CASE INFORMATION

Case ID: AIDK-001
Case Name: Daniel Hughes
Age: 28
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Code: L90 – Sprain/Strain of Knee

COMPETENCY OUTCOMES

Competency Domain	Competency Element
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 mechanism of injury, symptoms, 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 ligamentous, meniscal, and other knee injuries.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan. 4.5 Provides conservative and surgical referral recommendations where appropriate. 4.7 Uses shared decision-making to address patient concerns.
5. Preventive and Population Health	5.1 Provides education on knee injury prevention and rehabilitation strategies. 5.2 Identifies modifiable risk factors to prevent recurrent knee injuries.
6. Professionalism	6.2 Provides reassurance and addresses patient concerns sensitively.
7. General Practice Systems and Regulatory Requirements	7.1 Documents history, examination findings, and management plan appropriately.
8. Procedural Skills	8.1 Identifies when aspiration or immobilisation may be required.
9. Managing Uncertainty	9.3 Recognises when imaging or specialist referral is indicated.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies when an acute knee injury may require urgent orthopaedic referral.

CASE FEATURES

Young male presenting with acute knee injury after a sporting incident.
Significant pain and instability, raising concern for ligament or meniscal injury.
Patient concerned about long-term knee function and return to sport.
Requires discussion on diagnosis, imaging, rehabilitation, and possible surgical intervention.

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:

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

Daniel Hughes, a 28-year-old accountant and amateur soccer player, presents with acute right knee pain and swelling after an injury during a weekend soccer match. He describes attempting to change direction quickly, after which he felt a “pop” in his knee and collapsed to the ground. He was unable to continue playing and had to be helped off the field.

His observations today are:

BP: 118/75 mmHg
HR: 68 bpm, regular
Temp: 36.9°C
RR: 14 breaths/min
Oxygen saturation: 99% on room air

PATIENT RECORD SUMMARY

Patient Details

Name: Daniel Hughes
Age: 28
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular

Past History

No previous knee injuries
No history of inflammatory arthritis

Social History

Occupation: Accountant – desk-based job
Smoking: Non-smoker
Alcohol: Occasionally socially

Family History

Father: Hypertension
Mother: No significant conditions

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, I hurt my knee playing soccer on the weekend. I heard a pop, and now it’s swollen and painful. I can’t put much weight on it.”

General Information

You are a 28-year-old accountant and play soccer twice a week for an amateur team.
During a game two days ago, you were changing direction quickly when you suddenly felt a pop in your right knee and collapsed to the ground.
You were unable to continue playing and needed help getting off the field.
Over the next few hours, your knee swelled up significantly, and it has been stiff and painful since then.

Specific Information

(Only Provide If Asked)

Background Information

You can walk short distances but feel unstable and weak when putting weight on the knee.
You have been icing, resting, and elevating your knee, which has helped slightly.
You haven’t taken any painkillers but are considering trying ibuprofen.
You are worried about whether this is a serious injury and if you need a scan or surgery.

Symptoms and Red Flags

The pain is mainly around the front and inner side of the knee.
The knee feels unstable, as though it might give way.
You cannot fully straighten the knee, and bending it beyond 90 degrees is painful.
You have no numbness or tingling in your leg or foot.
You haven’t noticed any redness or fever.
You have no history of knee problems before this injury.
You haven’t had any previous knee surgeries.

Lifestyle and Functional Impact

You work as an accountant, so you spend most of your time sitting at a desk.
You play soccer twice a week and do some gym work on other days.
You are very active and want to return to sport as soon as possible.
You don’t smoke, and you drink alcohol socially on weekends.
You are worried that this might mean a long time away from sport or a permanent issue with your knee.

Concerns & Expectations

You are worried that you have torn a ligament and that this will need surgery.
You want to know if you need an MRI or if this can be diagnosed without one.
You want to avoid surgery if possible but want to ensure your knee heals properly.
You are worried about how long it will take to recover and when you can return to sport.

Possible Questions for the Candidate

“Do you think I’ve torn a ligament?”
“Do I need an MRI, or can you tell what’s wrong without one?”
“How long will it take to recover?”
“Will I be able to play soccer again?”
“Will I need surgery?”
“Should I be wearing a brace or using crutches?”
“What can I do to help it heal faster?”
“Would physiotherapy help, or should I just rest it?”

How to Respond to the Candidate’s Explanations

If the Candidate Explains That This Might Be an ACL or Meniscus Injury:

“So does that mean I definitely need surgery?”
“How can you tell if it’s the ACL or something else?”

If the Candidate Suggests an MRI Might Be Needed:

“Is an MRI necessary, or can we just treat it without one?”
“Would an X-ray be useful instead?”

If the Candidate Recommends Conservative Management First:

“So do I just wait and see, or should I start rehab straight away?”
“Would a knee brace help?”

If the Candidate Suggests Seeing a Physiotherapist:

“When should I start physio?”
“Can I do any exercises on my own?”

If the Candidate Mentions Surgery as a Possibility:

“What would the surgery involve?”
“Would I be able to play sport again after surgery?”

