CASE INFORMATION

Case ID: SHO-009
Case Name: Mark Stevens
Age: 47 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L92 – Shoulder Symptom/Complaint

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand concerns, ideas, and expectations 1.2 Provides clear explanations tailored to the patient’s level of health literacy 1.4 Uses effective consultation techniques, including active listening and empathy
2. Clinical Information Gathering and Interpretation	2.1 Takes a focused history to explore symptom onset, aggravating factors, and functional limitations 2.2 Selects appropriate investigations based on clinical presentation
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis for shoulder pain 3.2 Identifies red flags requiring urgent intervention
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a safe and effective management plan 4.2 Provides advice on pharmacological and non-pharmacological management
5. Preventive and Population Health	5.1 Discusses ergonomic and lifestyle modifications to prevent recurrence
6. Professionalism	6.1 Maintains patient confidentiality and demonstrates ethical practice
7. General Practice Systems and Regulatory Requirements	7.1 Documents accurately and ensures appropriate follow-up
9. Managing Uncertainty	9.1 Provides reassurance and safety-netting when the diagnosis is unclear
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises features suggestive of a serious underlying condition requiring further assessment

CASE FEATURES

Middle-aged male presenting with progressive shoulder pain affecting daily activities.
Exploring mechanical, inflammatory, and neurological causes of shoulder pain.
Assessing functional limitations and red flags such as trauma, systemic illness, and neurological deficits.
Balancing conservative vs. interventional management options, including physiotherapy, medications, and imaging.
Addressing the patient’s concerns about work impact and long-term disability.

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

Mark Stevens, a 47-year-old warehouse worker, presents with right shoulder pain that has been worsening over the past three months. He describes it as a dull ache with occasional sharp pain when reaching overhead or lifting objects.

PATIENT RECORD SUMMARY

Patient Details

Name: Mark Stevens
Age: 47
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Occasional ibuprofen for shoulder pain

Past History

Mild hypertension, managed with lifestyle changes
No previous musculoskeletal injuries

Social History

Works as a warehouse employee, performing repetitive lifting and overhead reaching.

Family History

No family history of rheumatoid arthritis or significant musculoskeletal disorders

Smoking

Non-smoker

Alcohol

Drinks socially, 2-3 standard drinks per week

Vaccination and Preventative Activities

Up to date with vaccinations

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 right shoulder has been aching for months now, and it’s starting to affect my work. Do you think I’ve torn something?”

General Information

Your name is Mark Stevens, and you are 47 years old.
You work as a warehouse employee, where you lift heavy boxes and reach overhead frequently.
You are generally healthy, apart from mild hypertension, which you manage with lifestyle changes.
You enjoy playing tennis on weekends, but you haven’t played for the past month due to pain.
You live with your wife and two teenage children.

Specific Information

(Reveal only when asked directly)

Background Information

You first noticed mild discomfort in your right shoulder three months ago.
The pain has gradually worsened and is now affecting your work and daily activities.
You haven’t had a specific injury, but your job requires a lot of lifting and overhead movement.
The pain is mostly a dull ache, but there are sharp twinges when you lift, reach overhead, or move your arm in certain directions.
It is worse at night, and sometimes wakes you up from sleep when you roll onto your right side.

Pain Characteristics

The pain is located around the top and outer part of your right shoulder.
It sometimes radiates down the upper arm but does not go past the elbow.
The pain is not constant—it is worse with certain movements and improves with rest.
It is aggravated by lifting, reaching behind your back, or overhead tasks.
Resting the arm on your lap feels fine, but you struggle to reach for objects on a high shelf.

Functional Limitations

You struggle with overhead tasks, such as stacking shelves or lifting boxes at work.
Reaching behind your back to put on a jacket is becoming difficult.
You haven’t played tennis for a month because swinging the racquet is too painful.
You have been using ibuprofen occasionally, but it only helps a little.

Concerns and Expectations

You are worried about a rotator cuff tear and whether you will need surgery.
You are concerned about how long this will take to heal and whether you will need time off work.
You want to know if you need imaging (X-ray or MRI) to check for damage.
You want to understand how to manage the pain while continuing to work.
You are hoping for treatment options beyond just taking painkillers.

Red Flag Symptoms (Reveal only when asked directly)

No numbness, tingling, or weakness in the arm or hand.
No history of fevers, chills, weight loss, or recent infections.
No history of trauma, falls, or dislocations.
No night sweats or unexplained fatigue.

Emotional Cues & Body Language

You appear concerned but not panicked.
If the doctor seems uncertain or vague, you may press further:
- “Do I need an MRI to check if something is torn?”
If the doctor doesn’t mention physiotherapy, you may ask:
- “Are there any exercises that could help?”
If the doctor only prescribes pain relief, you may ask:
- “But will that actually fix the problem, or just cover up the pain?”
If the doctor explains things well, you will feel reassured and motivated to follow the treatment plan.

Questions for the Candidate

(Ask these naturally throughout the consultation.)

“Could this be a rotator cuff tear? Do I need an MRI?”
“Will I need surgery for this?”
“How can I keep working without making it worse?”
“What exercises or treatments can help me recover?”
“Should I stop playing tennis completely?”
“If this doesn’t improve, what are my options?”
“How long will this take to heal?”
“Would a cortisone injection help?”

Key Behaviours & Approach

You are worried about long-term damage and want clear answers.
If the doctor only prescribes medication, you will ask about other treatment options.
If the doctor doesn’t discuss imaging, you may ask about whether an X-ray or MRI is needed.
If the doctor suggests modifying activities, you may ask for specific strategies to manage work and daily life.
If the doctor explains things well, you will feel reassured and willing to try physiotherapy or other treatments.

