CASE INFORMATION

Case ID: EMN001
Case Name: Sarah Thompson
Age: 45
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: T99 (Endocrine/metabolic/nutritional symptom/complaint, other)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Communicates appropriately 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. 1.4 Communicates effectively in routine and difficult situations.
2. Clinical Information Gathering and Interpretation	2.1 Gathers essential information relevant to the presenting complaint. 2.2 Identifies potential red flags requiring urgent investigation.
3. Diagnosis, Decision-Making and Reasoning	3.1 Formulates appropriate differential diagnoses. 3.2 Uses clinical reasoning to prioritise key conditions and investigations.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a patient-centred management plan. 4.2 Initiates appropriate investigations and treatment.
5. Preventive and Population Health	5.1 Identifies and manages risk factors for chronic disease.
6. Professionalism	6.1 Provides patient-centred, non-judgmental care.
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and follow-up.
9. Managing Uncertainty	9.1 Balances risk and reassurance in an undifferentiated complaint.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises when to escalate care and refer appropriately.

CASE FEATURES

Need for patient-centred education and shared decision-making.
Non-specific metabolic symptoms (fatigue, weight gain, brain fog).
Concern for possible endocrine disorder (thyroid dysfunction, insulin resistance, or adrenal insufficiency).
Lifestyle factors contributing to symptoms (sedentary lifestyle, poor diet, perimenopausal changes).
Risk of missing significant illness (e.g., diabetes, hypothyroidism, or metabolic syndrome).

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

Sarah Thompson is a 45-year-old woman who presents to the clinic complaining of fatigue, difficulty losing weight, and brain fog. She reports feeling constantly tired, even after a full night’s sleep, and struggles to focus at work. Over the past 6 months, she has gained 6 kg, despite maintaining the same diet and activity level.

She is worried that something is wrong with her metabolism and is concerned about developing diabetes because her mother was diagnosed with type 2 diabetes in her 50s. She asks if her thyroid might be the problem and wants to know if she needs hormone testing.

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Thompson
Age: 45
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

None regularly
Occasionally takes paracetamol for headaches

Past History

Gestational diabetes (resolved post-pregnancy)
No known thyroid issues
No history of autoimmune disease

Social History

Works full-time in administration (sedentary job)

Family History

Mother: Type 2 diabetes (diagnosed at age 52)
Father: Hypertension, no history of diabetes or thyroid disease

Smoking

Never smoked

Alcohol

Drinks socially (1–2 glasses of wine on weekends)

Vaccination and Preventative Activities

Last health check 2 years ago
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 SCRIPT

Opening Line

“Doctor, I feel so exhausted all the time. I can’t seem to lose weight, and my brain just feels foggy. Could this be my thyroid or something wrong with my metabolism?”

General Information

(Can be shared freely if asked open-ended questions)

Fatigue: Has been ongoing for about 6 months, gradually worsening. Feels tired even after a full night’s sleep.
Weight gain: About 6 kg in 6 months despite no major changes in diet or activity.
Brain fog: Struggles with focus and memory, especially at work. Feels slower in processing information.
Exercise: Walks 2–3 times a week, but finds it hard to stay motivated due to exhaustion.
No significant stressors, but feels frustrated and concerned about her health.

Specific Information

(Only revealed if asked directly)

Symptoms & Concerns

Skin and Hair: Skin feels drier than usual, but no major hair loss or brittle nails.
Temperature Sensitivity: Feels colder than usual, especially in the mornings, but not extreme.
Bowel Habits: No significant constipation or diarrhoea.
Menstrual Cycle: Regular cycles, no significant changes in flow or duration.
Thirst and Urination: No excessive thirst or frequent urination.
Palpitations or Dizziness: Occasionally light-headed when standing up quickly but no palpitations.
Sleep Quality: Sleeps 7–8 hours per night, but wakes up unrefreshed.

Medical & Family History

Gestational diabetes in second pregnancy (resolved postpartum).
Mother has type 2 diabetes, diagnosed in her 50s.
Father has hypertension.
No personal history of diabetes, high cholesterol, or autoimmune disease.

Patient’s Expectations & Questions

“Could this be my thyroid? I read online that low thyroid can cause weight gain and tiredness.”
“Do I need a blood test for my metabolism? What tests would you recommend?”
“My mum has diabetes—am I at risk? Should I check my sugar levels?”
“Can I take any vitamins or supplements to help with my energy?”
“I exercise a little, but it doesn’t seem to help with weight loss. What else can I do?”

Emotional Cues & Body Language

Concerned but open-minded. Expresses genuine worry about underlying illness but is receptive to explanations.
Slight frustration if concerns are dismissed or not properly addressed.
Becomes engaged if the doctor explains things well and provides a clear plan.
Motivated to make changes but wants guidance on what works.
If told to ‘just lose weight,’ becomes defensive and feels unheard.

Escalating Reactions Depending on the Doctor’s Approach

If the Doctor Provides a Clear Explanation & Plan

Listens attentively.
Asks clarifying questions but feels reassured.
Leaves feeling hopeful about improving her health.

