CCE-CE-119

CASE INFORMATION

Case ID: KNE-001
Case Name: James Mitchell
Age: 52
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Code: L15 – Knee Symptom/Complaint

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to understand their concerns and expectations.
1.2 Demonstrates active listening and empathy.
1.4 Explains diagnosis and management in a patient-centred manner.
2. Clinical Information Gathering and Interpretation2.1 Takes a comprehensive history, including pain characteristics and functional limitations.
2.2 Identifies red flags requiring further investigation.
3. Diagnosis, Decision-Making and Reasoning3.1 Establishes a working diagnosis based on history and examination findings.
3.2 Differentiates between mechanical and inflammatory causes of knee pain.
4. Clinical Management and Therapeutic Reasoning4.1 Develops an evidence-based management plan.
4.5 Provides lifestyle, physiotherapy, and pharmacological recommendations.
4.7 Ensures shared decision-making regarding treatment options.
5. Preventive and Population Health5.1 Discusses weight management and joint protection strategies.
5.2 Provides advice on maintaining knee function and preventing further injury.
6. Professionalism6.2 Provides reassurance and addresses patient concerns sensitively.
7. General Practice Systems and Regulatory Requirements7.1 Documents history, investigations, and management plan appropriately.
9. Managing Uncertainty9.3 Recognises when imaging or specialist referral is indicated.
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies when knee pain may indicate underlying inflammatory, infectious, or neoplastic disease.

CASE FEATURES

  • Middle-aged male presenting with chronic knee pain and functional limitations.
  • Concern about long-term mobility and impact on work and hobbies.
  • Possible degenerative joint disease (osteoarthritis) but needs red flag assessment.
  • Patient hesitant about invasive treatments and keen on conservative management.
  • Need for shared decision-making regarding weight management, exercise, and treatment options.

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 Mitchell, a 52-year-old warehouse supervisor, presents with a six-month history of right knee pain. The pain has gradually worsened and is now affecting his ability to work and stay active.

He describes the pain as dull and aching, worse after prolonged standing or walking, and improving with rest. He has noticed mild swelling but no redness or warmth. The knee occasionally “locks” or “gives way”, making him nervous about walking on uneven surfaces.

His observations today are:

  • BP: 135/85 mmHg
  • HR: 72 bpm, regular
  • BMI: 31 kg/m²

PATIENT RECORD SUMMARY

Patient Details

Name: James Mitchell
Age: 52
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Occasional ibuprofen for pain relief

Past History

  • No history of inflammatory arthritis or metabolic bone disease
  • Previous knee injury (sprain) in early 30s

Social History

  • Occupation: Warehouse supervisor – physically demanding work
  • Alcohol: Occasional, weekends only
  • Smoking: Non-smoker
  • Exercise: Decreased due to knee pain
  • Weight: Overweight (BMI 31)

Family History

  • Father: Type 2 diabetes, osteoarthritis
  • Mother: Hypertension

Vaccination and Preventative Activities

  • Influenza vaccine – 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 SCRIPTS

Opening Line

“Doctor, my knee has been playing up for months now, and I’m worried it’s going to get worse.”

General Information

  • You are a 52-year-old warehouse supervisor who is on your feet most of the day.
  • The right knee pain started about six months ago and has gradually worsened.
  • The pain is dull and aching, mostly on the inside of the knee.
  • The pain is worse after prolonged standing, walking, or going up and down stairs.

Specific Information

(Only Provide If Asked)

Background Information

  • Rest usually relieves the pain, but it sometimes returns later in the day.
  • You have noticed mild swelling at times, but no redness or warmth.
  • Your knee occasionally locks or gives way, making you feel unsteady, particularly on uneven surfaces.
  • You feel a bit stiff in the morning for a few minutes, but it goes away quickly once you start moving.
  • You haven’t had any recent injuries, but you recall spraining this knee in your 30s while playing football.

Pain and Functional Limitations

  • The pain is mainly medial (inside the knee), sometimes spreading to the front.
  • It has not improved despite trying rest, elevation, and over-the-counter ibuprofen.
  • You avoid bending or squatting because it makes the knee feel unstable.
  • The pain makes it harder to do your job, which involves lifting and standing for long hours.
  • You have cut back on exercise because you’re worried about making it worse.
  • You have no clicking or popping sounds unless the knee locks.

Red Flags (None Present)

  • No sudden or severe swelling.
  • No redness or warmth.
  • No fever, chills, or recent infections.
  • No unexplained weight loss.
  • No severe night pain.

