CCE-CE-105

CASE INFORMATION

Case ID: CCE-2025-13
Case Name: Michael Thompson
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L01 (Neck symptom/complaint)

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 and concerns.
1.4 Elicits the patient’s ideas, concerns, and expectations.
2. Clinical Information Gathering and Interpretation2.1 Takes a structured neck pain history, including red flags for serious conditions.
2.2 Identifies musculoskeletal, neurological, vascular, and systemic causes of neck pain.
2.3 Determines the need for further investigations (imaging, blood tests, referral).
3. Diagnosis, Decision-Making and Reasoning3.1 Recognises common and serious causes of neck pain.
3.3 Determines when urgent referral (e.g., cervical myelopathy, carotid dissection) is necessary.
4. Clinical Management and Therapeutic Reasoning4.1 Develops an appropriate management plan based on clinical findings.
4.3 Provides symptom control options (e.g., physiotherapy, analgesia, posture advice).
4.5 Refers to specialist care (neurology, rheumatology, orthopaedics) if indicated.
5. Preventive and Population Health5.2 Discusses ergonomic and lifestyle modifications for neck health.
6. Professionalism6.1 Ensures empathetic and professional communication regarding pain management.
7. General Practice Systems and Regulatory Requirements7.2 Follows appropriate guidelines for imaging and specialist referrals.
9. Managing Uncertainty9.1 Recognises when watchful waiting vs. urgent investigation is required.
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies red flag features requiring urgent intervention (e.g., infection, malignancy, neurological deficit).

CASE FEATURES

  • Middle-aged man presenting with subacute neck pain and stiffness.
  • Distinguishing between musculoskeletal, neurological, and vascular causes.
  • Ruling out serious conditions (e.g., cervical radiculopathy, carotid artery dissection, meningitis).
  • Discussing symptom management and ergonomic modifications.
  • Referring appropriately when needed.

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

Michael Thompson, a 45-year-old office worker, presents with a three-week history of neck pain and stiffness. He describes the pain as dull and aching, located mainly in the right side of his neck and upper shoulder. The pain worsens after long hours at his desk and is slightly relieved by stretching.

He is worried about something serious, as the pain has not improved, and he occasionally experiences numbness and tingling down his right arm.

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Thompson
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Paracetamol PRN for pain relief

Past History

  • Mild hypertension, well controlled with lifestyle measures
  • No previous neck or spine issues

Family History

  • No history of autoimmune disease, rheumatoid arthritis, or malignancy

Social History

  • Works full-time as an accountant, long hours at the computer.
  • Non-smoker, drinks alcohol occasionally (1–2 drinks per week).

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 neck has been hurting for the past few weeks, and I’m worried it might be something serious.”

General Information

You are Michael Thompson, a 45-year-old accountant. Over the past three weeks, you’ve noticed a dull, aching pain in the right side of your neck and upper shoulder. The pain started gradually and has worsened with time.

You spend long hours at your desk, often leaning forward while working on a computer. By the end of the day, your neck feels stiff and sore. You sometimes wake up with neck stiffness, and the pain is worse in the morning but improves slightly with movement.

Specific Information

(Revealed When Asked)

Background Information

You have occasional tingling down your right arm, which started a week ago. It feels like pins and needles running down the outside of your arm, but you can still use your arm normally. There is no weakness and no trouble gripping objects.

This pain is affecting your ability to concentrate at work. You feel uncomfortable by the afternoon, and sometimes you take breaks to stretch your neck or move around, which helps a little.

You are worried that this might be something serious, like a pinched nerve, arthritis, or even something like cancer.

Pain Characteristics:

  • Location: Right side of the neck and upper shoulder.
  • Nature: Dull ache, sometimes sharp when turning head too quickly.
  • Severity: 4–5/10 most of the time, but worse after sitting for long hours.
  • Aggravating factors: Prolonged sitting, looking down at screens, driving.
  • Relieving factors: Stretching, applying heat packs, taking breaks from the desk.
  • Radiation: Tingling down the right arm but no weakness or coordination issues.

