CASE INFORMATION

Case ID: THY-016
Case Name: Emma Lawson
Age: 38 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: T85 – Hyperthyroidism/Thyrotoxicosis

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 thorough history to assess symptoms, risk factors, and red flags 2.2 Identifies when further investigations are warranted
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis for unexplained weight loss and palpitations 3.2 Recognises red flags requiring urgent referral
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan 4.2 Provides appropriate treatment options and patient education
5. Preventive and Population Health	5.1 Discusses lifestyle modifications and long-term monitoring for thyroid disease
6. Professionalism	6.1 Maintains patient confidentiality and demonstrates ethical practice
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation, follow-up, and referrals
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 when hyperthyroidism requires urgent intervention

CASE FEATURES

Young woman presenting with weight loss, palpitations, and heat intolerance.
Exploring differential diagnoses, including Graves’ disease, toxic multinodular goitre, thyroiditis, and other metabolic conditions.
Addressing patient concerns, including fear of cancer, long-term health effects, and treatment options.
Balancing reassurance with appropriate investigation and management.

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

Emma Lawson, a 38-year-old teacher, presents with unexplained weight loss of 6kg over the past 3 months, palpitations, increased sweating, and irritability. She also reports difficulty sleeping and a persistent feeling of being “on edge”.

She is concerned that this could be something serious, like cancer or a heart problem.

PATIENT RECORD SUMMARY

Patient Details

Name: Emma Lawson
Age: 38
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Occasionally takes ibuprofen for headaches

Past History

No history of diabetes, cardiovascular disease, or autoimmune conditions
Two pregnancies, no complications

Social History

Works as a high school teacher, reports high stress levels.

Family History

Mother has hypothyroidism, cause unknown.
No family history of thyroid cancer or autoimmune diseases.

Smoking

Non-smoker

Alcohol

Drinks socially, 1-2 times per week

Vaccination and Preventative Activities

Up to date with vaccinations
Last general check-up was two years ago

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 been losing weight even though I’m eating normally, and my heart has been racing. I feel anxious all the time—could this be cancer?”

General Information

Your name is Emma Lawson, and you are 38 years old.
You work as a high school teacher and describe your job as stressful and demanding.
You live with your partner and two young children (ages 4 and 6).
You do not have any significant past medical history, except for mild headaches for which you occasionally take ibuprofen.

Specific Information

(Reveal only when asked directly)

Background Information

You have never had similar symptoms before and were feeling healthy until about three months ago.
Over the past three months, you have noticed unintentional weight loss of 6kg.
Despite eating normally, you continue to lose weight, which is making you anxious.
You experience frequent heart palpitations, even when sitting still.
You feel restless and on edge all the time, making it difficult to focus at work.
You feel hot all the time, even when others seem comfortable.
You have occasional hand tremors, which are worse when holding small objects (e.g., a pen or cup).
Your sleep has been poor, and you wake up feeling restless and sweaty.

Symptoms and Triggers

Your palpitations occur randomly, even when you are relaxed and not drinking coffee.
You have noticed that your periods have become lighter and more irregular.
You have occasional diarrhoea but no abdominal pain or blood in stools.
Your appetite has increased, but you are still losing weight.
Your energy levels are inconsistent—you feel restless but also tired.
You haven’t had any fainting episodes or dizziness.

Lifestyle Factors

You have not changed your diet or exercise routine.
You drink 2-3 cups of coffee per day, but reducing caffeine has not improved the palpitations.
You are under significant stress at work, but you have never felt this anxious before.

Family History

Your mother has hypothyroidism, but you are not sure if it’s autoimmune (e.g., Hashimoto’s disease).
No family history of thyroid cancer, heart disease, or autoimmune conditions.

Concerns and Expectations

You are worried that your symptoms could be due to cancer.
You want to know if this is a serious or long-term condition.
You are concerned about whether you will need long-term medication.
You are afraid of becoming dependent on medication or needing surgery.
You are hoping for a clear diagnosis and treatment plan.

Red Flag Symptoms (Reveal only when asked directly)

No difficulty swallowing or breathing.
No unexplained lumps or masses in the neck.
No recent infections or history of fevers.
No changes in vision, eye pain, or bulging eyes.

Emotional Cues & Body Language

You appear worried and slightly agitated.
If the doctor seems uncertain or hesitant, you will ask:
- “But could this be something serious, like cancer?”
If the doctor suggests waiting before further testing, you may say:
- “I’ve already had these symptoms for three months—shouldn’t we check now?”
If the doctor explains things well and provides a clear management plan, you will feel reassured and ready to follow their advice.

Questions for the Candidate

(Ask these naturally throughout the consultation.)

“Why am I losing weight? Could this be cancer?”
“Why is my heart racing even when I’m sitting still?”
“Do I need a scan or any blood tests?”
“Is this something that will go away on its own?”
“What are the treatment options, and will I need lifelong medication?”
“Could stress be causing all of this?”
“Is this related to my hormones? I’ve noticed my periods have been lighter.”
“Will this affect my ability to have children in the future?”

Key Behaviours & Approach

You are worried about a serious illness and want reassurance.
If the doctor only talks about anxiety without considering other causes, you will ask:
- “But I’ve never felt this anxious before—could there be another reason?”
If the doctor focuses too much on ruling out cancer and doesn’t suggest treatment, you may say:
- “That’s good to hear, but what can I do about these symptoms?”
If the doctor mentions lifestyle modifications, you might ask:
- “Will that be enough, or do I need medication?”
If the doctor explains everything clearly and provides a step-by-step plan, you will feel reassured and motivated to follow their advice.

