CASE INFORMATION

Case ID: HZ-008
Case Name: James Reynolds
Age: 54 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A72 – Herpes Zoster (Shingles)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand concerns, ideas, and expectations 1.2 Provides clear explanations tailored to the patient’s level of health literacy 1.4 Uses effective consultation techniques, including active listening and empathy
2. Clinical Information Gathering and Interpretation	2.1 Takes a focused history to explore symptom onset, pain characteristics, and risk factors 2.2 Selects appropriate investigations based on clinical presentation
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis for a unilateral, vesicular rash with pain 3.2 Identifies potential complications such as postherpetic neuralgia and ophthalmic involvement
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a safe and effective management plan 4.2 Provides advice on pharmacological and non-pharmacological management
5. Preventive and Population Health	5.1 Discusses vaccination and strategies to prevent complications
6. Professionalism	6.1 Maintains patient confidentiality and demonstrates ethical practice
7. General Practice Systems and Regulatory Requirements	7.1 Documents accurately and ensures appropriate follow-up
9. Managing Uncertainty	9.1 Provides reassurance and safety-netting when the diagnosis is unclear
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises complications such as postherpetic neuralgia and disseminated disease requiring urgent intervention

CASE FEATURES

Middle-aged male presenting with a painful, unilateral vesicular rash.
Recognising classic signs of herpes zoster and differentiating from other dermatological conditions.
Discussing antiviral therapy, pain management, and prevention of complications.
Addressing patient concerns about transmission, prognosis, and vaccination.
Safety-netting for complications such as postherpetic neuralgia and ophthalmic zoster.

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

James Reynolds, a 54-year-old accountant, presents with a painful, red rash with blisters on the left side of his torso. The rash started three days ago with a burning sensation before blisters appeared.

The pain is sharp and shooting, sometimes feeling like electric shocks. He has mild fatigue but no fever or other systemic symptoms.

PATIENT RECORD SUMMARY

Patient Details

Name: James Reynolds
Age: 54
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Nil regular medications

Past History

Mild hypertension (diet-controlled)
History of chickenpox as a child
No history of immunosuppression or recent illness

Social History

Works as an accountant, mostly desk-based job

Family History

No family history of autoimmune or dermatological conditions

Smoking

Non-smoker

Alcohol

Drinks socially, 3-4 standard drinks per week

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, I’ve had this painful rash on my side for a few days now, and it’s getting worse. What’s happening to me?”

General Information

Your name is James Reynolds, and you are 54 years old.
You work as an accountant, spending most of your day at a desk.
You are generally healthy, apart from mild hypertension, which you manage with diet and exercise.
You live with your wife and grandchildren (ages 2 and 4).
You have never had the shingles vaccine.

Specific Information

(Reveal only when asked directly)

Background Information

Three days ago, you noticed a burning sensation on the left side of your torso.
The next day, a red, blistering rash appeared, running from your back to the front of your chest.
The rash is unilateral, staying only on the left side.
The pain is sharp, shooting, and sometimes feels like electric shocks.
The affected area is very sensitive to touch, and even clothing brushing against it is uncomfortable.
You have mild fatigue but no fever or flu-like symptoms.

Rash Characteristics

The blisters are grouped together, filled with clear fluid, and do not cross the midline.
The skin around the rash is red and slightly swollen.
Some blisters have started to crust over, but new ones are still appearing.
The rash is not spreading to other areas of your body.

Pain Characteristics

The pain started as a tingling or burning sensation, then became sharp and shooting.
It sometimes feels like sudden electric shocks.
You have not taken any pain relief yet because you were hoping it would go away on its own.
The pain is worse at night, making it difficult to sleep.

Concerns and Expectations

You are worried about whether this is contagious because you live with young grandchildren.
You want to know how long the rash will last and if it will leave a scar.
You are concerned about pain and want to know how to relieve it.
You are worried that this pain might last even after the rash disappears.
You want to know if you should get the shingles vaccine after this.

Red Flag Symptoms (Reveal only when asked directly)

No pain or blisters near the eye or forehead.
No severe headache, vision changes, or weakness.
No fever, chills, or swollen lymph nodes.

Emotional Cues & Body Language

You appear mildly anxious but are trying to stay calm and logical.
If the doctor seems uncertain or vague, you may press further:
- “Are you sure this isn’t something more serious?”
If the doctor explains things well, you become more reassured.
If the doctor does not discuss postherpetic neuralgia, you may ask:
- “Will the pain go away after the rash disappears?”
If the doctor does not mention vaccination, you may ask:
- “Can I still get the shingles vaccine after this?”
If the doctor only prescribes antivirals and does not discuss pain relief, you may ask:
- “What about the pain? Do I need something for that?”

Questions for the Candidate

(Ask these naturally throughout the consultation.)

“Is this contagious? Can I pass this to my grandchildren?”
“How long will this last? Will it leave a scar?”
“Is there anything I can do to stop the pain?”
“Should I get the shingles vaccine after this?”
“Do I need any medication for this?”
“What are the chances this pain will last even after the rash is gone?”
“Could this happen again?”
“If the pain gets worse, what should I do?”

Key Behaviours & Approach

You want clear answers and a treatment plan.
You expect reassurance and practical advice.
If the doctor does not explain pain management well, you will push for options.
If the doctor explains postherpetic neuralgia, you may sound concerned and ask how to prevent it.
If the doctor mentions the shingles vaccine, you may ask:
- “Wouldn’t it be too late to get it now?”