Role-Playing Tips for the Candidate Assessment

You are concerned but not panicked. You want clear answers about your injury and recovery time.
You are very motivated to return to sport. If the candidate only suggests rest, push back by asking about rehab and exercises.
You don’t want unnecessary treatment. If the candidate suggests an MRI or surgery, ask “Is that really necessary?”
If the candidate dismisses your concerns, push back. Ask “How do you know for sure what’s wrong?”
If the candidate does not mention physiotherapy, ask about it. “Would physio help, or do I just need to rest?”

Final Line (If the Candidate Handles the Case Well)

“Thanks, Doctor. I feel a bit more reassured now. I’ll try the exercises you suggested, and I’ll follow up if it’s not improving.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including mechanism of injury, symptoms, and functional limitations.

The competent candidate should:

Engage the patient with open-ended questions to establish the sequence of events leading to the injury.
Take a detailed history, including:
- Mechanism of injury – pivoting, twisting, direct trauma.
- Immediate symptoms – pain, swelling, instability, or a “pop” sensation.
- Progression of symptoms – increasing swelling, stiffness, or difficulty weight-bearing.
- Current limitations – difficulty walking, locking, or giving way.
Identify red flags for severe injury, such as:
- Inability to bear weight at all.
- Visible deformity or severe swelling.
- Numbness, tingling, or vascular compromise.
Assess patient’s concerns, including return to sport and need for imaging or surgery.

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

The competent candidate should:

Explain the likely diagnosis based on the history:
- Anterior cruciate ligament (ACL) injury – common with a “pop” sound, instability, and rapid swelling.
- Meniscal tear – locking, clicking, or difficulty extending the knee.
- Medial collateral ligament (MCL) sprain – pain on the inner side of the knee.
- Patellar dislocation – feeling of the knee “shifting” with spontaneous reduction.
Discuss why an X-ray is not immediately necessary, unless:
- Suspected fracture based on Ottawa Knee Rules (age >55, tenderness at patella, fibular head, inability to bear weight).
Explain initial management (RICE principles):
- Rest – avoid weight-bearing.
- Ice – apply for 15-20 minutes every few hours.
- Compression – knee brace for stability.
- Elevation – to reduce swelling.
Prescribe simple analgesia (paracetamol ± NSAIDs) for pain relief.
Advise early physiotherapy referral to improve mobility and strength.
Arrange follow-up within a week to reassess the knee and determine if imaging (MRI) or specialist referral is needed.

Task 3: Address the patient’s concerns about severity, imaging, and long-term outcomes.

The competent candidate should:

Acknowledge the patient’s anxiety about a potential ligament tear.
Explain that ACL and meniscus injuries require further assessment, but not all require surgery.
Clarify the role of imaging:
- MRI is useful for soft tissue assessment but may not change initial management.
- X-ray is only needed if a fracture is suspected.
Discuss return to sport timelines:
- Minor sprains: 2-6 weeks with rehab.
- Meniscal injury without locking: up to 3 months.
- ACL tear (if surgery needed): 9-12 months for full recovery.
Provide clear safety-netting advice, including signs that require urgent reassessment (e.g., worsening pain, increasing instability).

Task 4: Develop a comprehensive management plan, including investigations, physiotherapy, and referral options.

The competent candidate should:

Initial management (first-line treatment):
- RICE principles – rest, ice, compression, elevation.
- NSAIDs or paracetamol for pain control.
- Knee brace or crutches if weight-bearing is difficult.
Referral considerations:
- Physiotherapy for early mobilisation and strengthening.
- Sports physician or orthopaedic review if instability persists.
- MRI referral if symptoms suggest an ACL tear, meniscus tear, or significant structural injury.
Education on rehabilitation:
- Gradual return to activity with physiotherapy guidance.
- Strengthening exercises to prevent future injuries.
- Proper warm-ups and stretching before sports.
Follow-up in 1-2 weeks to assess progress and determine need for further intervention.

SUMMARY OF A COMPETENT ANSWER

Takes a detailed history, focusing on the mechanism of injury and functional limitations.
Establishes a differential diagnosis, differentiating between ligamentous and meniscal injuries.
Provides an evidence-based management plan, incorporating conservative care and timely referral.
Addresses patient concerns regarding severity, imaging, and return to sport.
Explains the role of physiotherapy, ensuring a structured rehabilitation plan.
Uses shared decision-making to guide investigations and potential specialist referral.

PITFALLS

Failing to assess red flags, such as vascular compromise or inability to bear weight.
Over-relying on imaging instead of clinical assessment.
Not explaining conservative management adequately, leading to patient uncertainty.
Neglecting to discuss physiotherapy, which is key for recovery.
Not providing a clear return-to-sport timeline, leaving the patient with unrealistic expectations.
Failing to arrange appropriate follow-up, missing potential deterioration.

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 mechanism of injury, symptoms, 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 ligamentous, meniscal, and other knee injuries.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.5 Provides conservative and surgical referral recommendations where appropriate.
4.7 Uses shared decision-making to address patient concerns.

Competency at Fellowship Level

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