CASE INFORMATION

Case ID: IB-001
Case Name: John Thompson
Age: 35
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: S23 (Insect bite/sting)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Communicates appropriately for the sociocultural context. 1.2 Engages the patient to gather information about symptoms, ideas, concerns, and expectations. 1.4 Communicates effectively in routine and urgent situations.
2. Clinical Information Gathering and Interpretation	2.1 Takes a structured history to assess the severity of the reaction and potential complications.
3. Diagnosis, Decision-Making and Reasoning	3.1 Identifies whether the insect bite is mild, moderate, or severe and assesses for anaphylaxis.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an appropriate management plan, including pharmacological and non-pharmacological interventions.
5. Preventive and Population Health	5.1 Provides education on insect bite prevention and appropriate first aid measures.
6. Professionalism	6.1 Demonstrates patient-centred care and appropriate reassurance.
9. Managing Uncertainty	9.1 Manages potential complications and provides clear follow-up advice.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and appropriately manages systemic allergic reactions or anaphylaxis.

CASE FEATURES

Wants to know if he needs antibiotics, antihistamines, or a tetanus booster.
35-year-old male presenting with a painful, swollen insect bite on his forearm.
Symptoms include itching, redness, and mild swelling, with no systemic symptoms.
Concerned about possible allergic reaction due to a past reaction to a bee sting.
Unsure if it was a bee, wasp, or spider that bit him.
No current wheeze, swelling of lips/tongue, or breathing difficulty.

INSTRUCTIONS

You have 15 minutes to complete this case.

You should treat this as a face-to-face consultation.

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

John Thompson, a 35-year-old electrician, presents with a painful and swollen insect bite on his right forearm. He was working outdoors yesterday and felt a sudden sting. The area became red and swollen overnight. He is worried it may be serious because he had a mild reaction to a bee sting five years ago, though he does not carry an EpiPen.

On examination, you observe:

A 5 cm erythematous, swollen area on his right forearm.
No systemic symptoms (no wheeze, angioedema, dizziness, nausea, or fever).
No fluctuance or spreading cellulitis.

PATIENT RECORD SUMMARY

Patient Details

Name: John Thompson
Age: 35
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Previous mild reaction to bee sting (localized swelling, no anaphylaxis).

Medications

Nil regular medications.
Occasionally takes ibuprofen for muscle aches.

Past History

No significant medical history.

Social History

Works as an electrician, frequently outdoors.

Smoking & Alcohol

Smokes 5 cigarettes/day.
Drinks socially (1-2 times per week).

Vaccination and Preventative Activities

Tetanus booster last received >10 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

“Hi, Doc. I got bitten by something on my arm yesterday, and now it’s really swollen and itchy. Should I be worried?”

General Information

(These details can be provided if the candidate asks open-ended questions.)

You were working outdoors yesterday afternoon when you suddenly felt a sharp sting on your right forearm.
At the time, you brushed something off your arm but didn’t get a good look at what it was.
Within a few minutes, the area became red and a little swollen, but you kept working and didn’t think much of it.
Overnight, the swelling and itching worsened, and the bite area is now very red and warm to touch.

Specific Information

(Only if asked by the candidate)

Background Information

You haven’t had any fevers, chills, or nausea, but you feel like the bite is getting more swollen.
You remember having a mild reaction to a bee sting about five years ago (localized swelling) but did not need an EpiPen or emergency treatment.
You have never had a serious allergic reaction before and do not carry an EpiPen.
You do not feel dizzy, short of breath, or have swelling of the lips or throat.

Symptoms

Pain: 3/10, mostly itchy rather than painful.
Swelling: About 5 cm in diameter, but not spreading rapidly.
Colour: Red, slightly raised, warm to touch.
No pus or drainage.
No numbness, tingling, or loss of movement in the arm or hand.

Past Medical & Allergy History

Generally healthy, no major medical conditions.
Had a bee sting five years ago, which caused some swelling but no breathing difficulties or rash.
No known drug allergies.
Tetanus vaccine was over 10 years ago (not sure exactly when).

Social & Occupational History

Works as an electrician, frequently outdoors on construction sites.
Married, has two kids, lives in a house with a backyard.
Smokes 5 cigarettes/day, drinks alcohol socially (1-2 times per week).
No recent travel or exposure to unusual insects.

Emotional Cues & Body Language

Mildly anxious, scratching the bite area occasionally.
Leaning forward slightly, clearly seeking reassurance.
Frowns when describing the swelling, showing concern.
Eyes widen when talking about past allergic reaction, unsure if this bite could be serious.
Nods while listening, appears receptive to information and advice.

Patient Concerns and Expectations

“Could this be serious?”
- You are worried because of your past bee sting reaction and are unsure if this could be a sign of an allergic reaction.
“Do I need antibiotics?”
- You have heard that insect bites can get infected and want to know if you need medication to stop this from getting worse.
“Should I have a tetanus shot?”
- You can’t remember your last tetanus vaccine, so you’re wondering if this is needed.
“What should I do if it gets worse?”
- You’re not sure when to seek urgent medical attention or what warning signs to look out for.
“How can I prevent insect bites in the future?”
- You work outside a lot, so you want to know if there are practical ways to avoid getting bitten again.

