CCE-CE-180

CASE INFORMATION

Case ID: HS-004
Case Name: Peter Lawson
Age: 67
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: L16 (Hip symptom/complaint)​

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to understand their concerns and expectations
1.2 Explains diagnosis and management clearly
1.5 Uses active listening and empathy
2. Clinical Information Gathering and Interpretation2.1 Gathers a thorough history of hip pain, functional impact, and risk factors
2.2 Identifies key physical examination findings to guide diagnosis
3. Diagnosis, Decision-Making and Reasoning3.1 Forms an appropriate differential diagnosis
3.2 Recognises red flag symptoms requiring urgent referral
4. Clinical Management and Therapeutic Reasoning4.2 Develops a patient-centred management plan, considering pharmacological and non-pharmacological options
4.3 Provides advice on lifestyle modifications to optimise hip function
5. Preventive and Population Health5.1 Identifies and addresses modifiable risk factors for osteoarthritis and falls prevention
5.3 Encourages appropriate exercise and weight management strategies
6. Professionalism6.2 Maintains patient confidentiality and builds a therapeutic relationship
7. General Practice Systems and Regulatory Requirements7.3 Provides appropriate documentation and referral where necessary
9. Managing Uncertainty9.1 Recognises when further imaging or specialist referral is required
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies red flag features suggestive of significant underlying pathology

CASE FEATURES

  • 67-year-old male presenting with gradual onset of right hip pain over the past 6 months.
  • Intermittent stiffness and pain, worse in the morning and after prolonged activity.
  • Difficulty walking long distances and recent mild limp.
  • No history of trauma, but progressive functional decline.
  • Concerned about needing a hip replacement.
  • Examination findings suggestive of osteoarthritis, but differential includes trochanteric bursitis, inflammatory arthritis, and occult fracture.
  • Discussion around conservative vs. surgical management and appropriate investigations.

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 a physical 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

Peter Lawson, a 67-year-old retired builder, presents with right hip pain that has been worsening over the past six months. He describes the pain as a deep, aching discomfort, mainly in the groin and outer hip. The pain is worst in the morning and after prolonged walking, but eases with movement.

He reports some stiffness, particularly when getting out of bed or standing after sitting for a long time. He limps slightly after long walks but denies any locking or giving way of the joint.

He is concerned that he may need a hip replacement, as his father had one at a similar age. He would prefer to delay surgery if possible.

PATIENT RECORD SUMMARY

Patient Details

  • Name: Peter Lawson
  • Age: 67
  • Gender: Male
  • Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Perindopril 5mg daily (for hypertension)

Past History

  • Hypertension (well controlled)
  • No previous joint conditions or fractures

Social History

  • Retired builder, previously very active
  • No smoking, drinks 2-3 standard drinks per week

Family History

  • Father had a hip replacement at 70 due to osteoarthritis
  • No family history of rheumatoid arthritis or osteoporosis

Vaccination and Preventive 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 hip has been aching for months now, and I’m starting to limp a little. I’m worried I might need a hip replacement.”

General Information

(Freely Shared if Asked Open-Ended Questions)

  • The hip pain started gradually about six months ago.
  • No specific injury triggered it, just a slow build-up of discomfort.
  • The pain is mainly in the groin and outer hip area.
  • Worst in the morning and after sitting for a long time.

Specific Information

(Only If Asked Targeted Questions)

Background Information

  • It eases slightly after some movement but worsens after long walks.
  • Recently noticed some stiffness, making it harder to put on socks and shoes.
  • Mild limp after long walks, but no significant balance issues.
  • No pain at rest or during the night.

Pain Characteristics and Functional Impact

  • The pain is dull and aching, not sharp or stabbing.
  • No clicking, catching, or locking in the joint.
  • No swelling, redness, or warmth over the hip.
  • No significant pain in the opposite hip or other joints.
  • Can still go up and down stairs, but it’s getting harder.
  • The pain is limiting long walks and hobbies like gardening.
  • Has not tried painkillers yet because he prefers to avoid medication.

Red Flag Symptoms (No Symptoms Present)

  • No recent trauma, falls, or sudden worsening of pain.
  • No unexplained weight loss, fevers, or night sweats.
  • No history of cancer, prolonged steroid use, or alcohol dependence.
  • No numbness, tingling, or weakness in the leg.

Medical History and Risk Factors

  • Mild hypertension, well controlled with perindopril.
  • No diabetes, osteoporosis, or inflammatory conditions like rheumatoid arthritis.
  • Father had a hip replacement at 70 due to osteoarthritis.
  • BMI of 29 – knows he could lose some weight but hasn’t been very active.

