CCE-CE-096

CASE INFORMATION

Case ID: CCE-2025-04
Case Name: James Carter
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S77 (Skin Infection)

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Establishes rapport and engages with the patient empathetically.
1.2 Uses clear, patient-centred language to explore symptoms.
1.4 Elicits patient’s ideas, concerns, and expectations.
2. Clinical Information Gathering and Interpretation2.1 Takes a structured skin infection history.
2.2 Identifies risk factors (e.g., diabetes, immunosuppression, hygiene).
2.3 Determines need for further investigation (e.g., wound swab, blood tests).
3. Diagnosis, Decision-Making and Reasoning3.1 Recognises differentials for skin infections, including cellulitis, abscess, fungal infection.
3.3 Determines when escalation (e.g., IV antibiotics, referral) is required.
4. Clinical Management and Therapeutic Reasoning4.1 Develops an appropriate antibiotic and wound care plan.
4.3 Provides patient-centred education on infection management and prevention.
4.5 Escalates to hospital if signs of severe infection (e.g., systemic symptoms).
5. Preventive and Population Health5.2 Discusses skin hygiene, diabetes control, and infection prevention.
6. Professionalism6.1 Ensures empathetic and respectful communication.
7. General Practice Systems and Regulatory Requirements7.2 Follows appropriate antibiotic prescribing guidelines.
9. Managing Uncertainty9.1 Recognises when empirical treatment vs. further workup is required.
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies complicated infections requiring urgent intervention (e.g., necrotising fasciitis, septic arthritis).

CASE FEATURES

  • Middle-aged man presenting with a worsening skin infection.
  • Risk factors (e.g., diabetes, obesity, poor hygiene) influencing healing and recurrence.
  • Differentiation between bacterial, fungal, or other skin infections.
  • Antibiotic stewardship and wound care management.
  • Decision-making regarding outpatient vs. inpatient management.

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

James Carter, a 45-year-old delivery driver, presents with a painful, red, swollen area on his left lower leg, which started five days ago and has progressively worsened. He initially thought it was a mosquito bite, but it has become warm and tender, and the redness is spreading.

His wife is worried, as he had a similar infection last year, which required oral antibiotics. He has type 2 diabetes, and his blood sugar control is not ideal.

PATIENT RECORD SUMMARY

Patient Details

Name: James Carter
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Metformin 1g BD
  • Ramipril 5 mg OD

Past History

  • Type 2 Diabetes (diagnosed 7 years ago, suboptimal control – last HbA1c 8.9%)
  • Hypertension
  • Previous episode of cellulitis (12 months ago, treated with flucloxacillin)

Social History

  • Works as a delivery driver, long hours on his feet
  • No smoking, drinks alcohol occasionally

Family History

  • Father had type 2 diabetes and cardiovascular disease

Smoking and Alcohol

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

Vaccination and Preventative Activities

  • Influenza and tetanus 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 leg has been red and swollen for a few days now, and it just keeps getting worse.”

General Information

You are James Carter, a 45-year-old delivery driver who has noticed a red, swollen, and painful area on your left lower leg over the past five days. Initially, you thought it was a mosquito bite or a minor skin irritation, but the redness has spread, and the area has become more tender and warm.

Specific Information

(Revealed When Asked)

Background Information

Your wife is worried because you had a similar skin infection last year, and she thinks you might need stronger antibiotics this time. You are starting to feel more tired than usual, and you’re concerned that this infection could be something serious.

You have type 2 diabetes, and while you know that infections can be worse for diabetics, you haven’t been checking your blood sugar as often as you should. You’ve been busy with work and haven’t been eating as well as you should, so you suspect your diabetes might not be under control.

Your leg feels hot and tender, but you haven’t noticed any pus or an open wound. You haven’t had any fevers or chills, but you are feeling a little run down. You’re worried about how this might affect your work, as you can’t afford to take too much time off.

Skin Infection Characteristics:

  • The redness started as a small patch and has spread gradually.
  • The area is warm, swollen, and tender, especially when touched.
  • No pus, abscess, or open wound is visible.
  • The skin feels tight, but there is no blistering or necrosis.
  • No history of recent scratches, insect bites, or injuries to the area.

Systemic Symptoms:

  • No fever, chills, nausea, or vomiting.
  • Feeling more fatigued than usual, but still able to go to work.
  • No dizziness or confusion.