Questions for the Doctor (Ask at Natural Points During the Consultation)

“How do I know if this is an allergic reaction or just a normal bite?”
“What can I do to make the swelling go down faster?”
“If this was a spider bite, should I be worried?”
“Would an antihistamine help with the itching?”
“Do I need to avoid work until this heals?”

If the Doctor Suggests No Antibiotics

You should ask why and whether there is a risk of infection developing later.
“But what if it gets worse? How will I know if I need antibiotics later?”

If the Doctor Recommends a Tetanus Shot

You might hesitate and ask:
- “I don’t even know if it was a dirty wound. Is it really necessary?”
- “Will I feel unwell after getting the shot?”

If the Doctor Mentions an Allergic Reaction

“So does this mean I’m allergic now?”
“Do I need to carry an EpiPen from now on?”

Closing the Consultation

If the doctor explains the management plan well and reassures you, you should:

Appear relieved and satisfied.
Nod and say something like:
- “Okay, that makes sense. I’ll try the antihistamines and ice packs first, and I’ll keep an eye out for any warning signs.”
- “Thanks for explaining that. I’ll go ahead with the tetanus shot, just in case.”

If the doctor doesn’t provide enough reassurance, you should:

Still appear worried and unconvinced.
Press further with:
- “Are you sure I don’t need antibiotics?”
- “So I don’t need to see a specialist or anything?”
- “What if the swelling gets worse tomorrow?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient.

The competent candidate should:

Use open-ended questions to gather information about the onset, duration, progression, and associated symptoms of the insect bite.
Identify red flag symptoms such as breathing difficulties, facial or throat swelling, systemic symptoms (fever, dizziness, anaphylaxis signs).
Explore previous allergic reactions and history of anaphylaxis or hospitalisation due to bites or stings.
Inquire about tetanus vaccination status.
Gather relevant medical history including immunosuppression, diabetes, or other conditions affecting healing.
Explore occupational and environmental exposure risks (e.g., working outdoors, travel history).
Assess the patient’s concerns and expectations about the bite, infection risk, and management options.

Task 2: Explain your differential diagnosis and rationale.

The competent candidate should:

Outline common causes of local reactions, including:
- Mild local allergic reaction (common with mosquito or ant bites).
- Cellulitis or local bacterial infection (if warmth and redness persist).
- Delayed hypersensitivity reaction (if worsening days after the bite).
- Spider bite (e.g., redback, white-tailed spider) if severe pain or necrotic changes.
Explain why anaphylaxis is unlikely (absence of systemic symptoms, airway swelling).
Reassure the patient regarding normal immune responses and expected progression of symptoms.

Task 3: Develop a safe and patient-centred management plan.

The competent candidate should:

Provide first-line symptomatic treatment:
- Antihistamines for itch and swelling.
- Cold compress and elevation for local swelling.
- Topical corticosteroids if itching is significant.
- Pain relief (paracetamol, NSAIDs if appropriate).
Educate on warning signs of infection (spreading redness, pus, fever) and anaphylaxis (difficulty breathing, dizziness, throat swelling).
Discuss whether antibiotics are needed (if signs of bacterial superinfection).
Recommend a tetanus booster if vaccination is outdated.
Advise when to seek urgent medical attention, including signs of serious allergic reactions or sepsis.

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, including symptom onset, progression, past reactions, and vaccination status.
Provides a differential diagnosis, distinguishing between normal inflammatory response, allergic reaction, and infection.
Reassures the patient based on clinical findings, explaining why anaphylaxis is unlikely.
Outlines a clear treatment plan with antihistamines, cold compress, pain relief, and tetanus vaccination if needed.
Provides safety netting advice, including when to seek medical attention for worsening symptoms.

PITFALLS

Failing to assess for anaphylaxis symptoms (breathing difficulty, dizziness, facial swelling).
Overprescribing antibiotics for a non-infected insect bite.
Missing tetanus prophylaxis if vaccination history is unclear or outdated.
Inadequate patient education on self-care, warning signs, and when to seek further care.
Not considering occupational or environmental factors that might lead to repeated exposure.

REFERENCES

MARKING

Each competency area is assessed on a 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, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Applies structured history-taking to assess symptoms and risk factors.
2.3 Recognises red flag symptoms requiring urgent intervention.

3. Diagnosis, Decision-Making, and Reasoning

3.1 Formulates a differential diagnosis and explains reasoning clearly.
3.2 Identifies and manages potential complications.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.2 Recommends appropriate pharmacological and non-pharmacological treatments.

5. Preventive and Population Health

5.1 Provides preventive advice regarding insect bites, including protective measures.

6. Professionalism

6.1 Provides clear and compassionate patient education.

7. General Practice Systems and Regulatory Requirements

7.1 Documents the encounter appropriately, including vaccination status and treatment plan.

8. Procedural Skills

8.1 Administers tetanus vaccination if required.

9. Managing Uncertainty

9.1 Recognises when to refer or escalate care (e.g., rapidly worsening symptoms).

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and manages complications such as cellulitis or anaphylaxis.

Competency at Fellowship Level

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