CASE INFORMATION

Case ID: CCE-2025-FT01
Case Name: Michael Thompson
Age: 52
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L98 (Foot/Toe Symptom/Complaint)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
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, expectations of healthcare, and the full impact of their illness experience on their lives. 1.4 Communicates effectively in routine and difficult situations.
2. Clinical Information Gathering and Interpretation	2.1 Gathers and interprets relevant clinical information systematically. 2.2 Identifies risk factors affecting foot health.
3. Diagnosis, Decision-Making, and Reasoning	3.1 Develops a patient-centred problem list. 3.2 Differentiates between common foot conditions and urgent concerns.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan. 4.2 Provides appropriate referral and follow-up when necessary.
5. Preventive and Population Health	5.1 Provides education on foot health, footwear, and prevention of complications.
6. Professionalism	6.1 Demonstrates patient-centred care and shared decision-making.
7. General Practice Systems and Regulatory Requirements	7.1 Documents patient concerns and management appropriately.
9. Managing Uncertainty	9.1 Recognises red flags requiring referral.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and manages complications such as diabetic foot ulcers or infections.

CASE FEATURES

Possible differential diagnoses: cellulitis, diabetic foot ulcer, gout, osteomyelitis, or trauma-related injury.
Middle-aged male with foot pain and swelling.
History of type 2 diabetes.
Recent minor foot trauma (stepped on something, but no immediate wound).
Concerns about an infection, redness, and difficulty walking.
Potential for underlying peripheral neuropathy or vascular disease.

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

Michael Thompson, a 52-year-old man with type 2 diabetes, presents to your clinic with a painful, swollen right foot. He reports that he stepped on something sharp two weeks ago but didn’t think much of it at the time. Over the past five days, the area has become increasingly red, warm, and swollen, and he is now finding it difficult to walk.

His main concern is: “Doctor, do I need antibiotics? I’m worried about my foot getting worse.”

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Thompson
Age: 52
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies.

Medications

Metformin 1000 mg BD
Atorvastatin 20 mg OD
Ramipril 5 mg OD

Past History

Type 2 Diabetes Mellitus (diagnosed 8 years ago)
Hypertension
Hyperlipidaemia

Social History

Works as a truck driver (long hours sitting).

Family History

Father had diabetes and peripheral vascular disease.

Smoking

Current smoker (10/day).

Alcohol

Moderate alcohol use (socially).

Vaccination and Preventative Activities

Last foot check: 1 year ago.
Flu vaccine up to date.
Last HbA1c: 8.2% (3 months ago).

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 foot has been getting worse, and I’m worried I might have an infection. Do I need antibiotics?”

General Information

(Freely Given If Asked Open-Ended Questions)

You are Michael Thompson, a 52-year-old truck driver who works long hours sitting.
You have type 2 diabetes, high blood pressure, and high cholesterol.
You don’t check your feet daily, and the last time a doctor checked them was a year ago.

Specific Information

(Only Revealed If Directly Asked)

Background Information

Your blood sugar control has been a bit off lately, but you’re not sure why.
You smoke 10 cigarettes a day but don’t think it affects your health.
You drink 3-4 beers on weekends but wouldn’t call yourself a heavy drinker.
You live with your wife, and she has been nagging you to see the doctor.

Presenting Complaint – Foot Pain and Swelling

You stepped on something sharp two weeks ago, but there was no bleeding, just a bit of soreness.
For the past 5 days, your right foot has been red, swollen, and a bit painful.
The pain is dull and throbbing, worse when you put pressure on it.
You haven’t had a fever, but you feel more tired than usual.
You haven’t noticed any pus or discharge.
You have been wearing the same pair of work boots for years.

Diabetes and Neuropathy

You often feel tingling or numbness in both feet, which has been getting worse over the past 6 months.
You don’t regularly check your feet, since you never thought it was necessary.
Your blood sugar levels have been higher than usual, but you don’t know the exact numbers.

Smoking and Lifestyle

You smoke 10 cigarettes a day.
You know smoking is bad, but say:
“I know I should quit, but I’ve been smoking for years. It helps with stress.”
You sit for long hours while driving and don’t exercise much.
Your diet is “not great”, but you try to cut down on sugar.

Family History and Concerns

Your father had diabetes and had to have part of his foot amputated.
You are worried this could happen to you, even though you don’t want to admit it.
You’ve seen pictures of “diabetic feet” getting worse, which has scared you a little.
You don’t want to stop working, as you can’t afford time off.

Patient Concerns and Emotional Cues

1. Worried About Infection and Amputation

“Doctor, do I need antibiotics? Is this an infection?”
“Is this something serious? I heard that diabetics can lose their feet.”
“Could this be gangrene?”