Neurological Symptoms:

  • Occasional right-arm tingling, but no constant numbness, weakness, or loss of grip strength.
  • No trouble walking, no dizziness or balance issues.
  • No headaches, double vision, or slurred speech.

Medical History & Risk Factors:

  • No recent infections, fevers, or night sweats.
  • No history of trauma or accidents.
  • No unexplained weight loss.
  • No history of rheumatoid arthritis or autoimmune disease.
  • No history of cancer in the family.

Work and Lifestyle:

  • Full-time accountant, working 8–10 hours per day at a desk.
  • Sits with poor posture, sometimes slouching forward.
  • Minimal exercise, apart from occasional weekend walks.
  • Non-smoker, occasional alcohol (1–2 drinks per week).

Emotional Cues and Body Language

  • Concerned but not overly anxious.
  • Leans in attentively when the doctor explains things.
  • Frowns if the doctor suggests “waiting” without a clear plan.
  • Appears relieved if reassured with a structured treatment approach.

Patient Concerns and Questions

1. “Is this a pinched nerve or something worse?”

  • You are worried about nerve compression and want a clear answer.
  • If the doctor says it’s muscle-related, you ask:
    • “But what about the tingling in my arm? Doesn’t that mean nerve damage?”

2. “Do I need a scan?”

  • You feel like an MRI might be necessary.
  • If the doctor says it’s not needed, you ask:
    • “How can you be sure without a scan?”

3. “Will this get better, or do I need treatment?”

  • You want realistic expectations about recovery time.
  • If the doctor suggests watchful waiting, you ask:
    • “How long should I wait before getting another opinion?”

4. “Should I see a physio or a specialist?”

  • You expect advice on treatment options.
  • If physiotherapy is recommended, you ask:
    • “What will a physio do for me? Do I need to see a specialist instead?”

5. “Could this be something serious like arthritis or cancer?”

  • You are concerned about a more serious condition.
  • If the doctor reassures you, you ask:
    • “How do you know for sure?”

Possible Reactions Based on the Doctor’s Approach

If the doctor reassures you and provides a clear plan:

  • You feel relieved and open to trying physiotherapy and ergonomic changes.
  • You may say, “Okay, I’ll give the stretches and posture changes a try.”

If the doctor dismisses your concerns:

  • You push for more tests or a referral.
  • You might say, “I don’t want to just wait and see. What if it gets worse?”

If the doctor explains nerve irritation well:

  • You feel more confident in the diagnosis and ask about specific exercises.

If the doctor offers medication but no other plan:

  • You may say, “I’d rather fix the problem than just take painkillers.”

Your Expectations from This Consultation

  • You want to know if this is serious or just a muscle strain.
  • You expect practical advice on managing the pain.
  • You need to know if a scan or referral is necessary.
  • You want a clear recovery timeline and action plan.

End of Consultation Cues

  • If the doctor explains things clearly and provides a structured plan, you feel reassured and ready to make changes.
  • If the doctor brushes off your concerns, you push for further investigation.
  • If the doctor talks about posture, exercises, and when to follow up, you feel more confident in managing your symptoms.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including the nature of the neck pain, red flags, and contributing factors.

The competent candidate should:

  • Clarify the nature of the neck pain, including:
    • Onset, duration, and progression (acute vs. chronic, worsening or improving).
    • Location (specific side, radiating to shoulders, arms, or head).
    • Severity and impact on daily activities.
  • Assess aggravating and relieving factors, including:
    • Posture, work-related strain, recent physical activity, sleep position.
    • Pain relief with rest, stretching, or medication.
  • Screen for red flags, including:
    • Neurological symptoms (weakness, numbness, gait disturbance, incontinence).
    • Systemic symptoms (fever, weight loss, night sweats, history of malignancy).
    • Trauma history, infection risk (IV drug use, immunosuppression).
  • Explore patient concerns and expectations, including:
    • “What are you most worried this could be?”
    • “Are you concerned about needing a scan or specialist referral?”