If the Doctor Dismisses Her Concerns

Frustrated or doubtful.
May push back and ask more questions.
“But what if it is my thyroid? Can I still get tested?”

If the Doctor Focuses Only on Weight Loss

Feels unheard.
Pushes back:
- “I know I need to lose weight, but that doesn’t explain why I feel so tired all the time.”
- “It’s not just about weight—I feel like something is off.”

If the Doctor Recommends Multiple Expensive or Unnecessary Tests

Becomes skeptical.
“Do I really need all these tests? I don’t want to spend money on things that aren’t necessary.”

Closing Thoughts & Expectations

Wants a clear explanation of possible causes.
Willing to do lifestyle modifications, but needs practical steps.
Wants to know what tests are useful vs unnecessary.
Hopes for a follow-up plan rather than a one-off appointment.
If satisfied with the consultation, feels empowered and ready to take control of her health.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including biopsychosocial factors contributing to the patient’s symptoms.

The competent candidate should:

Establish the onset, duration, and progression of symptoms, including fatigue, weight gain, and cognitive difficulties (brain fog).
Explore associated symptoms such as cold intolerance, dry skin, constipation, menstrual changes, or mood alterations that may suggest endocrine or metabolic dysfunction.
Assess dietary habits, physical activity, and lifestyle factors contributing to symptoms.
Take a thorough medication and supplement history, including over-the-counter and herbal treatments.
Identify family history of metabolic disorders such as diabetes, thyroid disease, and cardiovascular risk factors.
Assess psychosocial factors, including stress, mood disturbances, and occupational or family stressors.
Screen for red flags such as significant weight loss, persistent headaches, or neurological symptoms.

Task 2: Identify and discuss the most likely differential diagnoses.

The competent candidate should:

Acknowledge the patient’s concerns and explain that multiple conditions could contribute to her symptoms.
Provide a structured differential diagnosis:
- Hypothyroidism (primary or secondary).
- Insulin resistance/metabolic syndrome.
- Iron deficiency anaemia.
- Chronic fatigue syndrome.
- Depression or other mental health conditions.
- Perimenopause-related symptoms.
Prioritise differential diagnoses based on history and risk factors (e.g., prior gestational diabetes, family history).

Task 3: Explain the investigations required and the rationale for each test.

The competent candidate should:

Explain the need for targeted investigations rather than broad screening.
Discuss appropriate initial tests:
- Full blood count (FBC): To check for anaemia.
- Thyroid function tests (TSH, free T4, +/- T3): To rule out hypothyroidism.
- Fasting glucose and HbA1c: To assess diabetes risk.
- Lipid profile: To evaluate cardiovascular risk.
- Iron studies and ferritin: To assess for iron deficiency.
- Electrolytes and renal function: To assess for underlying metabolic issues.
Justify each test based on symptoms and patient risk factors.
Address any misconceptions about unnecessary “metabolism tests.”

Task 4: Provide initial management and lifestyle advice, addressing the patient’s concerns.

The competent candidate should:

Reassure the patient that many metabolic conditions are manageable with appropriate treatment.
Provide lifestyle advice:
- Encourage a balanced diet with whole foods, lean proteins, and complex carbohydrates.
- Recommend regular physical activity suited to the patient’s abilities.
- Discuss sleep hygiene to improve fatigue.
If a diagnosis is confirmed, provide condition-specific management:
- Hypothyroidism → Consider thyroxine replacement if diagnosed.
- Insulin resistance → Lifestyle modification and possible metformin.
- Anaemia → Iron supplementation and dietary changes.
Offer follow-up to review test results and ongoing symptoms.

SUMMARY OF A COMPETENT ANSWER

Takes a structured and patient-centred history addressing symptoms, lifestyle, and psychosocial factors.
Provides a clear and logical differential diagnosis based on history and risk factors.
Explains investigations clearly, ensuring appropriate and evidence-based testing.
Offers realistic, practical management tailored to the patient’s needs.
Ensures ongoing follow-up and shared decision-making.

PITFALLS

Failing to acknowledge the patient’s concerns about metabolism and thyroid function.
Ordering excessive or inappropriate tests without justification.
Focusing solely on weight loss without addressing fatigue and cognitive symptoms.
Overlooking mental health screening for underlying depression or stress-related fatigue.
Dismissing symptoms as “normal aging” without further investigation.
Neglecting a follow-up plan for test results and ongoing symptom management.

REFERENCES

MARKING

Each competency area is assessed on a 0–3 scale:

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communicates appropriately 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.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers essential information relevant to the presenting complaint.
2.2 Identifies potential red flags requiring urgent investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulates appropriate differential diagnoses.
3.2 Uses clinical reasoning to prioritise key conditions and investigations.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a patient-centred management plan.
4.2 Initiates appropriate investigations and treatment.

5. Preventive and Population Health

5.1 Identifies and manages risk factors for chronic disease.

6. Professionalism

6.1 Provides patient-centred, non-judgmental care.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up.

9. Managing Uncertainty

9.1 Balances risk and reassurance in an undifferentiated complaint.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises when to escalate care and refer appropriately.

Competency at Fellowship Level

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