CCE-CE-061.1 - GP Exams

CASE INFORMATION

Case ID: CCE-ADR-021
Case Name: Elizabeth Grant
Age: 58
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A85 – Adverse Effect of Medication

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 history, including onset, type of reaction, and medication timeline 2.2 Identifies risk factors for adverse drug reactions (e.g., polypharmacy, renal impairment)
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between an adverse drug reaction, allergy, and expected side effect 3.2 Identifies when further investigations or specialist referral is required
4. Clinical Management and Therapeutic Reasoning	4.1 Provides evidence-based recommendations for medication modification or discontinuation 4.2 Implements strategies to manage symptoms and prevent recurrence
5. Preventive and Population Health	5.1 Identifies high-risk medications and advises on monitoring 5.2 Educates the patient on recognising early signs of adverse reactions
6. Professionalism	6.1 Demonstrates empathy and a patient-centred approach
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and reporting of the adverse reaction 7.2 Liaises with the prescribing doctor and/or pharmacist where necessary
8. Procedural Skills	8.1 Orders and interprets relevant investigations if required (e.g., renal/liver function tests, drug levels)
9. Managing Uncertainty	9.1 Recognises when a medication reaction requires immediate intervention versus monitoring
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies severe reactions requiring urgent escalation (e.g., anaphylaxis, severe angioedema)

CASE FEATURES

Importance of patient education on medication safety
New-onset rash and fatigue after starting a new antihypertensive medication
Concern about a possible drug allergy or intolerance
Need for medication review and alternative management options

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, including onset of symptoms, medication timeline, and associated features.
Differentiate between an allergic reaction, adverse drug effect, and an expected side effect.
Provide a diagnosis and discuss an initial management plan.
Educate the patient on medication safety, alternative options, and when to seek urgent care.

SCENARIO

Elizabeth Grant, a 58-year-old retired schoolteacher, presents with a widespread rash and fatigue that started a week ago. She recently started amlodipine for high blood pressure and is concerned that the medication is causing her symptoms.

She describes the rash as red and slightly itchy, mainly on her torso and arms. She has not experienced any breathing difficulties or swelling but feels more tired than usual.

Her main concerns are:

“Is this an allergic reaction?”
“Should I stop taking my blood pressure medication?”
“Will I need to try a different medication?”
“What should I do if this happens again?”

PATIENT RECORD SUMMARY

Patient Details

Name: Elizabeth Grant
Age: 58
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Amlodipine 5mg daily (started two weeks ago for hypertension)
Atorvastatin 40mg daily (for hyperlipidaemia)
Paracetamol as needed (for mild osteoarthritis)

Past History

Hypertension (diagnosed recently)
Hyperlipidaemia
Osteoarthritis
Mild renal impairment (eGFR 55 mL/min)

Social History

Non-smoker
Social drinker (1–2 glasses of wine per week)
Active lifestyle, enjoys walking and gardening

Family History

Mother had hypertension and diabetes
Father had a history of stroke

Vaccination and Preventative Activities

No recent travel
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.

SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, I’ve developed this rash, and I think it might be from my new blood pressure medication. Should I stop taking it?”

General Information

Elizabeth Grant is a 58-year-old retired schoolteacher presenting with a widespread rash and fatigue that started about a week ago. She recently started amlodipine for high blood pressure and is concerned the medication is causing her symptoms.

Rash appeared gradually over a few days, affecting her torso and arms.
Mildly itchy but not painful.
Fatigue started around the same time as the rash, and she feels more tired than usual.
No fever, joint pain, or swelling.
No difficulty breathing, wheezing, or facial swelling.

Her main concerns are:

“Is this an allergic reaction?”
“Should I stop taking my blood pressure medication?”
“Will I need to try a different medication?”
“What should I do if this happens again?”

Specific Information (To be revealed only when asked)

Symptoms and Progression

Started noticing a few red patches on her torso and arms a week ago, which gradually spread.
Slightly itchy but not severe.
Has not changed soaps, detergents, or skincare products recently.
No blistering, peeling skin, or mouth ulcers.
No swollen lymph nodes.

Medication History and Timeline

Started amlodipine two weeks ago, rash appeared one week later.
Has been taking atorvastatin for over a year with no issues.
No history of medication allergies.
Has not missed any doses of medication.

Risk Factors and Background Health

Mild renal impairment (eGFR 55 mL/min).
Non-smoker, social alcohol use (1–2 glasses of wine per week).
No history of autoimmune disease or chronic skin conditions.

Concerns About Treatment and Side Effects

Worried this might be a serious allergic reaction.
Anxious about stopping the medication and whether her blood pressure will get worse.
Wants to know what alternative treatments exist.
Unsure if she needs tests or a specialist referral.

Impact on Daily Life

The rash is irritating but not preventing daily activities.
Fatigue is bothersome, making her feel less energetic than usual.
Feels uneasy about continuing a medication that might be causing a reaction.

Emotional Cues

Elizabeth is concerned but not in distress.

Anxious about medication safety: “I don’t want to take something that’s harming me.”
Worried about hypertension control: “If I stop this medication, will my blood pressure get worse?”
Seeking reassurance: “Is this serious, or will it go away on its own?”

If the candidate provides a structured explanation and treatment plan, Elizabeth will be reassured and open to medication adjustments.