Lifestyle Factors

  • You used to go for long walks, but now you feel too uncomfortable.
  • You’ve gained a few kilos over the past couple of years and know you should exercise more.
  • You don’t smoke and drink only occasionally on weekends.
  • Your diet is average, but you often eat quick meals or takeaway due to your work schedule.
  • You feel like you don’t have time to manage this knee pain properly.

Psychological & Emotional State

  • You are frustrated because the knee pain is limiting your ability to stay active.
  • You feel worried about the future, especially whether this will affect your ability to keep working.
  • You don’t want surgery unless it’s the last option.
  • You are open to physiotherapy and lifestyle changes but unsure if they will help.
  • You are concerned that if this keeps getting worse, you might struggle to stay independent in later years.

Concerns & Expectations

  • You want to know what is causing the pain and if it will get worse over time.
  • You are worried that this might be arthritis, as your father had osteoarthritis in his knees.
  • You want to know what you can do to stop this from getting worse.
  • You wonder if you need an X-ray or MRI to check for damage.
  • You don’t want to rely on painkillers long-term.
  • You’re curious whether losing weight or exercising could help.

Possible Questions for the Candidate

  1. “Is this arthritis? My dad had bad knees at my age.”
  2. “Will I need a knee replacement?”
  3. “Do I need an X-ray or MRI to find out what’s going on?”
  4. “Can exercise make this worse?”
  5. “Would losing weight help my knee pain?”
  6. “What can I do to stop this from getting worse?”
  7. “Are there any treatments apart from painkillers?”
  8. “How long will this take to get better?”

How to Respond to the Candidate’s Explanations

If the Candidate Explains That the Pain Is Likely Osteoarthritis:

  • “So, does that mean my knee will keep getting worse?”
  • “Can arthritis be reversed, or do I just have to live with it?”

If the Candidate Recommends Lifestyle Changes:

  • “I know I should lose weight, but will that really help my knee?”
  • “I’m not sure what exercises are safe to do. Could I make this worse?”

If the Candidate Mentions Physiotherapy:

  • “How will physio help? Will I need to go every week?”
  • “Would I need special exercises, or can I just go for walks?”

If the Candidate Suggests Medications (e.g., NSAIDs or Paracetamol):

  • “I don’t want to rely on tablets. Is there anything else I can do?”
  • “Are there any side effects if I take these for a long time?”

If the Candidate Mentions Joint Injections or Surgery:

  • “I’ve heard about cortisone injections. Do they actually work?”
  • “I really don’t want surgery. Can I avoid that?”

Role-Playing Tips for the Candidate Assessment

  • You are engaged but concerned. You are looking for clear answers and practical solutions.
  • You don’t want surgery unless necessary. If surgery is mentioned, ask about alternatives.
  • If the candidate dismisses your concerns, push back. Ask, “So this isn’t something serious? How do you know?”
  • If the candidate focuses only on weight loss, show doubt. Say, “Will that actually work, or do I need something stronger?”
  • If the candidate doesn’t explain things well, ask for more details. For example, “What exactly happens to my knee with arthritis?”

Final Line (If the Candidate Handles the Case Well)

“Thanks, Doctor. I feel a bit better knowing this isn’t something too serious. I’ll give those exercises a go and look into physio. If things don’t improve, I’ll come back for a follow-up.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including pain characteristics, functional limitations, and red flag symptoms.

The competent candidate should:

  • Engage the patient in a patient-centred discussion to establish their concerns and expectations.
  • Use open-ended questions to explore:
    • Onset, duration, and progression of knee pain.
    • Location and nature of pain (e.g., medial, lateral, anterior; dull vs sharp).
    • Aggravating and relieving factors (e.g., standing, walking, rest, activity).
    • Presence of swelling, instability, locking, or giving way.
    • Morning stiffness and its duration (to differentiate inflammatory vs mechanical causes).
  • Screen for red flags that may indicate serious pathology:
    • Sudden onset severe pain or swelling (suggesting trauma, infection, or crystal arthropathy).
    • Persistent night pain or unintentional weight loss (suggesting malignancy).
    • Fever, redness, or warmth (suggesting septic arthritis).
    • Acute locking (suggesting meniscal tear).
  • Identify functional limitations affecting work, daily activities, and exercise.
  • Review past knee injuries or surgeries.
  • Obtain a medical history, including osteoarthritis, rheumatoid arthritis, gout, and metabolic disorders.
  • Discuss lifestyle factors, including weight, physical activity, and occupation-related strain.

Task 2: Discuss your differential diagnosis and outline an initial management plan.