Task 2: Formulate a differential diagnosis, distinguishing between mechanical, neurological, and systemic causes.

The competent candidate should:

  • Differentiate between common causes of neck pain:
    • Mechanical/musculoskeletal:
      • Cervical strain/postural pain (desk work, poor ergonomics).
      • Facet joint dysfunction (localised pain, worse with extension).
    • Neurological:
      • Cervical radiculopathy (pain radiating down arm, tingling, weakness).
      • Cervical myelopathy (bilateral symptoms, gait changes, bowel/bladder issues).
    • Serious/systemic conditions (red flags):
      • Carotid artery dissection (sudden onset pain, vision changes, stroke-like symptoms).
      • Meningitis (neck stiffness, fever, photophobia).
      • Malignancy, infection, autoimmune disease (persistent pain, night sweats, weight loss).

Task 3: Explain the likely diagnosis to the patient, addressing concerns empathetically.

The competent candidate should:

  • Acknowledge the patient’s concerns:
    • “I understand why you’re worried, especially with the tingling in your arm.”
  • Explain the likely diagnosis in simple terms:
    • “Your symptoms are most consistent with postural neck strain with mild nerve irritation.”
    • “This is common in people who spend long hours at a desk, and it usually improves with posture correction and physiotherapy.”
  • Reassure but provide clear guidance:
    • “There are no signs of a serious condition, such as a spinal cord issue or infection.”
    • “However, we will monitor your symptoms and act if they worsen.”
  • Encourage patient involvement:
    • “Would you like to discuss non-medication options first, or would you prefer something for symptom relief as well?”

Task 4: Develop a management plan, including symptom relief, ergonomic advice, and referral if needed.

The competent candidate should:

  • Short-term management:
    • Pain relief: Consider paracetamol, NSAIDs, or muscle relaxants if required.
    • Physiotherapy referral for manual therapy, strengthening, and postural correction.
    • Workplace modifications: Ergonomic desk setup, regular stretching breaks.
  • Safety-netting and follow-up:
    • “If you develop worsening numbness, weakness, or difficulty walking, return immediately.”
    • “Let’s follow up in 2–4 weeks to assess progress and consider imaging if no improvement.”
  • Referral considerations:
    • If progressive neurological symptoms develop, refer to neurology.
    • If pain persists despite conservative treatment, consider MRI and orthopaedic referral.

SUMMARY OF A COMPETENT ANSWER

  • Takes a structured history, ruling out red flags and assessing contributing factors.
  • Identifies a likely mechanical cause, while considering neurological and systemic differentials.
  • Explains the diagnosis in clear, patient-friendly terms, addressing concerns.
  • Provides a structured management plan, including symptom relief and ergonomic advice.
  • Discusses when to escalate care, ensuring appropriate follow-up.

PITFALLS

  • Failing to ask about red flag symptoms, missing a serious underlying condition.
  • Over-reassuring without addressing the patient’s concerns, leading to dissatisfaction.
  • Not providing clear ergonomic and lifestyle advice, limiting the effectiveness of conservative management.
  • Ordering imaging prematurely, without an indication for urgent investigation.
  • Not arranging follow-up, missing potential deterioration.

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 the neck pain and associated symptoms.
2.2 Identifies risk factors for serious spinal pathology.
2.3 Determines when further investigation or referral is needed.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises common and serious causes of neck pain.
3.3 Determines when urgent referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate management plan, including physiotherapy and ergonomic advice.
4.3 Provides symptom control options.
4.5 Refers to neurology or orthopaedics if indicated.

5. Preventive and Population Health

5.2 Discusses ergonomic and lifestyle modifications for neck health.

7. General Practice Systems and Regulatory Requirements

7.2 Follows appropriate guidelines for imaging and specialist referrals.

Competency at Fellowship Level

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