CASE INFORMATION

Case ID: CCE-ENT-015
Case Name: Emily Dawson
Age: 29
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: R97 – Allergic rhinitis

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages the patient 1.2 Explores the patient’s concerns, ideas, and expectations 1.3 Provides clear and structured explanations about diagnosis, prognosis, and management
2. Clinical Information Gathering and Interpretation	2.1 Takes a structured allergy history, including triggers, seasonal variation, symptom severity, and associated conditions 2.2 Identifies red flags and risk factors for complications (e.g., asthma, sinusitis)
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between allergic rhinitis, non-allergic rhinitis, and other upper respiratory conditions 3.2 Identifies when further investigations or referral to an allergist is required
4. Clinical Management and Therapeutic Reasoning	4.1 Provides evidence-based pharmacological and non-pharmacological management 4.2 Educates the patient on trigger avoidance and long-term symptom control
5. Preventive and Population Health	5.1 Identifies risk factors for allergic rhinitis and advises on environmental control measures 5.2 Encourages proactive management to reduce long-term complications
6. Professionalism	6.1 Demonstrates empathy and a patient-centred approach
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and follow-up for persistent or severe symptoms
8. Procedural Skills	8.1 Orders and interprets relevant investigations, such as skin prick testing or serum IgE, if indicated
9. Managing Uncertainty	9.1 Recognises when symptoms may overlap with other conditions (e.g., sinusitis, viral rhinitis)
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and appropriately manages allergic rhinitis while screening for associated conditions such as asthma

CASE FEATURES

Impact on daily activities, including work and sleep
Recurrent nasal congestion, sneezing, and itchy eyes
Symptoms worse in spring, around pets, and in dusty environments
Concerns about long-term management and effectiveness of treatments

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

Emily Dawson, a 29-year-old marketing professional, presents with ongoing nasal congestion, sneezing, and itchy eyes for several years, which worsen in spring and around pets. She has tried over-the-counter antihistamines with some relief, but her symptoms have been worsening over the past year.

She is frustrated by the constant congestion and sneezing, which disrupt her sleep and affect her focus at work. She wonders if she should see a specialist or if there are better treatments available.

PATIENT RECORD SUMMARY

Patient Details

Name: Emily Dawson
Age: 29
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Mild reaction to dust mites (known from past experience but never formally tested)

Medications

Occasionally takes over-the-counter antihistamines (loratadine) with partial relief

Past History

No history of asthma but experiences occasional wheezing with colds
No history of chronic sinusitis or nasal polyps

Social History

Works in an office, exposed to air conditioning and dust

Family History

Mother has hay fever
Father has asthma

Smoking

Non-smoker

Alcohol

Drinks socially on weekends

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 INSTRUCTIONS

SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, my nose is always blocked, and I can’t stop sneezing. I think my allergies are getting worse—what can I do?”

General Information

Emily Dawson is a 29-year-old marketing professional presenting with persistent nasal congestion, sneezing, and itchy, watery eyes, which have worsened over the past year.

Symptoms began in her early 20s, initially mild but now significantly affecting her daily life.
Symptoms occur year-round, but are worse in spring and around pets.
Feels congested almost every morning, with frequent sneezing fits and a runny nose.

Specific Information

(To be revealed only when asked)

Background Information

Itchy, red eyes often accompany the nasal symptoms, especially when outdoors.
Tried loratadine (non-drowsy antihistamine) with partial relief, but congestion persists.

Her main concerns are:

“Why do I get these symptoms every year?”
“Are there stronger treatments that will actually work?”
“Could this get worse over time?”
“Should I get tested for allergies?”

Triggers and Patterns

Worst in spring, around dusty environments, and after playing with her cat.
Mornings are the worst, but symptoms fluctuate throughout the day.
Feels worse in air-conditioned rooms at work.
No clear food triggers and no symptoms in winter.

Impact on Daily Life

Struggles with sleep due to nasal congestion at night.
Frequently rubs her nose and eyes, making them sore.
Feels embarrassed sneezing at work, especially during meetings.
Has considered seeing an allergist but hasn’t yet.
Occasionally wheezes when she has a cold, but no diagnosed asthma.

Medication and Treatment History

Loratadine (antihistamine) helps a bit but doesn’t fully relieve congestion.
Has never tried a nasal spray.
Uses saline rinses occasionally, with little effect.
No previous allergy testing or formal diagnosis of allergic rhinitis.

Concerns About Treatment

Wants to avoid taking medication daily if possible.
Worried about developing resistance to antihistamines.
Curious about long-term management and whether allergies can worsen over time.
Wonders if immunotherapy (allergy shots) could help.

Emotional Cues

Emily is frustrated but hopeful for better treatment.

Frustrated with persistent symptoms: “I feel like I’m constantly blowing my nose.”
Concerned about long-term effects: “Is this going to get worse as I get older?”
Seeking reassurance: “Are there better treatments than just antihistamines?”

If the candidate provides a clear explanation and structured plan, Emily will be reassured and willing to try new treatments.

If the candidate is vague or dismissive, she may become more insistent on seeing a specialist or getting allergy testing.