Concerns and Expectations

  • Worried about needing a hip replacement because of his father’s history.
  • Prefers to avoid surgery if possible and wants to know what he can do.
  • Interested in exercises or physiotherapy but unsure what would help.
  • Hasn’t had imaging yet but is wondering if an X-ray would show anything.
  • Not sure if he should keep walking or rest the hip more.

Emotional Cues & Reactions

  • Mildly anxious about long-term mobility but open to discussion.
  • More concerned if surgery is mentioned too early.
  • Relieved if given practical advice on pain relief and exercises.
  • Reassured if the doctor acknowledges his concerns and explains options clearly.

Questions the Patient Might Ask

  1. “Do you think I need a hip replacement?”
    • (If the doctor suggests surgery too quickly, he will become anxious.)
  2. “What can I do to stop this from getting worse?”
  3. “Will exercise make this better or worse?”
  4. “Should I get an X-ray? Will that tell us what’s wrong?”
  5. “What pain relief would you recommend?”
  6. “Is there anything I can do at home to help with this?”
  7. “How long can I wait before seeing a specialist?”

How to Play the Role

Opening Scene (First Few Minutes)

  • Appear mildly concerned but not in distress.
  • Speak in a calm and thoughtful tone, describing how the pain is affecting daily activities.
  • Make eye contact but occasionally rub the hip to indicate discomfort.
  • Lean slightly to one side to subtly show favouring the good hip.

If the Doctor Explores Symptoms and History Thoroughly:

  • Answer openly and provide details about functional limitations.
  • Express interest in conservative options like exercise and weight loss.

If the Doctor Dismisses the Pain or Provides Vague Advice:

  • Show mild frustration and say, “So do I just have to put up with this?”
  • Ask more pointed questions about imaging and treatment options.
  • Become more anxious if surgery is mentioned without discussing other options first.

If the Doctor Recommends Conservative Management:

  • React positively if explanations about weight loss, physiotherapy, and medication are clear.
  • Ask about what type of exercises are safe to do.

If the Doctor Mentions a Hip Replacement as a Future Possibility:

  • Look slightly uneasy and ask, “But how long can I delay that?”
  • Open to the idea if explained well, but prefers to try other options first.

Ending the Consultation (Final Reaction Depending on the Doctor’s Approach)

If the Doctor Provides a Clear Plan and Reassurance:

  • Nods in agreement and looks more relaxed.
  • Says, “That makes sense, I’ll try those exercises and see how it goes.”
  • Appreciates being involved in the decision-making.

If the Doctor Is Unclear or Dismissive:

  • Appears unsure and hesitant.
  • Says, “I guess I’ll just wait and see, but I was hoping for more guidance.”
  • May request imaging or a specialist referral sooner than necessary.

Key Features for the Examiner to Observe

  • How well the candidate takes a structured history, covering pain characteristics, functional limitations, and red flags.
  • Whether the candidate provides a logical differential diagnosis, considering osteoarthritis, trochanteric bursitis, occult fracture, avascular necrosis, and inflammatory arthritis.
  • Ability to discuss conservative management options, including exercise, physiotherapy, weight loss, and analgesia.
  • Clear communication of the role of imaging and specialist referral, avoiding unnecessary investigations.
  • Empathy and reassurance, particularly around the patient’s concern about hip replacement surgery.

Summary

This role-player script presents a realistic and clinically relevant case where the candidate must:

  1. Take a thorough history, assessing pain characteristics, functional impact, and risk factors.
  2. Consider key differential diagnoses, prioritising osteoarthritis while excluding serious conditions.
  3. Develop a patient-centred management plan, including conservative treatment and lifestyle modifications.
  4. Explain indications for imaging and referral, ensuring the patient feels informed and reassured.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a detailed history of the hip pain, including impact on function and quality of life.

The competent candidate should:

  • Elicit the key characteristics of the pain, including:
    • Onset (gradual or sudden).
    • Duration (how long it has been present).
    • Location (groin, lateral hip, buttock).
    • Nature and severity (aching, sharp, intermittent, constant).
    • Aggravating and relieving factors (activity, rest, morning stiffness, night pain).
  • Assess functional impact, including:
    • Difficulty with walking, climbing stairs, putting on socks/shoes.
    • Presence of limping or reliance on walking aids.
    • Any recent avoidance of physical activity.
  • Screen for red flag symptoms, including:
    • Rest pain or night pain.
    • Unintentional weight loss or fever.
    • History of cancer or prolonged steroid use (risk of avascular necrosis).
    • Neurological symptoms (numbness, weakness, saddle anaesthesia).
  • Explore medical and lifestyle history, including:
    • Previous joint issues or family history of osteoarthritis.
    • Body weight and activity levels.
    • Occupation and daily activities affected.

