
    • Full blood count (FBC) – to check for thrombocytopenia or haematological malignancy.
    • Coagulation studies (PT/INR, aPTT) – to assess clotting function.
    • Liver function tests (LFTs) – to assess clotting factor production.
    • Iron studies, vitamin C, and vitamin K levels (if clinically indicated).
  • Optimise medication safety:
    • Do not stop apixaban without specialist advice.
    • Consider a review of anticoagulation need if bruising is frequent.
  • Provide advice on minimising bruising:
    • Be mindful of trauma prevention (fall-proof home, use of walking aids if needed).
    • Apply cold packs to new bruises.
    • Avoid excessive alcohol or NSAID use.
  • Discuss follow-up:
    • “If the bruising worsens or new symptoms develop, we should reassess.”
    • “A review in two to four weeks may help track any changes.”

SUMMARY OF A COMPETENT ANSWER

  • Takes a structured history, screening for red flags and medication effects.
  • Considers a broad differential, distinguishing between benign and serious causes.
  • Provides a clear and patient-centred explanation, addressing concerns about cancer.
  • Develops an appropriate management plan, including targeted investigations.
  • Provides practical advice on medication safety and bruising prevention.
  • Uses safety-netting strategies, ensuring follow-up if symptoms progress.

PITFALLS

  • Failing to ask about medication use, especially anticoagulants and steroids.
  • Not screening for red flags, such as weight loss, persistent bleeding, or systemic symptoms.
  • Overlooking falls risk, which could contribute to minor trauma.
  • Reassuring the patient too quickly without considering blood tests if indicated.
  • Stopping anticoagulation without a clear indication, risking thrombotic events.
  • Neglecting to screen for elder abuse, particularly in unexplained bruising.

REFERENCES

MARKING

Each competency area is assessed on the following scale from 0 to 3:

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency Areas Assessed

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, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history of bruising and associated symptoms.
2.2 Identifies potential medication-related and systemic causes.
2.3 Screens for bleeding disorders, malignancy, or elder abuse.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between benign vs. pathological bruising causes.
3.3 Determines when further investigation is warranted.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a safe, evidence-based management plan.
4.3 Provides patient-centred education on bruising causes.
4.5 Refers for specialist assessment if indicated.

5. Preventive and Population Health

5.2 Screens for falls risk, medication safety, and elder abuse.

7. General Practice Systems and Regulatory Requirements

7.2 Understands when to escalate concerns (e.g., haematology referral, safeguarding authorities).

Competency at Fellowship Level

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