ℹ️ This is the case information for the doctor.
Name
John Anderson
Age
83 years
Address
42 Willow Crescent
Social history
• Lives alone in a ground-floor flat.
• key-safe; code is 2341.
Past history
• Osteoarthritis (knees and hands – left knee flares occasionally)
• Type 2 diabetes (diet/tablet controlled, stable HBA1c)
• Ischaemic heart disease (previous angina, well controlled)
• Varicose eczema (legs, mild/occasional topical steroids)
• Hypercholesterolaemia
• Hypertension
Investigation results
• Latest HbA1c: 53 mmol/mol
• eGFR: 63 ml/min/1.73m² (stable)
• Cholesterol: Last 4.2 mmol/L
• Recent BP: 138/86
• Recent bloods otherwise unremarkable
• No recent X-rays or joint aspiration
Medication
• Paracetamol 500mg 2 tablets QDS
• Aspirin 75mg daily
• Amlodipine 5mg daily
• Ramipril 2.5mg daily
• Atorvastatin 40mg daily
• Metformin 500mg TDS
• Recently stopped furosemide 20mg after 3 days for ankle swelling
Booking note
Telephone call to patient. Appointment booking reason: Painful knee.
ℹ️ This is the information for the person role playing the patient.
Name
John Anderson
Age
83 years
Address
42 Willow Crescent
Social history
• Lives alone in a ground-floor flat.
• key-safe; code is 2341.
Past history
• Osteoarthritis (knees and hands – left knee flares occasionally)
• Type 2 diabetes (diet/tablet controlled, stable HBA1c)
• Ischaemic heart disease (previous angina, well controlled)
• Varicose eczema (legs, mild/occasional topical steroids)
• Hypercholesterolaemia
• Hypertension
Medication
• Paracetamol 500mg 2 tablets QDS
• Aspirin 75mg daily
• Amlodipine 5mg daily
• Ramipril 2.5mg daily
• Atorvastatin 40mg daily
• Metformin 500mg TDS
• Recently stopped furosemide 20mg after 3 days for ankle swelling
"My knee’s just so sore, doctor. It’s really red and swollen. I can’t walk on it at all. I just didn’t know what to do."
• The pain started about 3 days ago, gradually got much worse.
• "It’s my left knee, it feels hot and looks swollen. I can hardly bend it."
• "I’ve needed to take more painkillers than usual, but they aren’t helping much."
• "I’ve felt a bit hot and sweaty at times and have had less appetite since it started."
Symptoms
• “I’ve just had a bit of a cold, nothing major. No cough or chest problems now.”
• "I’m still passing urine and can drink alright."
• No vomiting, no diarrhoea, breathing fine, not drowsy or confused.
• "The knee is much more painful than usual. I can’t remember it being like this even with my arthritis flares."
• "It’s red and I think a bit swollen compared to the other side."
• "I haven’t fallen or injured it."
• "I tried keeping the leg up and used a cool flannel, but it didn’t help much."
Impact
• "I used to get aches with my arthritis but it’s never been this bad, and I’m struggling to get to the toilet now."
Support
• "My daughter’s nearby and happy to help. He offered to bring me in, but I just can’t manage the car."
Ideas
• “Could this be an infection? Will I need to go to hospital?”
Concerns
• “I’m a bit worried about how I’ll manage if I can’t walk to the toilet – I live on my own and don’t want to be a nuisance to my daughter.”
Expectations
• “If it’s arthritis, could you give me something stronger for the pain?”
• “If you think I need to be seen, I'm happy for someone to visit—just not sure how I’d cope until tomorrow.”
• "If you think it’s safe to wait, my daughter can check in until someone comes."
Family history
• No family history of inflammatory arthritis or autoimmune disease.
• Sister died of heart disease in her 80s.
• Start the call sounding a bit weary and in distress but polite and grateful.
• Initially calm, but voice trembles slightly with pain during the first few minutes.
• Sighs or winces if asked to describe moving the leg.
• If doctor is empathetic, explains safety issues and why/when a visit can be arranged, you are understanding and not demanding.
• If the doctor seems dismissive or tells you to just wait till tomorrow without explanation, express more concern and ask if there is anything that can be done to make you safer at home.
• If explicitly advised to wait, will accept but ask for any advice to help manage at home and clarify when to seek urgent help (“what should I do if it gets worse?”).
• Express gratitude for any practical suggestions or arrangements.
• If a prescription (for pain relief) is offered, happy to accept and will ask if daughter can collect.
• If offered a clinician visit tomorrow, agreeable but wants to know what to look out for overnight.
• If the doctor proposes hospital admission, express willingness to go if it’s absolutely necessary, but concern about logistics and being alone.
ℹ️ To mark data gathering & diagnosis select from the descriptors below.