Additional Context for the Role-Player

You are willing to follow medical advice, but you need a clear explanation.
You prefer conservative treatments but will take medication if necessary.
You want to return to work soon and are worried about how long this will last.
You do not want to spread the infection to your grandchildren and want to know how to prevent that.

Role-Player Summary

This case assesses the candidate’s ability to:

Recognise and diagnose herpes zoster based on history and rash characteristics.
Explain transmission risk and precautions, particularly regarding young children.
Discuss treatment options, including antivirals, pain management, and prevention of complications.
Provide reassurance and safety-netting, particularly for postherpetic neuralgia risk.
Address vaccination recommendations, explaining why vaccination is still beneficial after an episode of shingles.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, considering symptom onset, risk factors, and complications.

The competent candidate should:

Elicit the onset and progression of symptoms, including initial burning pain, vesicular rash development, and distribution.
Clarify the pain characteristics: burning, shooting, sensitivity, or associated numbness.
Ask about risk factors, such as history of chickenpox, immunosuppression, recent illness, stress, or trauma.
Identify red flags, including rash near the eye, facial weakness, fever, or severe systemic symptoms.
Assess the impact on daily life, including pain severity, sleep disturbance, and emotional distress.
Address the patient’s concerns, particularly about contagion, scarring, and long-term pain.

Task 2: Formulate a differential diagnosis and explain it to the patient.

The competent candidate should:

Explain that herpes zoster (shingles) is the most likely diagnosis, given the unilateral vesicular rash following a dermatome.
Discuss other possible conditions:
- Contact dermatitis – bilateral, itchy, no dermatomal pattern.
- Herpes simplex virus – often localised, recurrent, not dermatomal.
- Cellulitis – usually without vesicles, more systemic signs.
- Eczema or impetigo – chronic course, different lesion morphology.
Explain why shingles is not contagious like chickenpox, but can transmit varicella-zoster virus (VZV) to non-immune individuals.
Address the patient’s concerns about severity and complications.

Task 3: Address the patient’s concerns, including pain management, risk of transmission, and prognosis.

The competent candidate should:

Explain that antivirals (if started early) can reduce severity and duration.
Discuss pain management, including paracetamol, NSAIDs, and neuropathic agents if needed.
Reassure about transmission, advising that shingles is not spread through respiratory droplets but direct contact with fluid from blisters.
Advise the patient to cover the rash, maintain good hygiene, and avoid contact with infants, pregnant women, and immunocompromised individuals.
Set expectations: rash resolves in 2-4 weeks, but pain may persist (postherpetic neuralgia).

Task 4: Develop an initial management plan, including antiviral therapy, symptomatic treatment, prevention strategies, and follow-up.

The competent candidate should:

Initiate antiviral therapy (valaciclovir or famciclovir) within 72 hours to reduce complications.
Prescribe pain relief: paracetamol, NSAIDs, or neuropathic agents (amitriptyline, pregabalin) if needed.
Advise on skin care, including keeping the rash dry, using calamine lotion, and avoiding scratching.
Discuss postherpetic neuralgia risk, advising early follow-up if pain persists after rash resolution.
Encourage shingles vaccination for future prevention (Shingrix recommended).
Arrange follow-up in 1-2 weeks to assess pain and rash resolution.

SUMMARY OF A COMPETENT ANSWER

Takes a thorough history, assessing pain characteristics, rash evolution, and risk factors.
Provides a structured differential diagnosis, clearly explaining why shingles is the most likely.
Reassures and educates the patient, addressing concerns about contagion, prognosis, and long-term effects.
Develops an effective treatment plan, including antivirals, pain relief, and preventive strategies.
Ensures safety-netting, advising when to seek urgent medical attention (e.g., ophthalmic involvement or severe pain).

PITFALLS

Failing to initiate antiviral therapy early, missing the optimal 72-hour window for effectiveness.
Not screening for postherpetic neuralgia risk, leading to unpreparedness if pain persists.
Overlooking potential complications, such as ophthalmic zoster or bacterial superinfection.
Providing vague pain management advice, instead of specific recommendations for neuropathic pain if needed.
Not discussing shingles vaccination, missing a key opportunity for prevention.
Failing to reassure the patient about contagion, causing unnecessary fear and social isolation.

REFERENCES

MARKING

Each competency area is assessed 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 patient’s concerns and sociocultural context.
1.2 Engages the patient to gather information about symptoms, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Elicits a comprehensive history, including risk factors and red flags.
2.2 Orders appropriate investigations only if needed, avoiding unnecessary testing.

3. Diagnosis, Decision-Making and Reasoning

3.1 Develops a structured differential diagnosis for vesicular rash and pain.
3.2 Identifies complications requiring urgent referral (e.g., ophthalmic zoster).

4. Clinical Management and Therapeutic Reasoning

4.1 Formulates an evidence-based treatment plan, including antivirals and pain relief.
4.2 Provides pharmacological and non-pharmacological treatment options, ensuring a patient-centred approach.

5. Preventive and Population Health

5.1 Discusses shingles vaccination and its role in preventing future episodes.

6. Professionalism

6.1 Maintains confidentiality and ethical decision-making.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures accurate documentation and appropriate follow-up.

9. Managing Uncertainty

9.1 Provides reassurance and safety-netting, ensuring the patient understands when to seek urgent care.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises complications such as postherpetic neuralgia or ophthalmic involvement requiring escalation.

Competency at Fellowship Level

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