Medical History and Risk Factors:

  • Type 2 diabetes (diagnosed 7 years ago, last HbA1c was 8.9%).
  • Hypertension, managed with medication.
  • Overweight (BMI 32).
  • Long hours at work, often standing for extended periods.
  • Wears work boots all day, but doesn’t always check his feet for cuts.
  • Sometimes forgets to wash his legs thoroughly after work.

Previous Skin Infection:

  • Had cellulitis last year, which was treated with oral flucloxacillin for 7 days.
  • The infection cleared up, but it took about two weeks to fully recover.

Emotional Cues and Body Language

  • Concerned but not panicked about the infection.
  • Mildly anxious about the possibility of needing hospital treatment.
  • Downplays symptoms at first, but becomes more engaged when the doctor explains things clearly.
  • Visibly more concerned if hospitalisation or a serious infection is mentioned.

Patient Concerns and Questions

1. “Do I need to go to hospital?”

  • You are worried about missing work and prefer to be treated as an outpatient if possible.
  • If the doctor suggests hospitalisation, you will ask if there are any other options.

2. “Do I need antibiotics?”

  • You suspect you might need them since your wife mentioned it.
  • You want to know what type of antibiotic is best and how long you’ll need to take them.

3. “Why do I keep getting these infections?”

  • You are frustrated that this has happened again.
  • If the doctor mentions diabetes as a risk factor, you will admit that your blood sugar has not been well controlled.

4. “How can I stop this from happening again?”

  • You want practical advice on preventing future infections.
  • If the doctor suggests better diabetes control, you will ask for specific steps to improve it.

5. “Will this affect my work?”

  • You are worried about needing time off.
  • You will ask if you can keep working while on antibiotics.

Possible Reactions Based on the Doctor’s Approach

If the doctor reassures you and explains things clearly:

  • You will feel relieved and trust the advice.
  • You will be open to taking antibiotics and making lifestyle changes.
  • You might say, “Okay, so I need to take these for a week, and then if it’s not better, I come back?”

If the doctor dismisses your concerns or is unclear:

  • You will push for more tests or a stronger treatment.
  • You might say, “But what if this gets worse? Shouldn’t we be doing more?”

If the doctor suggests hospitalisation without explanation:

  • You will resist the idea and ask, “Isn’t there another way? Can’t I try tablets first?”

If the doctor focuses only on diabetes without addressing the infection:

  • You will become frustrated and say, “I know my diabetes isn’t perfect, but right now, I need to fix this infection.”

Your Expectations from This Consultation

  • You want a clear diagnosis—is this cellulitis, or something worse?
  • You need to know if antibiotics are necessary and which ones to take.
  • You want to avoid hospitalisation if possible.
  • You want practical advice on preventing future infections.
  • You need to feel heard, not dismissed.

End of Consultation Cues

  • If the doctor provides clear reassurance and explains things well, you accept the plan and feel relieved.
  • If the doctor brushes off your concerns, you push for stronger treatment or further tests.
  • If the doctor recommends lifestyle changes, you are open to making improvements if they feel realistic and achievable.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including details of the skin infection, risk factors, and systemic symptoms.

The competent candidate should:

  • Elicit a structured history of the infection, including:
    • Onset and progression (worsening vs. improving).
    • Location, size, and spread of the affected area.
    • Associated symptoms (pain, warmth, swelling, pus, fever, systemic symptoms).
    • Previous similar episodes and response to treatment.
  • Assess systemic symptoms and red flags, such as:
    • Fever, chills, rigors (suggesting systemic infection).
    • Rapidly spreading redness, necrosis, or severe pain (concern for necrotising fasciitis).
    • Lymphangitic streaking or proximal lymphadenopathy.
  • Explore predisposing factors, including:
    • Diabetes and glycaemic control.
    • Obesity, hygiene, occupational exposure (e.g., prolonged standing, sweating, minor traumas).
    • Recurrent infections and history of antibiotic use.
  • Identify possible sources of infection, including:
    • Skin trauma, insect bites, tinea, or chronic wounds.
    • Foot infections (common in diabetics).
  • Review current medications, especially:
    • Steroids or immunosuppressants.
    • Previous antibiotic use and resistance concerns.

Task 2: Formulate a differential diagnosis, considering bacterial, fungal, and other potential causes.