2. Hesitant About Lifestyle Changes

“I know smoking isn’t great, but it’s hard to quit.”
“I don’t really check my feet much. Do I really need to?”
“I’m always on the road, so it’s tough to eat healthy.”

3. Concerns About Work and Finances

“I can’t afford to stop working. Will this get better on its own?”
“I don’t want to go to the hospital. Can I just take some medicine and rest?”

Emotional and Physical Behaviour During the Consultation

You are a bit anxious but trying to downplay the situation.
You seem reluctant to take time off work and hesitant about lifestyle changes.
You occasionally rub your foot as if uncomfortable.
If the doctor mentions your smoking, you may cross your arms and become a little defensive.
If the doctor reassures you, you relax slightly but still seem uncertain.

Questions You Might Ask the Doctor

“Do I need antibiotics or something stronger?”
“Is this just a normal infection, or something worse?”
“Will this heal on its own?”
“What can I do to stop this from happening again?”
“Should I be worried about losing my foot?”
“Do I need to see a specialist for this?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient regarding his foot swelling and pain.

The competent candidate should:

Use open-ended questions to explore the onset, duration, and progression of the foot swelling and pain.
Ask about precipitating events (e.g., injury, infection, new footwear).
Assess red flags such as fever, systemic symptoms, spreading redness, or pus.
Evaluate for diabetic complications (neuropathy, ulcers, delayed healing).
Ask about self-care and past medical history, including diabetes control, medications, smoking, and lifestyle factors.
Use an empathetic approach to explore patient concerns about amputation and infection.

Task 2: Explain to the patient your differential diagnosis and reasoning.

The competent candidate should:

Provide a structured differential diagnosis, including:
- Diabetic foot infection (cellulitis, abscess, osteomyelitis).
- Peripheral vascular disease (poor circulation, delayed healing).
- Neuropathy-related injury (unnoticed trauma due to loss of sensation).
- Gout or inflammatory arthritis (if history suggests acute joint involvement).
Explain risk factors, particularly poor diabetes control and smoking.
Address patient concerns in simple, non-alarmist language.
Reassure and explain the next steps for investigation and management.

Task 3: Outline your management plan, including investigations and treatment.

The competent candidate should:

Order investigations:
- Blood tests (FBC, CRP, HbA1c, renal function, inflammatory markers).
- Wound swab or culture if signs of infection.
- Doppler ultrasound if concerns about peripheral arterial disease.
- X-ray if concerns about osteomyelitis.
Start empiric treatment:
- If infection is suspected, start oral antibiotics (e.g., flucloxacillin, cephalexin).
- Advise rest, elevation, and proper wound care.
- If severe infection or concern for deep tissue involvement, refer for hospital admission.
Address lifestyle factors:
- Reinforce the importance of foot care and daily foot inspections.
- Provide smoking cessation advice and referral.
- Offer diabetes education and consider referral to a diabetes educator or podiatrist.

SUMMARY OF A COMPETENT ANSWER

Takes a thorough history, covering foot symptoms, diabetes control, and lifestyle factors.
Explains differential diagnoses in a clear and non-frightening way.
Orders appropriate investigations (blood tests, imaging, Doppler if needed).
Implements an urgent management plan with wound care, antibiotics, and referral if required.
Addresses modifiable risk factors, including smoking, poor footwear, and diabetes control.
Uses an empathetic approach to acknowledge the patient’s fears and concerns.

PITFALLS

Failing to explore diabetes history and foot care routine.
Not considering urgent referral if there are signs of deep infection or vascular compromise.
Overlooking neuropathy and vascular risk factors, leading to a missed diagnosis of peripheral arterial disease.
Providing too much technical jargon, causing confusion or anxiety.
Ignoring the patient’s fear of amputation or not providing reassurance and education.

REFERENCES

MARKING

Each competency area is assessed on the following scale:

☐ 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 person 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 Takes a structured history, identifying red flags and risk factors.
2.2 Uses appropriate investigations to guide diagnosis.

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulates an appropriate differential diagnosis.
3.2 Explains findings in a way that addresses patient concerns.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides safe and effective management for diabetic foot complications.
4.2 Considers non-pharmacological interventions (e.g., foot care education).

5. Preventive and Population Health

5.1 Identifies preventable risk factors and provides appropriate interventions.

6. Professionalism

6.1 Demonstrates compassion and empathy when discussing the patient’s fears.

7. General Practice Systems and Regulatory Requirements

7.1 Recognises when referral to specialists (podiatrist, vascular surgeon, diabetes educator) is necessary.

8. Procedural Skills

8.1 Knows when to perform a diabetic foot assessment, including monofilament testing.

9. Managing Uncertainty

9.1 Recognises when further investigations are needed to rule out serious conditions.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies potentially limb-threatening complications and acts promptly.

Competency at Fellowship Level

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