CASE INFORMATION

Case ID: CCE-CE-012
Case Name: John Richards
Age: 62
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S18 (Wound/Injury Skin), T90 (Hypertension), T89 (Type 2 Diabetes Mellitus), A04 (Fatigue)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their concerns and expectations 1.2 Uses active listening and empathy to explore the patient’s illness experience 1.5 Provides clear and sensitive explanations of wound management and healing
2. Clinical Information Gathering and Interpretation	2.1 Takes a thorough history to assess wound cause, risk factors, and healing barriers 2.2 Identifies red flags for infection, delayed healing, or vascular compromise 2.3 Orders and interprets appropriate investigations for wound assessment
3. Diagnosis, Decision-Making and Reasoning	3.1 Recognises clinical features suggestive of wound infection, chronicity, or underlying disease 3.3 Considers and rules out alternative diagnoses (e.g., vascular insufficiency, pressure injury)
4. Clinical Management and Therapeutic Reasoning	4.2 Provides appropriate wound care, dressing selection, and treatment 4.4 Arranges specialist referral if indicated (e.g., vascular, endocrinology, wound care clinic)
5. Preventive and Population Health	5.2 Provides education on wound prevention, skin care, and diabetes control
6. Professionalism	6.2 Demonstrates sensitivity in discussing chronic disease and wound healing implications
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate follow-up and continuity of care for wound management
9. Managing Uncertainty	9.1 Addresses patient concerns about delayed healing and risk of complications
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and initiates management for complications of chronic wounds (e.g., infection, osteomyelitis, gangrene)

CASE FEATURES

Doesn’t check his feet regularly and wears tight shoes.
62-year-old man presenting with a chronic non-healing wound on his lower leg.
Diabetic with poor blood sugar control, hypertension, and obesity.
Developed a small ulcer two months ago after a minor scratch.
Concerned about persistent pain, redness, and slow healing.
Worried about amputation due to family history of diabetic complications.

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

John Richards, a 62-year-old retired truck driver, presents to your general practice with a chronic wound on his right lower leg that has not healed for two months.

He initially scraped his leg on a chair at home. He cleaned it himself, but it has not fully healed, and now there is redness and oozing. He is worried about infection and potential amputation because his father lost a leg due to diabetes complications.

PATIENT RECORD SUMMARY

Patient Details

Name: John Richards
Age: 62
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Metformin 1g BD
Amlodipine 5mg daily
Atorvastatin 20mg daily

Past History

Type 2 Diabetes Mellitus (HbA1c 9.2%)
Hypertension
Obesity (BMI 32)

Social History

Retired truck driver with a sedentary lifestyle.
Smokes 10 cigarettes/day for the past 30 years.

Family History

Father had diabetes and lower limb amputation.
Mother had hypertension and cardiovascular disease.

Vaccination and Preventative Activities

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, this wound on my leg just won’t heal. It’s been two months now, and I’m worried it’s getting infected.”

General Information

(Can be shared freely if the candidate asks open-ended questions like “Tell me more about that.”)

You scraped your leg on a chair two months ago while at home.
At first, the wound was small, but it hasn’t healed properly and seems to be getting worse.
You cleaned it with water and a bandage, but it kept reopening when walking.

Specific Information

(Only Reveal When Asked Directly)

Background Information

You feel mild pain and tenderness around the wound, especially when standing or moving around for a long time.
You’ve noticed some clear or yellowish fluid coming from it, but you haven’t noticed a bad smell.
The surrounding skin looks red and swollen, and it feels warm to touch.
You’ve had no fevers or chills, but you feel more tired than usual.

Wound Characteristics

The wound is about 3 cm in size, located on your right shin.
It started as a minor scratch, but it hasn’t scabbed over or closed up properly.
You haven’t noticed pus, but you’re worried about infection.
You haven’t tried any medicated creams, just a basic dressing.
You sometimes feel numbness or tingling in your feet, especially at night.

Diabetes and Lifestyle Factors

You’ve had type 2 diabetes for 10 years, and your last HbA1c was 9.2%.
You take metformin, but you sometimes forget doses, especially on weekends.
You don’t check your feet regularly, and you’ve never seen a podiatrist.
You wear tight shoes and haven’t changed footwear despite mild foot discomfort.
Your diet includes takeaway food 2–3 times per week, and you rarely exercise.
You smoke 10 cigarettes per day and haven’t seriously tried to quit.
You sit for long periods at home and don’t elevate your legs much.

Concerns and Emotional State

You are worried about losing your leg, as your father had an amputation due to diabetes.
You feel frustrated because the wound should have healed by now.
You’re not sure if your diabetes is making it worse, but you suspect it might be a factor.
You feel guilty because you haven’t been managing your diabetes well.
You haven’t told your children about the wound, as you don’t want them to worry.

Concerns and Questions for the Candidate

(Ask these naturally during the consultation, especially when discussing diagnosis or management.)

“Why isn’t this healing? Am I going to lose my leg like my dad did?”
“Do I need antibiotics? Is this infected?”
“Should I be putting cream on it, or just leaving it to dry?”
“Is my diabetes making this worse? What can I do to help it heal?”
“Do I need to see a specialist for this? Should I go to hospital?”
“Would quitting smoking help, or is the damage already done?”
“How long will this take to heal? What if it doesn’t?”

Role-Playing Emotional Cues

(Act these out realistically to simulate a real patient encounter.)