The competent candidate should:

  • Differentiate between bacterial, fungal, and other skin infections:
    • Bacterial:
      • Cellulitis – Diffuse erythema, warmth, tenderness, no pus.
      • Abscess – Fluctuant, tender, pus-filled lesion.
      • Erysipelas – Well-demarcated erythema, more superficial.
      • Necrotising fasciitis – Severe pain out of proportion, rapid progression, systemic symptoms.
    • Fungal:
      • Tinea corporis – Annular, scaly border, itchy.
      • Intertrigo – Moist, red patches in skin folds.
    • Other:
      • Venous stasis dermatitis – Chronic swelling, haemosiderin staining.
      • Contact dermatitis – History of new irritants, itchy rash.
      • Gout or septic arthritis – If overlying a joint.
  • Consider systemic causes contributing to infection, including:
    • Diabetes-related skin infections.
    • Immunosuppression (HIV, chemotherapy, chronic steroid use).
  • Determine when urgent referral is needed (e.g., suspected necrotising fasciitis, septic shock).

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

The competent candidate should:

  • Explain the likely diagnosis:
    • “Your symptoms are most consistent with cellulitis, a bacterial skin infection that can develop when bacteria enter through small cracks or breaks in the skin.”
  • Address patient concerns:
    • “Although the redness has spread, you do not have signs of severe infection, such as fever or severe pain.”
    • “Your diabetes may be making you more prone to these infections.”
  • Reassure while setting expectations:
    • “With the right antibiotics and wound care, this should improve in about 7–10 days.”
    • “You do not currently need hospital treatment, but if your symptoms worsen, we may need to reassess.”
  • Educate on warning signs that require urgent review:
    • Rapidly worsening redness or pain.
    • Development of fever, chills, or dizziness.
    • Blistering, dark skin changes, or spreading infection.

Task 4: Develop a safe and effective management plan, including antibiotic use, wound care, and follow-up.

The competent candidate should:

  • Initiate appropriate antibiotic therapy based on local guidelines:
    • Mild-moderate cellulitis: Oral flucloxacillin 500mg QID for 7 days.
    • Penicillin allergy: Cephalexin or clindamycin.
    • Severe or worsening cases: Consider IV therapy (e.g., benzylpenicillin, flucloxacillin).
  • Advise on wound care and symptom management:
    • Elevate the affected leg to reduce swelling.
    • Apply cool compresses to reduce discomfort.
    • Pain relief with paracetamol or NSAIDs if no contraindications.
  • Optimise diabetes management to aid healing:
    • “Good blood sugar control will help your body fight infections more effectively.”
  • Provide safety-netting advice:
    • “If your symptoms do not start improving in 48 hours, or if they worsen, return for review.”
  • Follow up in 2–3 days to ensure response to treatment.

SUMMARY OF A COMPETENT ANSWER

  • Takes a structured history, identifying risk factors and red flags.
  • Considers a broad differential, distinguishing between bacterial, fungal, and other causes.
  • Provides a clear and patient-centred explanation, addressing concerns about severity.
  • Develops an appropriate antibiotic and wound care plan.
  • Provides practical prevention advice, including diabetes optimisation.
  • Uses safety-netting strategies, ensuring follow-up and escalation if needed.

PITFALLS

  • Failing to assess systemic symptoms, missing signs of severe infection.
  • Overlooking diabetes as a risk factor, missing an opportunity for preventive care.
  • Prescribing inappropriate antibiotics, not considering local guidelines or resistance patterns.
  • Not educating the patient on warning signs, leading to delayed presentation for deterioration.
  • Neglecting preventive strategies, increasing the risk of recurrence.
  • Over-reliance on antibiotics without addressing wound care and other supportive measures.

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 skin infection history.
2.2 Identifies risk factors, including diabetes and poor glycaemic control.
2.3 Determines need for further investigation or escalation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises differentials, including bacterial and fungal causes.
3.3 Determines when referral or IV antibiotics are necessary.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate antibiotic and wound care plan.
4.3 Provides patient-centred education on infection management.
4.5 Escalates care if severe infection is suspected.

5. Preventive and Population Health

5.2 Provides education on diabetes control and skin hygiene.

7. General Practice Systems and Regulatory Requirements

7.2 Prescribes antibiotics according to guidelines.

Competency at Fellowship Level

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