Task 2: Formulate an appropriate differential diagnosis, considering red flags.

The competent candidate should:

  • Consider common causes of hip pain, including:
    • Osteoarthritis (age-related degeneration, morning stiffness, gradual worsening).
    • Trochanteric bursitis (pain over lateral hip, worse with direct pressure).
    • Hip labral tear (locking, catching sensation, history of trauma).
    • Avascular necrosis (history of alcohol use, steroids, or trauma).
  • Identify red flag conditions, including:
    • Septic arthritis (acute, severe pain, fever, joint swelling).
    • Hip fracture (acute pain, inability to bear weight, history of osteoporosis).
    • Malignancy or metastases (history of cancer, night pain, weight loss).
  • Differentiate mechanical vs. inflammatory causes:
    • Mechanical pain (worsens with activity, relieved by rest).
    • Inflammatory arthritis (prolonged morning stiffness, multiple joint involvement).

Task 3: Discuss initial management options, including conservative and pharmacological measures.

The competent candidate should:

  • Provide a stepwise management approach, including:
    • Education and reassurance about hip pain and modifiable risk factors.
    • Lifestyle modifications, including weight management and regular low-impact exercise.
    • Physiotherapy referral for hip-strengthening exercises and gait training.
    • Pain management, using:
      • Paracetamol as first-line therapy.
      • NSAIDs (if no contraindications) for short-term relief.
      • Topical NSAIDs if systemic risks are present.
    • Walking aids (e.g., cane) if mobility is significantly affected.
    • Corticosteroid injections if symptoms persist despite conservative measures.
  • Address patient concerns about hip replacement, explaining that:
    • Surgery is usually considered when conservative treatments fail.
    • It is not always necessary in the early stages of osteoarthritis.
  • Encourage gradual return to activity, avoiding excessive load-bearing exercises.

Task 4: Outline indications for imaging and specialist referral.

The competent candidate should:

  • Order imaging if clinically indicated, including:
    • Hip X-ray (AP and lateral views) to assess joint space narrowing, osteophytes, fractures.
    • MRI or CT if concerns about soft tissue pathology (e.g., labral tear, avascular necrosis).
  • Refer to a specialist if the patient has:
    • Severe functional limitation despite conservative management.
    • Progressive pain not responding to first-line treatments.
    • Signs of inflammatory arthritis requiring rheumatology input.
    • Findings suggestive of malignancy or infection.
  • Provide safety netting and follow-up, ensuring:
    • The patient understands when to return if symptoms worsen.
    • The management plan is reviewed within 4-6 weeks.

SUMMARY OF A COMPETENT ANSWER

  • Thorough history-taking, covering pain characteristics, functional impact, and red flags.
  • Comprehensive differential diagnosis, including mechanical, inflammatory, and red flag causes.
  • Stepwise management plan, incorporating exercise, physiotherapy, and appropriate pain relief.
  • Clear communication about conservative vs. surgical options, addressing patient concerns about hip replacement.
  • Indications for imaging and referral, ensuring appropriate escalation of care.
  • Effective safety netting and follow-up planning.

PITFALLS

  • Failing to ask about red flag symptoms, missing serious conditions like septic arthritis or malignancy.
  • Overlooking functional impact, not assessing limitations in daily activities.
  • Prematurely recommending surgery, increasing patient anxiety.
  • Over-reliance on imaging, rather than clinical diagnosis and conservative management.
  • Neglecting non-pharmacological treatments, such as physiotherapy, weight loss, and exercise.
  • Lack of safety netting, failing to provide follow-up or escalation plans.

REFERENCES

MARKING

Each competency area is 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 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.
1.5 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers a thorough history of hip pain, functional impact, and risk factors.
2.2 Identifies key physical examination findings to guide diagnosis.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms an appropriate differential diagnosis.
3.2 Recognises red flag symptoms requiring urgent referral.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops a patient-centred management plan, considering pharmacological and non-pharmacological options.
4.3 Provides advice on lifestyle modifications to optimise hip function.

5. Preventive and Population Health

5.1 Identifies and addresses modifiable risk factors for osteoarthritis and falls prevention.
5.3 Encourages appropriate exercise and weight management strategies.

9. Managing Uncertainty

9.1 Recognises when further imaging or specialist referral is required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies red flag features suggestive of significant underlying pathology.

Competency at Fellowship Level

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