Positive descriptors
Negative descriptors
Data gathering was systematic and targeted ensuring patient safety.
• Begins with open questions to explore the onset, severity, and impact of knee pain, then uses focused closed questions to clarify chronology, previous episodes, current function, and associated symptoms.
• Ensures safety by systematically checking for red flags (e.g., systemic symptoms, inability to weight-bear, fever, confusion).
Data gathering was incomplete, lacking structure and focus.
• Does not clarify the change from baseline or gather a full symptom history (e.g. when pain was noticed, what makes it better/worse, degree of swelling/redness).
• Omits exploration of key safety issues such as the extent of immobility, falls risk, or impact on ability to manage at home.
Makes effective use of existing information and considers the wider context.
• Reviews and incorporates existing notes and medication history, highlighting new ramipril, recent furosemide, diabetes control (HbA1c), and previous osteoarthritis flares.
• Considers home circumstance (living alone, careline pendant, daughter nearby) and mobility status in decision making.
Fails to use the information provided or understand the wider context.
• Ignores or overlooks key background information such as recent medication changes, previous knee problems, or living arrangements.
• Fails to consider how being housebound, alone and newly immobile increases the risk of harm.
The presence or absence of relevant red flags was establihed.
• Asks directly about red flag symptoms: fever, rigors, confusion, loss of consciousness, inability to weight-bear, sepsis indicators, trauma.
• Screens for systemic illness and clinical instability (e.g., new confusion, dehydration, reduced oral intake, signs of spread).
Fails to assess key information necessary to determine risk.
• Does not ask about fever, confusion, new falls, inability to weight-bear, or local/systemic complications.
• Overlooks critical features suggestive of joint infection or acute systemic illness.
A working diagnosis was reached using a structured, evidence-based approach.
• Conducts a thorough history distinguishing between an acute osteoarthritis flare, septic arthritis, gout, or trauma.
• Uses age, symptom profile, and comorbidities to construct a logical differential diagnosis and next steps.
The evidence collected was inadequate to support the conclusions reached.
• Assumes diagnosis (e.g. ‘just arthritis’) without gathering data to out-rule other acute causes such as infection or inflammatory/infective flare.
• Misses opportunity to use epidemiology (e.g. rare for OA alone to cause fever or inability to walk in elderly).
Uses an understanding of probability based on prevalence, incidence, and natural history to aid decision-making.
• Recognises infection (e.g., septic arthritis, cellulitis) is more likely in this context than a simple OA flare (considering inability to weight-bear, fever, diabetes).
• Recognises risk of joint sepsis in vulnerable elderly patients.
Choice of diagnosis and/or investigations does not reflect disease likelihood.
• Dismisses possibility of infection, or does not consider high-risk features for septic arthritis.
• Over-relies on past history of OA and misses new, more serious pathology.
Makes effective use of collateral history and safety-netting information.
• Checks history for any acute functional deterioration, confusion, falls, change in behaviour, or increased care needs overnight.
• Clarifies what arrangements are in place (careline, support, daughter’s availability) and sets clear safety netting instructions.
Fails to involve collateral history or to plan safety-netting adequately.
• Does not check for acute cognitive/functional decline, or consider collateral information (from daughter/neighbour).
• Omits to set explicit criteria for when to seek urgent help or how to access support if the situation worsens.
ℹ️ To mark clinical management & medical complexity select from the descriptors below.
Positive descriptors
Negative descriptors
Offers management options that are safe and appropriate:
• Considers the possibility of septic arthritis or acute joint infection given the red, hot, swollen joint and recent fever, and arranges for prompt face-to-face assessment within the constraints available.
• Carefully weighs the risks of home management vs. urgent hospital admission, taking account of comorbidities, functional status, and social circumstances.
• Advises on interim pain relief, but recognises when stronger analgesia or antibiotics must wait for assessment.
Fails to provide appropriate and or safe management choices:
• Reassures the patient without assessing for serious causes such as septic arthritis or ignores the need for urgent in-person evaluation.
• Instructs the patient to simply wait or self-medicate with stronger painkillers without safety-netting or arranging follow up, putting him at risk.
Prescribes safely considering local and national guidance:
• Considers comorbidities (renal function, diabetes, age, polypharmacy), avoids NSAIDs due to cardiovascular and renal risks, and reviews current analgesia for optimisation.
• Recognises that antibiotics should only be initiated after assessment if infection is suspected, following guidelines.
Unsafe prescribing ignoring best practice:
• Offers NSAIDs or inappropriate analgesia without checking for contraindications.
• Prescribes antibiotics over the phone without a clear diagnosis or a plan for subsequent review.