Questions for the Candidate

Emily will ask some of the following questions, especially if the doctor does not address them directly:

“Why do I get these symptoms every year?”
“Should I get an allergy test?”
“Are there better treatments than antihistamines?”
“Could this be something other than allergies?”
“Will my allergies get worse over time?”
“What can I do at home to help?”
“Is immunotherapy an option for me?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

Emily will feel reassured and engaged in her treatment plan.
She will accept recommendations for nasal sprays, antihistamines, and allergen avoidance.
She may say, “That makes sense. I’ll try the nasal spray and see if it helps.”

If the candidate is vague or dismissive:

Emily may insist on allergy testing or seek a specialist referral unnecessarily.
She may say, “Are you sure I don’t need something stronger?”

Key Takeaways for the Candidate

Take a structured allergy history, identifying triggers and seasonal patterns.
Differentiate allergic rhinitis from other nasal conditions.
Provide an evidence-based management plan, including intranasal steroids and allergen avoidance.
Address patient concerns about long-term treatment and symptom control.
Ensure follow-up to assess treatment response and adjust management if needed.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including symptom onset, triggers, seasonal variation, and impact on daily life.

The competent candidate should:

Elicit a detailed allergy history, including onset, duration, severity, and pattern of symptoms.
Identify common triggers, such as seasonal pollen exposure, dust, pet dander, and air conditioning.
Assess associated symptoms, including nasal congestion, rhinorrhoea, sneezing, postnasal drip, and itchy eyes.
Screen for related conditions, such as asthma, sinusitis, or atopic dermatitis.
Determine the impact on daily life, such as work performance, sleep quality, and social interactions.

Task 2: Differentiate between allergic rhinitis and other causes of nasal congestion.

The competent candidate should:

Consider allergic rhinitis when symptoms are recurrent, triggered by allergens, and associated with itching and sneezing.
Differentiate from other conditions, such as:
- Viral rhinitis – recent cold or flu, fever, thick nasal discharge.
- Chronic sinusitis – prolonged congestion, facial pain, postnasal drip.
- Non-allergic rhinitis – triggered by weather changes, strong odours, no itching.
Recognise red flags, such as persistent unilateral congestion, nasal obstruction, or epistaxis, which may require further investigation.

Task 3: Provide a diagnosis and discuss an initial management plan.

The competent candidate should:

Explain the diagnosis, reassuring the patient that allergic rhinitis is chronic but manageable.
Outline treatment options, including:
- Intranasal corticosteroids (e.g., fluticasone, budesonide) as first-line therapy.
- Non-sedating oral antihistamines (e.g., loratadine, fexofenadine) for intermittent symptoms.
- Saline nasal irrigation for symptom relief.
- Montelukast (leukotriene receptor antagonist) if asthma or concurrent allergic conditions are present.
Discuss when allergy testing (skin prick or IgE blood test) is appropriate, such as persistent or unclear triggers.

Task 4: Educate the patient on environmental control, medication options, and long-term symptom management.

The competent candidate should:

Provide allergen avoidance strategies, such as:
- Keeping windows closed during peak pollen seasons.
- Using dust mite covers on bedding.
- Minimising exposure to pet dander if symptomatic.
Explain correct nasal spray technique, emphasising consistent use for optimal benefit.
Discuss immunotherapy (allergy shots or sublingual tablets) for patients with severe, persistent symptoms.
Arrange follow-up in 4–6 weeks to assess response and adjust treatment if needed.

SUMMARY OF A COMPETENT ANSWER

Takes a structured allergy history, identifying triggers, seasonal patterns, and symptom severity.
Differentiates allergic rhinitis from other nasal conditions, such as sinusitis, viral infections, and non-allergic rhinitis.
Provides evidence-based treatment, including intranasal steroids, antihistamines, and allergen avoidance.
Educates the patient on long-term management, including medication adherence and environmental control.
Discusses allergy testing and immunotherapy when appropriate.

PITFALLS

Failing to differentiate allergic rhinitis from other causes of congestion, leading to misdiagnosis or unnecessary antibiotics.
Prescribing oral antihistamines alone, without recommending intranasal corticosteroids for long-term control.
Not addressing allergen avoidance strategies, leading to ongoing exposure and worsening symptoms.
Overlooking associated conditions, such as asthma or chronic sinusitis.
Providing vague follow-up instructions, risking poor symptom control and treatment adherence.

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.
1.3 Provides clear and structured explanations about diagnosis, prognosis, and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured allergy history, including triggers, seasonal variation, symptom severity, and associated conditions.
2.2 Identifies red flags and risk factors for complications (e.g., asthma, sinusitis).

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between allergic rhinitis, non-allergic rhinitis, and other upper respiratory conditions.
3.2 Identifies when further investigations or referral to an allergist is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides evidence-based pharmacological and non-pharmacological management.
4.2 Educates the patient on trigger avoidance and long-term symptom control.

5. Preventive and Population Health

5.1 Identifies risk factors for allergic rhinitis and advises on environmental control measures.
5.2 Encourages proactive management to reduce long-term complications.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up for persistent or severe symptoms.

8. Procedural Skills

8.1 Orders and interprets relevant investigations, such as skin prick testing or serum IgE, if indicated.

9. Managing Uncertainty

9.1 Recognises when symptoms may overlap with other conditions (e.g., sinusitis, viral rhinitis).

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and appropriately manages allergic rhinitis while screening for associated conditions such as asthma.

Competency at Fellowship Level

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