CASE INFORMATION

Case ID: APP-001
Case Name: Michael Anderson
Age: 25
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: D88 (Appendicitis)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages patient effectively 1.3 Explains medical information in an understandable way 1.5 Elicits patient concerns and expectations empathetically
2. Clinical Information Gathering and Interpretation	2.1 Takes a focused and hypothesis-driven history 2.2 Selects and interprets relevant clinical findings appropriately
3. Diagnosis, Decision-Making and Reasoning	3.1 Identifies red flags for acute abdominal pain 3.4 Prioritises differential diagnoses based on clinical reasoning
4. Clinical Management and Therapeutic Reasoning	4.2 Initiates appropriate urgent management 4.4 Discusses the role of referral to secondary care
5. Preventive and Population Health	5.2 Educates about preventing complications of delayed presentation
6. Professionalism	6.3 Demonstrates responsibility for patient safety and timely referral
7. General Practice Systems and Regulatory Requirements	7.2 Uses appropriate referral pathways for urgent conditions
9. Managing Uncertainty	9.1 Recognises and manages diagnostic uncertainty in acute abdominal pain
10. Identifying and Managing the Patient with Significant Illness	10.2 Identifies potentially serious conditions requiring emergency management

CASE FEATURES

Young male presenting with acute abdominal pain.
Classical symptoms of appendicitis, requiring urgent referral.
Decision-making under uncertainty – appendicitis can have atypical presentations.
Patient education on potential complications if left untreated.
Appropriate referral and management in the general practice setting.

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

Michael Anderson, a 25-year-old male, presents to your general practice with a 2-day history of abdominal pain. Initially, the pain was vague and around the umbilicus, but it has now migrated to the right lower quadrant and has worsened. He describes it as sharp and constant, rated 6/10 in intensity. He also reports mild nausea and loss of appetite. He denies vomiting but has felt increasingly unwell.

Your clinic nurse has recorded the following observations:

Temperature: 37.8°C
Heart rate: 96 bpm
Blood pressure: 118/76 mmHg
Respiratory rate: 18 breaths/min
Abdomen: Mild tenderness in the right lower quadrant, no palpable masses.

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Anderson
Age: 25
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

None

Past History

Nil significant

Social History

Works as a teacher

Family History

No family history of bowel disease or cancers

Smoking

Never smoked

Alcohol

Drinks socially, 1-2 times per week

Vaccination and Preventative Activities

Up to date with routine 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, my stomach has been hurting for two days now, and it’s getting worse. Do you think it’s just something I ate?”

General Information

(Freely Given if the Candidate Asks Open-Ended Questions)

The pain started about two days ago as a dull ache around my belly button. At first, I thought it was just a stomach bug or something I ate.
Over time, the pain moved to the lower right side of my belly and has become sharper. It feels deep inside, and moving around makes it worse.
I’ve felt a bit nauseous, and my appetite is not great. Normally, I eat a lot, but I’ve hardly had anything today because I just don’t feel like eating.

Specific Information

(Only Given if the Candidate Asks Direct Questions)

Background Information

I feel like I’ve had a low-grade fever, but I haven’t checked my temperature at home.
I haven’t vomited, but I’ve felt like I might a few times.
My bowels are a bit off—I haven’t gone to the toilet as much as usual, but when I do, it’s normal-looking, no diarrhoea or blood.
I haven’t had any burning or pain when passing urine.

Pain History:

The pain is worse when I move around, cough, or go over bumps in the car.
Lying still is better, but rolling over in bed hurts.
I would say the pain is about 6 out of 10, and it’s getting worse.

Red Flags (If the Candidate Asks About Worrying Symptoms):

No vomiting, but mild nausea.
I feel a little hot but haven’t checked my temperature at home.
I haven’t passed much wind today.

Past Medical History & Risk Factors:

I’ve never had this kind of pain before.
No recent travel or contact with sick people.
No history of food allergies or intolerances.
No previous stomach ulcers or acid reflux.

Medications & Lifestyle:

I don’t take any regular medications.
No history of kidney stones or gallstones.
I drink socially, maybe once or twice a week but haven’t had alcohol in over a week.
I’ve never smoked.

Emotional Cues & Patient’s Concerns

Initially, worried but unsure if the pain is serious.
Becomes more anxious if the doctor mentions hospital:
- “Wait, do you really think I need to go to hospital? Can’t I just take something and see if it goes away?”
Concerned about surgery:
- “You don’t think I need surgery, do you? I’ve never had an operation before, and that sounds scary.”
Worried about missing work:
- “I’m supposed to be teaching tomorrow. What if I need to take time off?”
Seeks reassurance:
- “How do you know this isn’t just food poisoning or gas?”
If the candidate explains appendicitis well, patient accepts the need for referral but still seems a little reluctant:
- “So you really think I should go to the hospital now? What happens if I just wait and see?”

Questions the Patient Might Ask

“Is this something serious?”
“Could this just be food poisoning?”
“How do you know it’s appendicitis? Do I need tests?”
“If I need surgery, how long will I be in hospital?”
“What happens if I don’t go to the hospital?”
“If I do need surgery, will I have a big scar?”
“Is there any chance this will go away on its own?”