Refers appropriately being mindful of resource:
• Explains the rationale for urgent home visit (or hospital admission if concerned for sepsis), using neighbourhood or community teams judiciously and prioritising based on clinical risk.
• Involves family to monitor the patient’s safety and escalate if needed, avoiding unnecessary A&E attendance unless clinically required.
Sends patients for specialist input unnecessarily:
• Refers indiscriminately to hospital without attempt to use appropriate local urgent visiting services or community support.
• Fails to involve support agencies or the family where appropriate before defaulting to hospital-based care.
Arranges appropriate follow up:
• Sets clear expectations about who will visit and when, and provides explicit safety-netting for signs of deterioration.
• Documents advice and informs practice/community team to ensure next steps are actioned.
Unclear or inadequate follow up:
• Omits plans for monitoring, review, or escalation, leaving patient without clear steps if condition changes.
• Safety-netting is vague or not provided.
Manages uncertainty, including that experienced by the patient:
• Acknowledges lack of direct assessment and risk of missing septic arthritis, explaining why urgent review is needed.
• Clearly explains signs/symptoms to monitor for and prepares the patient and daughter for next steps if the situation changes.
Struggles with uncertainty, leading to inconsistent decisions:
• Offers conflicting advice about seriousness of situation and does not explain the reasoning behind decisions.
• Leaves the patient anxious or confused about what to expect or when to worry.
Tailors management options responsively according to circumstances, priorities and preferences:
• Works with the patient to balance his wishes for staying at home with the need for safety.
• Adjusts management plan in response to the patient’s ability to manage at home, his own and his daughter’s willingness to monitor and escalate care, and the availability of visiting clinicians.
Management options fail to adequately consider patient preference and circumstance:
• Recommends rigid, inappropriate or unworkable solutions without considering home support, patient comfort, or logistical barriers.
• Fails to discuss or offer interim supportive measures in line with patient’s wihes.
ℹ️ To mark relating to others select from the descriptors below.
Positive descriptors
Negative descriptors
Shows ability to communicate in a person-centred way:
• Uses a warm and validating approach, acknowledging Mr Anderson’s significant pain, distress, and anxiety about the sudden functional decline.
• Adjusts explanations to take into account his age and current emotional state, ensuring language is plain and supportive.
• Responds to his worries about being “a nuisance” and reassures about accessing help.
Communication is doctor-centred and lacks empathy:
• Focuses on clinical assessment and management without showing understanding of the impact on Mr Anderson’s emotional wellbeing.
• Fails to acknowledge or address his distress, anxiety, or the seriousness of her social isolation.
Shows understanding of medical-legal principles and regulatory standards:
• Explains risks, benefits, and options clearly so Mr Anderson can make informed decisions about care.
• Checks understanding and assent before arranging a home visit or any changes in medication or care plans.
• Maintains confidentiality and explains how information will be shared with his daughter or support teams.
Fails to give appropriate regard to key legal aspects of consulting:
• Does not discuss consent for care or the need to share information with his family or the visiting team.
• Fails to explain risks/benefits of various management options or neglects to obtain agreement to the plan.
Explores the patient’s agenda, health beliefs and preferences:
• Asks what Mr Anderson thinks the problem could be (arthritis, infection) and explores his understanding of the symptoms.
• Asks about his management priorities, including preferences about admission or remaining at home. However also explains appropriate risks of staying at home versus admission.
• Engages with him to tailor the discussion to their concerns about pain/being alone.
Fails to recognise the patient’s agenda and impact of the problem:
• Does not ask about Mr Anderson’s ideas about the cause of symptoms or what he hopes will happen.
• Offers only generic advice or solutions without tailoring to his individual circumstances, fears, and priorities.
Recognises what matters to the patient and works collaboratively to enhance patient care:
• Negotiates a mutually agreed plan with Mr Anderson and that prioritises safety, pain relief, and timely review.
• Adjusts recommendations in response to expressed needs (“What matters to me is staying at home if possible”).
Fails to work with the patient to plan care:
• Makes decisions in isolation, failing to engage Mr Anderson or his daughter in planning.
• Does not adapt the care plan to his values, home circumstances, or preferences.
Demonstrates an empathic approach, and a willingness to help and care for the patient:
• Offers emotional support, acknowledges how frightening it is to lose independence, and reassures about short-term arrangements and ongoing review.
• Makes Mr Anderson feel cared for and listened to, not just processed as a “problem.”
Lacks empathy and fails to recognise emotional cues:
• Does not react to the patient’s distress or signs of fear about his health and independence.
• Ignores cues about anxiety or distress and fails to provide reassurance or support.
Checks the patient’s understanding of the consultation including any agreed plans:
• Summarises the agreed plan at the end of the call and explicitly checks Mr Anderson’s understanding.