Worry: Furrow your brow and look concerned when discussing infection and amputation.
Frustration: Shake your head or sigh when discussing slow healing and diabetes control.
Guilt: Look down or avoid eye contact when admitting to poor diabetes management.
Fear: Speak softly and hesitate when asking about amputation or long-term damage.
Relief (if reassured well): Sit up straighter, nod, and engage more in the conversation.

What You Are Expecting From the Doctor (Candidate)

To take your concerns seriously. You don’t want to be told it’s nothing—you need clear guidance.
To explain why it’s not healing. You suspect it’s related to your diabetes, but you want confirmation.
To tell you what to do next. Should you change dressings, take medication, or see a specialist?
To discuss long-term prevention. You don’t want this to happen again, but you need realistic advice.
To support you without judgement. You already feel guilty about not managing your diabetes—you need practical solutions, not blame.

Potential Curveballs

(Optional, if the Candidate Handles the Basics Well)

“I don’t have time for a specialist appointment. Can’t I just manage this at home?”
“I don’t like hospitals. Is there any way to avoid going if this gets worse?”
“If I change my diet now, will it actually make a difference?”
“I’ve heard hyperbaric oxygen therapy can heal wounds. Should I try that?”
“What if this keeps happening? Does this mean my diabetes is out of control?”

End of Consultation

(If the candidate provides a clear plan and reassurance, respond positively.)

“Okay, that makes sense. I just want this to heal properly and make sure it doesn’t get worse. I’ll follow what you’ve said and come back for the dressing change.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, exploring the patient’s wound, risk factors, and concerns.

The competent candidate should:

Use open-ended questions to assess onset, progression, and initial management of the wound.
Establish factors affecting healing, including diabetes control, smoking, footwear, and activity levels.
Identify red flag symptoms, such as worsening pain, increasing redness, foul-smelling discharge, or systemic symptoms (fever, chills).
Assess for neuropathy (tingling, numbness) and peripheral vascular disease (claudication, cold extremities, delayed capillary refill).
Explore the patient’s knowledge and concerns, including fears about amputation and infection.

Task 2: Identify red flags for serious complications such as infection, ischaemia, or neuropathy.

The competent candidate should:

Recognise signs of infection, including:
- Increasing pain, warmth, erythema, purulent discharge, malodour.
- Systemic signs (fever, rigors, malaise), suggesting deep or spreading infection.
Identify ischaemic signs, including:
- Pale, cold skin, absent pulses, delayed healing, pain at rest.
Assess for diabetic neuropathy, using:
- Loss of protective sensation, numbness, burning, or tingling.
Consider osteomyelitis, if:
- Persistent wound >4 weeks, exposed bone, or deep infection signs.

Task 3: Provide a structured wound management plan, including dressing selection, lifestyle advice, and referrals.

The competent candidate should:

Wound care:
- Cleanse with saline, apply appropriate dressing (moist healing environment).
- Avoid traditional antiseptics (e.g., hydrogen peroxide, iodine) unless treating infection.
Glycaemic control:
- Optimise diabetes management (adjust medication, diet, and exercise).
Lifestyle modifications:
- Encourage smoking cessation and refer to Quitline or pharmacotherapy if needed.
- Promote foot care, including regular foot checks and appropriate footwear.
Referrals and follow-up:
- Urgent vascular review if ischaemia is suspected.
- Wound clinic or podiatry referral for ongoing care.
- Follow-up within 1 week to reassess healing and infection status.

Task 4: Address the patient’s concerns regarding healing, complications, and long-term management.

The competent candidate should:

Reassure the patient that most wounds heal with proper care, while acknowledging his concerns about amputation.
Explain the role of diabetes in slow healing, and how improving blood sugar control can help.
Discuss the warning signs of infection or worsening circulation, advising immediate medical review if they occur.
Encourage regular foot care, including self-checks, podiatry visits, and protective footwear.

SUMMARY OF A COMPETENT ANSWER

Comprehensive history-taking, including wound characteristics, risk factors, and complications.
Recognition of red flags, such as infection, ischaemia, and neuropathy.
Structured wound care plan, including dressing selection, infection control, and referrals.
Patient-centred communication, addressing fears about amputation and poor healing.
Preventive strategies, including diabetes optimisation, smoking cessation, and foot care.

PITFALLS

Failing to recognise infection, leading to delayed antibiotic treatment.
Overlooking vascular insufficiency, missing urgent referral for revascularisation.
Inadequate patient education, not addressing diabetes control and foot care.
Inappropriate dressing selection, leading to delayed healing.
Not arranging timely follow-up, increasing risk of deterioration.

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 on their lives.
1.5 Provides clear and sensitive explanations of wound management and healing.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough history to assess wound cause, risk factors, and healing barriers.
2.2 Identifies red flags for infection, delayed healing, or vascular compromise.
2.3 Orders and interprets appropriate investigations for wound assessment.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises clinical features suggestive of wound infection, chronicity, or underlying disease.
3.3 Considers and rules out alternative diagnoses (e.g., vascular insufficiency, pressure injury).

4. Clinical Management and Therapeutic Reasoning

4.2 Provides appropriate wound care, dressing selection, and treatment.
4.4 Arranges specialist referral if indicated (e.g., vascular, endocrinology, wound care clinic).

5. Preventive and Population Health

5.2 Provides education on wound prevention, skin care, and diabetes control.

6. Professionalism

6.2 Demonstrates sensitivity in discussing chronic disease and wound healing implications.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate follow-up and continuity of care for wound management.

9. Managing Uncertainty

9.1 Addresses patient concerns about delayed healing and risk of complications.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and initiates management for complications of chronic wounds (e.g., infection, osteomyelitis, gangrene).

Competency at Fellowship Level

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