Additional Context for the Role-Player

You are keen to recover quickly, as you don’t want to take time off work.
You are willing to try exercises or physiotherapy, but you need clear instructions.
You don’t want unnecessary scans or surgery, but you also don’t want to ignore a serious injury.
You are worried that this might keep getting worse if left untreated.
You prefer practical advice on managing pain and preventing further injury.

Role-Player Summary

This case assesses the candidate’s ability to:

Diagnose common causes of shoulder pain (e.g., rotator cuff tendinopathy, impingement syndrome, adhesive capsulitis).
Provide a structured management plan, including pain relief, physiotherapy, workplace modifications, and follow-up.
Address patient concerns about imaging, treatment options, and recovery time.
Ensure appropriate safety-netting, advising when to seek further medical review if symptoms worsen.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, considering possible causes and risk factors for shoulder pain.

The competent candidate should:

Elicit key symptom details, including onset, duration, location, severity, and aggravating/alleviating factors.
Assess functional impact, including limitations in movement, overhead activities, and work duties.
Screen for red flag symptoms, such as trauma, neurological deficits, systemic symptoms (fever, weight loss), or night pain.
Explore occupational and recreational activities, including repetitive lifting, sports, or work-related strain.
Review previous treatments, including medications, physiotherapy, and any imaging or prior injuries.
Address patient concerns, particularly regarding long-term disability, imaging, and need for surgery.

Task 2: Formulate a differential diagnosis and explain it to the patient.

The competent candidate should:

Explain the most likely diagnosis, such as rotator cuff tendinopathy or impingement syndrome, based on gradual onset and worsening with overhead movement.
Discuss other possible conditions, including:
- Rotator cuff tear – if weakness and loss of function are present.
- Frozen shoulder (adhesive capsulitis) – if there is progressive stiffness.
- Osteoarthritis of the shoulder – if there is pain with crepitus.
- Referred pain from the cervical spine – if symptoms extend past the elbow.
Explain why immediate imaging may not be required, as clinical assessment guides initial management.

Task 3: Address the patient’s concerns, including functional limitations, treatment options, and prognosis.

The competent candidate should:

Reassure the patient that most cases of shoulder pain improve with conservative management.
Explain that imaging (X-ray or MRI) is not always required initially, unless there are red flags or persistent symptoms despite treatment.
Discuss prognosis, noting that recovery can take weeks to months, depending on the severity and adherence to rehabilitation.
Provide strategies for modifying work activities, including avoiding heavy lifting and taking breaks during repetitive movements.
Address concerns about surgery, explaining that most shoulder conditions do not require surgery unless there is a significant tear or failure of conservative management.

Task 4: Develop an initial management plan, including pharmacological and non-pharmacological treatment options, lifestyle modifications, and follow-up.

The competent candidate should:

Recommend first-line pain relief, such as paracetamol and NSAIDs, unless contraindicated.
Prescribe physiotherapy to improve range of motion, strength, and posture.
Discuss home exercises, including gentle stretches and strengthening routines.
Modify work duties to reduce strain while maintaining function.
Reassess in 4-6 weeks, with consideration of imaging or referral if symptoms persist.
Provide safety-netting, advising the patient to return if pain worsens, weakness develops, or function deteriorates.

SUMMARY OF A COMPETENT ANSWER

Takes a thorough history, covering pain characteristics, functional limitations, and occupational risk factors.
Provides a clear differential diagnosis, explaining why rotator cuff tendinopathy is likely and when imaging is necessary.
Addresses patient concerns empathetically, particularly regarding work impact, prognosis, and need for surgery.
Develops an evidence-based treatment plan, including pain relief, physiotherapy, activity modifications, and follow-up.
Ensures safety-netting, advising the patient when to seek further review.

PITFALLS

Failing to assess for red flags, such as neurological symptoms, trauma, or systemic illness.
Over-relying on imaging, rather than using a clinical diagnosis to guide management.
Not addressing functional limitations, particularly work modifications and daily activity adjustments.
Focusing only on pain relief, without discussing physiotherapy and rehabilitation.
Providing vague follow-up advice, instead of a clear timeline for reassessment and escalation if needed.

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

1. Communication and Consultation Skills

1.1 Communication is appropriate to the patient’s concerns and sociocultural context.
1.2 Engages the patient to gather information about symptoms, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Elicits a comprehensive history, including risk factors and functional impact.
2.2 Orders appropriate investigations only if needed, avoiding unnecessary imaging.

3. Diagnosis, Decision-Making and Reasoning

3.1 Develops a structured differential diagnosis for shoulder pain.
3.2 Identifies red flags requiring urgent referral or further assessment.

4. Clinical Management and Therapeutic Reasoning

4.1 Formulates an evidence-based treatment plan, including physiotherapy and pain management.
4.2 Provides pharmacological and non-pharmacological treatment options, ensuring a patient-centred approach.

5. Preventive and Population Health

5.1 Discusses workplace and lifestyle modifications to prevent recurrence.

6. Professionalism

6.1 Maintains confidentiality and ethical decision-making.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures accurate documentation and appropriate follow-up.

9. Managing Uncertainty

9.1 Provides reassurance and safety-netting, ensuring the patient understands when to seek urgent care.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises features suggestive of serious pathology requiring escalation.

Competency at Fellowship Level

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