The competent candidate should:

  • Explain that the most likely diagnosis is osteoarthritis, given:
    • Age >50.
    • Gradual onset of symptoms.
    • Pain worsened by activity and relieved by rest.
    • Mild morning stiffness (<30 minutes).
  • Differentiate from other causes of knee pain:
    • Meniscal tear – history of trauma or twisting injury, locking, or clicking.
    • Patellofemoral pain syndrome – anterior knee pain, aggravated by squatting or stairs.
    • Bursitis – localised swelling and tenderness over bursae.
    • Inflammatory arthritis – prolonged morning stiffness, symmetrical joint involvement.
  • Explain the initial management plan, which includes:
    • Lifestyle modifications – weight loss, low-impact exercise (e.g., swimming, cycling).
    • Physiotherapy referral – strengthening quadriceps, improving joint stability.
    • Pain relief – paracetamol, NSAIDs (if appropriate).
    • Joint protection strategies – knee supports, footwear modifications.
    • Investigations if indicated – X-ray if atypical features or persistent symptoms.

Task 3: Address the patient’s concerns about long-term mobility, work, and pain management.

The competent candidate should:

  • Acknowledge the patient’s concern about worsening mobility and work impact.
  • Reassure that early intervention and joint protection strategies can slow progression.
  • Explain that osteoarthritis is a chronic condition but can be well-managed with lifestyle and medical treatments.
  • Discuss workplace modifications (e.g., using knee braces, adjusting standing time).
  • Explain that exercise is beneficial and does not “wear out” the knee.
  • Address concerns about surgery:
    • Knee replacement is considered only for severe cases unresponsive to conservative management.
    • Many patients do well with non-surgical interventions.
  • Provide written resources and arrange follow-up to assess symptom progression.

Task 4: Develop a comprehensive management plan, including investigations, physiotherapy, lifestyle modifications, and pharmacological options as appropriate.

The competent candidate should:

  • Non-pharmacological interventions:
    • Weight loss – as little as 5% body weight loss can improve symptoms.
    • Exercise therapy – physiotherapy for muscle strengthening.
    • Activity modification – avoiding excessive strain on the knee.
    • Assistive devices – knee braces, walking aids if needed.
  • Pharmacological options:
    • Paracetamol as first-line.
    • Topical NSAIDs for localised pain.
    • Oral NSAIDs (if no contraindications – consider PPI if required).
    • Intra-articular corticosteroid injections for persistent symptoms.
  • Imaging and referral considerations:
    • X-ray if symptoms persist or worsen despite conservative management.
    • Consider rheumatology referral if inflammatory arthritis suspected.
    • Consider orthopaedic referral for patients with severe pain and functional impairment despite treatment.
  • Arrange follow-up in 4-6 weeks to review symptom progression and response to treatment.

SUMMARY OF A COMPETENT ANSWER

  • Takes a thorough history, identifying pain characteristics, functional impact, and red flags.
  • Establishes a working diagnosis based on clinical reasoning.
  • Differentiates between mechanical and inflammatory causes of knee pain.
  • Provides a structured management plan, including lifestyle, physiotherapy, and pharmacological interventions.
  • Addresses patient concerns about mobility, work, and long-term joint health.
  • Uses shared decision-making to tailor treatment to patient preferences.
  • Provides clear safety-netting and follow-up plans.

PITFALLS

  • Failing to assess red flags (e.g., night pain, fever, swelling, trauma).
  • Over-investigating without clinical justification (e.g., ordering MRI without red flags).
  • Dismissing the patient’s concerns about mobility and work impact.
  • Neglecting lifestyle advice, particularly weight loss and exercise.
  • Relying solely on medications without addressing physiotherapy and self-management strategies.
  • Failing to consider alternative diagnoses (e.g., meniscal tear, bursitis, inflammatory arthritis).
  • Not arranging follow-up, missing the opportunity to reassess symptoms and adjust treatment.

REFERENCES

MARKING

Each competency area is rated 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 Engages the patient to understand their concerns and expectations.
1.2 Demonstrates active listening and empathy.
1.4 Explains diagnosis and management in a patient-centred manner.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history, including pain characteristics and functional limitations.
2.2 Identifies red flags requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Establishes a working diagnosis based on history and examination findings.
3.2 Differentiates between mechanical and inflammatory causes of knee pain.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.5 Provides lifestyle, physiotherapy, and pharmacological recommendations.
4.7 Ensures shared decision-making regarding treatment options.

Competency at Fellowship Level

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