• Asks him to demonstrate understanding clarifying when to call for help or what to expect from the visiting service.
• Offers additional support materials or written instructions if needed.
Does not seek to confirm understanding:
• Ends the call without summarising, or assuming that Mr Anderson has understood key details.
• Does not check if he knows when/help to seek or what the plan actually is.
ℹ️ Insights from the examiner
An 83-year-old man with acute, severe knee pain, fever, and significant immobility, phoning for help.
Being time efficient in this case requires careful listening followed by targeted questions so that you rapidly identify the key clinical issues and patient concerns. Some open question that might help you get off to a good start might be.
"Can you tell me what’s been happening with your knee since it started hurting?"
"What have you tried so far"
"How are you coping"
Short, simple sentences help the patient process your questions and keep the consultation focused.
It is important to pick up on the key areas for concern (fever/confusion/incontinence/unsteadiness/can’t get to the toilet).
Reference: RCGP SCA Toolkit - Data Gathering
This is a consultation where picking up on cues is important. John lives alone and is worried. Recognise and respond to verbal and emotional cues: the patient’s distress, worry about falling, fear of hospital, and reluctance to trouble his daughter.
Example: He might say
"I didn’t want to be a nuisance."
A good response might be:
"It’s perfectly reasonable to call if you’re struggling or worried—your safety comes first. How are you feeling about things at the moment?"
Rather than ignoring the cue, you can acknowledge and validate the issue showing empathy and concern. If the patient sighs, pauses, downplays risk (“it’s probably just my arthritis…”)—address these directly.
Reference: Linguistic and cultural factors in the MRCGP examination
Keep the most likely causes at the top, and show you’re clear about risks:
1. Septic (infective) arthritis—must be out-ruled (acute onset, severe pain, fever, diabetes, functional decline).
2. Cellulitis/soft tissue infection.
3. Gout/pseudogout.
4. Flare of osteoarthritis (less likely with warmth, fever, and inability to walk).
5. Other rarer causes (trauma, haemarthrosis). Reference: NICE: Suspected septic arthritis in adults
Impact
John lives alone and is vulnerable so understanding impact is particuiilarly important in this case. Explicitly elicit the impact on daily life, safety, and support needs:
Examples:
"How are you getting to the toilet?
Are you safe moving around your home?
Do you have any help at hand if you can’t manage?"
Check for: risk of falls, dehydration, new confusion, self-care, dietary intake, and medication adherence.
Convey information clearly and succinctly:
Example:
"A hot, swollen joint with fever in someone like you could mean infection, which can be serious."
"While we wait for someone to see you, please use your pendant if you become weaker, unwell, or can’t get up safely. Drink water. Only walk if you’re confident you won’t fall. Call if there’s any change."
Avoid unnecessary jargon or long-winded explanations.
Reference: Performance Features in CSA: Language
Make your reasoning explicit and clear involve the patient:
Example:
"Because your knee is hot, swollen, and you’re struggling to walk, infection is a real concern. That’s why I think it’s safer for you to be seen as soon as possible at home so we don’t miss anything serious. How do you feel about that?"
This helps the patient understand why offering more painkillers or waiting is not good enough.
Provide a range of practical, guideline-supported options. At least 8 to consider in this case:
1. Arrange urgent home assessment (same day or sooner if deteriorating; via visiting GP/neighbourhood team/hospital outreach).
2. Hospital attendance if deteriorating/likely septic arthritis/rapid functional loss or delirium.
3. Interim enhanced pain relief once assessed (paracetamol regular, careful with codeine/tramadol given frailty/falls risk; avoid NSAIDs due to comorbidity).
4. Safety netting: What to do if worse—clear “alert” symptoms (confusion, rigors, being unable to get to toilet, no drinking or passing urine).
5. Enhanced support from daughter/family—ask daughter to check in more frequently, ideally in person.
6. Proactive use of the careline—remind to use pendant for emergencies, and explain what would trigger immediate help.
7. Advice on mobility/fall risk—move only with support, keep phone/pendant close, avoid icy outdoor trips.
8. Lifestyle/comfort measures: Rest, elevate leg, keep warm, keep hydrated, easy-to-prepare foods at hand.
9. Urine monitoring: Watch for new confusion, urine changes (UTI risk increased with immobility).
10. Arrange proactive social services referral if decline continues.
Note:
Simply prescribing painkillers without considering septic arthritis or offering only next-day assessment without safety nets would be unsafe and not in keeping with NICE or best practice.
Reference:
• NICE – Septic Arthritis, RCP Guidelines - Red, hot, swollen joint
• NICE: Septic arthritis
• NICE: Social care for older people
• RCGP SCA Toolkit
• Simulated consultations: a sociolinguistic perspective
• RCP - Red, hot, swollen joint