Additional Context for the Role-Player

You trust medical advice but want a logical explanation of the diagnosis.
You are not opposed to taking medication, but you want to understand if it is necessary.
You are worried about long-term health effects, including fertility, heart health, and weight loss.
You want to take action quickly rather than waiting to see if symptoms improve on their own.

Role-Player Summary

This case assesses the candidate’s ability to:

Take a structured history, identifying features of hyperthyroidism.
Provide a broad differential diagnosis, considering thyroid disease, cardiac conditions, and anxiety.
Explain the need for investigations, balancing reassurance with appropriate testing.
Offer initial management strategies, including symptom relief and long-term treatment planning.
Address patient concerns about serious illness, ensuring a patient-centred approach.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, considering potential causes of hyperthyroidism.

The competent candidate should:

Elicit key symptom details, including onset, duration, severity, and impact on daily life.
Assess systemic symptoms, such as weight loss, heat intolerance, palpitations, tremors, irritability, fatigue, and sleep disturbances.
Review menstrual history, identifying changes in cycle regularity and flow.
Identify potential triggers, including recent infections, stress, iodine intake, or new medications.
Assess past medical history, including autoimmune disorders, thyroid disease, cardiovascular conditions, and anxiety disorders.
Explore family history, particularly thyroid disease, autoimmune conditions, and endocrine disorders.
Address patient concerns, particularly about cancer, long-term health risks, and treatment options.

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

The competent candidate should:

Explain the most likely diagnosis, considering thyroid hormone excess based on symptoms.
Discuss other possible conditions, including:
- Graves’ disease – most common cause, associated with autoimmune thyroid stimulation.
- Toxic multinodular goitre – in cases with thyroid enlargement and nodules.
- Thyroiditis – if history suggests recent viral illness or postpartum state.
- Factitious thyrotoxicosis – if exogenous thyroid hormone use is suspected.
- Anxiety or cardiac causes – if hyperthyroidism is excluded.
Reassure the patient that cancer is unlikely, as hyperthyroidism is rarely caused by thyroid malignancies.
Explain the need for further investigations to confirm the cause and guide management.

Task 3: Address the patient’s concerns, including the need for investigations and long-term management.

The competent candidate should:

Acknowledge the patient’s concerns about weight loss and palpitations, providing clear explanations.
Explain why blood tests (thyroid function tests) are needed, including:
- TSH (thyroid-stimulating hormone) – expected to be low in hyperthyroidism.
- Free T3 and T4 levels – to confirm thyroid hormone excess.
- Thyroid receptor antibodies (TRAb) and thyroid peroxidase (TPO) antibodies – to assess for Graves’ disease.
Discuss the potential need for imaging, such as:
- Thyroid ultrasound, if nodules are suspected.
- Thyroid uptake scan, to differentiate causes of thyrotoxicosis.
Reassure the patient that hyperthyroidism is treatable, and management depends on the underlying cause.
Discuss potential treatment options, including:
- Medications (carbimazole or propylthiouracil).
- Radioactive iodine therapy.
- Surgery (thyroidectomy) in selected cases.
Provide realistic expectations, discussing symptom relief, potential side effects, and long-term monitoring.

Task 4: Develop an initial management plan, including further investigations, lifestyle modifications, and follow-up.

The competent candidate should:

Order initial investigations, including:
- Thyroid function tests (TSH, free T3, free T4).
- Thyroid autoantibodies (TRAb, TPO) if autoimmune thyroid disease is suspected.
- Full blood count and liver function tests, as baseline before initiating anti-thyroid medications.
- ECG, if palpitations or tachycardia are present.
Provide symptomatic relief, including:
- Beta-blockers (e.g., propranolol or atenolol) to control palpitations, tremors, and anxiety symptoms.
- Lifestyle modifications, such as reducing caffeine, improving sleep hygiene, and managing stress.
Discuss potential treatment pathways, depending on investigation results.
Ensure safety-netting, advising the patient to seek urgent care if symptoms worsen (e.g., severe palpitations, chest pain, or confusion – signs of thyroid storm).
Arrange follow-up in 1-2 weeks to review test results and confirm diagnosis.

SUMMARY OF A COMPETENT ANSWER

Takes a comprehensive history, assessing symptoms, family history, and lifestyle factors.
Provides a structured differential diagnosis, explaining why Graves’ disease or thyroiditis is most likely.
Addresses patient concerns empathetically, particularly about weight loss, palpitations, and cancer fears.
Develops an evidence-based management plan, including appropriate investigations and symptom control.
Ensures clear follow-up and safety-netting, advising when to return if symptoms worsen.

PITFALLS

Failing to assess red flag symptoms, such as thyroid eye disease (exophthalmos, diplopia), dysphagia, or stridor.
Not considering other differentials, such as cardiac arrhythmias, anxiety, or factitious thyrotoxicosis.
Delaying investigations, leading to patient anxiety and untreated disease progression.
Over-reassuring the patient without arranging follow-up, missing an opportunity for early intervention.
Neglecting symptom relief, such as not offering beta-blockers for palpitations and tremors.

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 systemic symptoms and risk factors.
2.2 Orders appropriate investigations, balancing clinical suspicion and patient anxiety.

3. Diagnosis, Decision-Making and Reasoning

3.1 Develops a structured differential diagnosis, prioritising thyroid disorders, cardiac causes, and anxiety.
3.2 Identifies indications for further assessment or referral, ensuring red flags are addressed.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a structured, evidence-based treatment plan, incorporating symptom control and long-term management.
4.2 Ensures appropriate pharmacological and non-pharmacological treatment options, promoting preventive health.

5. Preventive and Population Health

5.1 Discusses lifestyle modifications, including stress management, diet, and exercise.

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 further medical care.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises features suggestive of thyroid storm or other serious complications requiring escalation.

Competency at Fellowship Level

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