Escalating the Scenario Based on the Candidate’s Approach

If the candidate hesitates about referral, the patient will express concern about being in pain but still reluctant to go to hospital.
If the candidate firmly recommends hospital, the patient will question it at first but accept the advice with good explanation.
If the candidate does not explain appendicitis well, the patient will keep asking if painkillers will help and whether they can wait it out at home.
If the candidate fails to mention complications, the patient will not feel urgency and may say, “I’ll wait and see how I feel tomorrow.”
If the candidate explains complications well, the patient will show concern and become more accepting of referral.

End of Scenario

If the candidate has explained things clearly, the patient accepts hospital referral and asks for reassurance:
- “Okay, I trust you, Doctor. I’ll go. But what should I expect when I get there?”
If the candidate is unclear or passive, the patient will still hesitate, saying:
- “Maybe I’ll just rest and see how I feel later. If it’s worse, I’ll go then.”
The candidate must address concerns and encourage immediate action for a successful consultation.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, considering the possible causes of abdominal pain.

The competent candidate should:

Use open-ended and focused questions to gather relevant details about the pain (onset, location, character, radiation, severity, exacerbating/relieving factors).
Recognise the evolution of pain from periumbilical to right lower quadrant, suggesting appendicitis.
Identify red flag symptoms (worsening pain, fever, nausea, reduced bowel movements).
Explore other possible causes (e.g., gastroenteritis, urinary tract infection, testicular pathology, gynaecological causes in female patients).
Assess risk factors (previous similar episodes, family history of gastrointestinal conditions, recent infections).
Explore the impact on daily activities and patient concerns (anxiety about work, fear of surgery).

Task 2: Outline the differential diagnosis and your rationale.

The competent candidate should:

List primary differential diagnoses with justification:
- Appendicitis – classic presentation with migratory pain and worsening right lower quadrant tenderness.
- Gastroenteritis – would typically involve diarrhoea, widespread cramping, and no localisation of pain.
- Renal colic – intermittent, severe pain radiating to the groin, possibly with haematuria.
- Testicular torsion – should be considered in young males, though usually presents with scrotal pain and swelling.
Consider red flag conditions, such as perforated appendicitis or ruptured ectopic pregnancy (in female patients).
Use clinical reasoning to prioritise appendicitis as the most likely and requiring urgent referral.

Task 3: Explain your proposed management plan to the patient.

The competent candidate should:

Clearly communicate the high suspicion of appendicitis and the need for urgent hospital referral.
Explain why delaying treatment is risky (risk of perforation, peritonitis).
Discuss next steps at the hospital: clinical assessment, blood tests, imaging, possible surgery.
Address patient concerns (pain, fear of surgery, work commitments).
Provide safety-netting advice if the patient is reluctant (e.g., worsening pain, fever, vomiting → immediate ED presentation).

Task 4: Discuss next steps, including referral and patient education.

The competent candidate should:

Organise urgent referral to emergency department for further assessment and likely surgical intervention.
Provide reassurance about the standard and effectiveness of treatment.
Educate about post-operative care if surgery is required (recovery expectations, wound care, follow-up).
Emphasise importance of timely intervention and risks of untreated appendicitis.

SUMMARY OF A COMPETENT ANSWER

History-taking is systematic, identifying classic features of appendicitis and excluding differentials.
Differential diagnosis is well-structured, prioritising appendicitis while considering other possibilities.
Management is clear and appropriate, with urgent referral and explanation of risks.
Communication is patient-centred, addressing concerns and providing reassurance.
Referral and follow-up plans are well-defined, ensuring patient safety.

PITFALLS

Failing to recognise appendicitis as a time-critical diagnosis requiring urgent referral.
Not considering red flags (e.g., worsening pain, fever, signs of peritonitis).
Providing unclear or vague advice instead of firm recommendations.
Dismissing patient concerns or failing to address fear of surgery.
Not explaining the risks of delaying treatment, leading to patient reluctance.

REFERENCES

MARKING

Each competency area is assessed on the following scale:

☐ 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 symptoms, ideas, concerns, and expectations.
1.4 Communicates effectively, even in challenging situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a focused history, identifying key symptoms and red flags.
2.2 Uses clinical reasoning to interpret findings appropriately.

3. Diagnosis, Decision-Making and Reasoning

3.1 Prioritises differential diagnoses based on history and clinical presentation.
3.4 Recognises urgency and need for immediate action.

4. Clinical Management and Therapeutic Reasoning

4.2 Provides safe and effective management, including urgent referral.
4.4 Explains the rationale behind decisions, ensuring patient understanding.

5. Preventive and Population Health

5.2 Educates patient on the importance of timely intervention to prevent complications.

6. Professionalism

6.3 Demonstrates responsibility for patient safety and appropriate decision-making.

7. General Practice Systems and Regulatory Requirements

7.2 Uses appropriate referral pathways to ensure timely management.

9. Managing Uncertainty

9.1 Handles diagnostic uncertainty appropriately, using risk stratification.

10. Identifying and Managing the Patient with Significant Illness

10.2 Recognises the need for urgent intervention in potential serious illness.

Competency at Fellowship Level

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