If the candidate is vague or dismissive, she may become anxious and insist on stopping the medication immediately.

Questions for the Candidate

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

“Is this an allergic reaction?”
“Should I stop taking my medication?”
“What are my other options for blood pressure control?”
“Will I need any tests to check for drug reactions?”
“How will I know if this happens again with another medication?”
“What symptoms should I watch out for that would be serious?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

Elizabeth will feel reassured and willing to follow recommendations.
She will accept a medication change if necessary.
She may say, “I’ll try the alternative medication if needed.”

If the candidate is vague or dismissive:

Elizabeth may insist on stopping the medication immediately, possibly affecting hypertension control.
She may say, “So, should I just wait and hope it goes away?”

Key Takeaways for the Candidate

Take a structured adverse reaction history, assessing medication timeline and symptoms.
Differentiate between an adverse effect, allergy, and expected side effect.
Provide a safe medication management plan, including alternative options if needed.
Educate on monitoring for future reactions and when to seek urgent care.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including onset of symptoms, medication timeline, and associated features.

The competent candidate should:

Elicit a structured history, including:
- Onset and progression of symptoms (rash developed one week ago, fatigue started around the same time).
- Description of the rash (widespread, red, slightly itchy, affecting torso and arms, no blistering or ulceration).
- Presence of systemic symptoms (fatigue, but no fever, joint pain, or lymphadenopathy).
- Timing in relation to medication initiation (amlodipine started two weeks ago, symptoms began one week later).
Identify risk factors for adverse drug reactions, including:
- Renal impairment (eGFR 55 mL/min), age, and polypharmacy.
- No history of medication allergies or previous reactions.

Task 2: Differentiate between an allergic reaction, adverse drug effect, and an expected side effect.

The competent candidate should:

Differentiate potential causes:
- Drug hypersensitivity reaction (delayed-type, non-life-threatening, likely related to amlodipine).
- Common side effects of amlodipine (ankle oedema, headache, flushing—rash is uncommon).
- Other differential diagnoses (viral exanthem, contact dermatitis, idiopathic urticaria).
Recognise red flags for serious drug reactions, such as:
- Severe rash with blistering (Stevens-Johnson syndrome, toxic epidermal necrolysis).
- Facial swelling or breathing difficulty (anaphylaxis, angioedema).
- Systemic involvement (fever, eosinophilia, multi-organ dysfunction—DRESS syndrome).

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

The competent candidate should:

Explain the likely diagnosis:
- Mild drug reaction to amlodipine, not an immediate allergy.
- Unlikely to be a severe hypersensitivity reaction but requires monitoring.
Outline the management plan:
- Cease amlodipine and switch to an alternative antihypertensive (e.g., ACE inhibitor if appropriate).
- Symptomatic relief with oral antihistamines (e.g., loratadine) and topical emollients.
- Monitor blood pressure and ensure adequate control with alternative therapy.

Task 4: Educate the patient on medication safety, alternative options, and when to seek urgent care.

The competent candidate should:

Discuss medication safety:
- Document the reaction as an adverse effect (not a true allergy) in medical records.
- Advise avoiding amlodipine or related calcium channel blockers in the future.
Provide education on recognising future drug reactions:
- Symptoms to watch for with any new medication (rash, swelling, breathlessness, systemic signs).
- When to seek urgent medical attention (severe rash, blistering, fever, facial swelling).
Ensure appropriate follow-up:
- Review in one to two weeks to monitor resolution of symptoms and response to the new antihypertensive.

SUMMARY OF A COMPETENT ANSWER

Takes a structured medication reaction history, assessing timing, symptom onset, and risk factors.
Differentiates between an adverse drug effect, allergy, and expected side effect.
Recognises red flags for severe drug reactions, ensuring safe medication management.
Provides an appropriate management plan, including cessation of the likely offending agent and initiation of an alternative.
Educates the patient on medication safety, recurrence risk, and when to seek urgent care.

PITFALLS

Failing to consider medication timing, leading to misdiagnosis of the cause.
Misinterpreting a mild adverse drug reaction as a true allergy, unnecessarily limiting future treatment options.
Not recognising red flags for severe drug reactions, delaying appropriate escalation if needed.
Discontinuing amlodipine without offering an alternative antihypertensive, risking poor blood pressure control.
Lack of patient education, increasing anxiety and reducing confidence in future medication use.

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 history, including onset, type of reaction, and medication timeline.
2.2 Identifies risk factors for adverse drug reactions (e.g., polypharmacy, renal impairment).

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between an adverse drug reaction, allergy, and expected side effect.
3.2 Identifies when further investigations or specialist referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides evidence-based recommendations for medication modification or discontinuation.
4.2 Implements strategies to manage symptoms and prevent recurrence.

5. Preventive and Population Health

5.1 Identifies high-risk medications and advises on monitoring.
5.2 Educates the patient on recognising early signs of adverse reactions.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and reporting of the adverse reaction.
7.2 Liaises with the prescribing doctor and/or pharmacist where necessary.

8. Procedural Skills

8.1 Orders and interprets relevant investigations if required (e.g., renal/liver function tests, drug levels).

9. Managing Uncertainty

9.1 Recognises when a medication reaction requires immediate intervention versus monitoring.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies severe reactions requiring urgent escalation (e.g., anaphylaxis, severe angioedema).

Competency at Fellowship Level

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