Case Information
- Case ID: RX-009
- Patient Name: David Coleman
- Age: 39
- Gender: Male
- Indigenous Status: Non-Indigenous
- Year: 2025
- ICPC-2 Codes: A50 – Request for Medication Prescription
Competency Outcomes
| Competency Domain | Competency Element |
|---|---|
| 1. Communication and Consultation Skills | Establishing rapport, discussing medication safety, and addressing patient concerns about access to prescriptions |
| 2. Clinical Information Gathering and Interpretation | Reviewing medication history, indication, adherence, and potential side effects |
| 3. Diagnosis, Decision-Making and Reasoning | Evaluating the appropriateness of the prescription request based on clinical need and guidelines |
| 4. Clinical Management and Therapeutic Reasoning | Ensuring safe and rational prescribing while considering alternatives if necessary |
| 5. Preventive and Population Health | Promoting medication adherence and lifestyle modifications to optimise health outcomes |
| 6. Professionalism | Managing prescription requests ethically, including potential misuse and regulatory considerations |
| 7. General Practice Systems and Regulatory Requirements | Adhering to PBS regulations and safe prescribing guidelines, including S8 medications if applicable |
| 9. Managing Uncertainty | Identifying when further assessment or referral is required before prescribing |
| 10. Identifying and Managing the Patient with Significant Illness | Recognising when medication changes are needed due to evolving health conditions |
Case Features
- Reports recent work stress and difficulty sleeping, concerned about coping without medication.
- 39-year-old male requesting a repeat prescription for diazepam (Valium), stating he has run out and needs it urgently.
- Reports previous use for anxiety and muscle spasms, prescribed by a different doctor while travelling.
- No recent GP visits, and uncertain about dosage and duration of previous prescriptions.
- History of occasional alcohol use and past cannabis use, denies illicit drug use.
Instructions
The candidate is expected to review the following patient record and scenario. The examiner will ask a series of questions based on this information. The candidate has 15 minutes to complete this case.
The approximate time allocation for each question:
- Question 1: 3 minutes
- Question 2: 3 minutes
- Question 3: 3 minutes
- Question 4: 3 minutes
- Question 5: 3 minutes
Patient Record Summary
Patient Details
- Name: David Coleman
- Age: 39
- Gender: Male
- Indigenous Status: Non-Indigenous
Allergies and Adverse Reactions
- No known drug allergies
Medications
- Previously prescribed diazepam (unknown dose/duration) by another doctor
Past History
- History of anxiety, no documented diagnosis of generalised anxiety disorder (GAD)
- No prior psychiatric hospitalisations or specialist mental health input
- Occasional alcohol use, past cannabis use
Social History
- Works as a marketing executive, high-stress role
- Lives alone, reports poor sleep and recent relationship breakdown
- No history of illicit drug use other than past cannabis
Family History
- No family history of anxiety or substance use disorders
Vaccination and Preventive Activities
- Influenza vaccine: Up to date
- COVID-19 booster: Received
Scenario
David Coleman, a 39-year-old marketing executive, presents requesting a repeat prescription for diazepam (Valium), stating that he has run out and urgently needs it.
He was prescribed diazepam by another doctor while travelling, supposedly for anxiety and muscle spasms, but he is uncertain about the dosage and duration.
He describes recent work stress, difficulty sleeping, and feeling overwhelmed, especially after a relationship breakdown.
He denies illicit drug use but has a history of occasional alcohol consumption and past cannabis use.
On examination:
- General appearance: Well-dressed, no overt distress
- Mental state: Appears anxious but cooperative
- Vitals: BP 124/78 mmHg, HR 76 bpm, RR 16 bpm, SpO2 98%
- Neurological exam: No focal deficits
Likely Diagnosis: Medication Request – Requires Review for Appropriateness
THE COMPETENT CANDIDATE
The competent candidate should be able to:
Q1: How would you assess the appropriateness of prescribing diazepam for David?
The competent candidate should:
- Explore the indication and prescribing history:
- Confirm who prescribed diazepam previously, the dose, and duration of use.
- Clarify whether it was for anxiety, muscle spasm, or insomnia.
- Assess past and current adherence and whether the patient has required escalating doses.
- Screen for risks of benzodiazepine dependence:
- Ask about daily or escalating use, withdrawal symptoms, or craving.
- Assess for concurrent alcohol or substance use (risk of sedation and respiratory depression).
- Assess for underlying mental health conditions:
- Screen for anxiety disorders using GAD-7.
- Assess insomnia triggers and explore alternative treatment options.
- Consider safer alternatives:
- If anxiety-related, discuss CBT, SSRIs, or SNRIs as long-term management.
- If sleep-related, discuss sleep hygiene and melatonin.
Q2: How would you communicate with David about the risks and limitations of benzodiazepine use?
The competent candidate should:
- Acknowledge his concerns about stress and difficulty coping.
- Explain short-term benefits vs. long-term risks:
- Initially effective for anxiety and muscle relaxation.
- Risk of dependence, tolerance, withdrawal symptoms, and cognitive impairment.
- Long-term use is not first-line for anxiety or insomnia.
- Discuss tapering if already dependent:
- Gradual dose reduction plan to avoid withdrawal.
- Referral to a psychologist for non-drug therapy.
- Offer alternative treatments:
- If anxiety: CBT, mindfulness, SSRI/SNRI consideration.
- If insomnia: Sleep hygiene, melatonin, non-drug interventions.
Q3: What are the non-pharmacological strategies for managing David’s anxiety and sleep difficulties?
The competent candidate should:
- Lifestyle and behavioural changes:
- Regular exercise, mindfulness, and stress reduction techniques.
- Caffeine and alcohol reduction (can worsen anxiety and sleep issues).
- Cognitive Behavioural Therapy (CBT):
- Referral to psychologist or online CBT programs (e.g., MindSpot, This Way Up).
- Sleep hygiene:
- Regular sleep schedule, screen reduction, relaxation techniques.
- Consider SSRI or SNRI if anxiety is persistent.
Q4: What are the regulatory and safety considerations when prescribing benzodiazepines?
The competent candidate should:
- PBS and state regulations:
- Diazepam is Schedule 4, but some states require permits for long-term prescribing.
- Safe prescribing principles:
- Short courses only (2-4 weeks maximum).
- Monitor for signs of dependence and misuse.
- Document rationale clearly in the medical record.
- Follow-up and review:
- Arrange regular reviews to monitor ongoing need.
- Tapering plan if stopping long-term use.
Q5: When would you consider referral to a specialist?
The competent candidate should:
- Refer to a psychiatrist if:
- Severe generalised anxiety disorder not responding to first-line treatment.
- History of complex trauma or treatment-resistant symptoms.
- Refer to an addiction specialist if:
- Signs of benzodiazepine dependence, withdrawal, or misuse.
- Co-existing substance use disorder.
- Multidisciplinary approach:
- Psychologist for CBT.
- Pharmacist for medication review and tapering support.
SUMMARY OF A COMPETENT ANSWER
- Takes a thorough history of diazepam use, indication, and risks.
- Explains the risks of long-term benzodiazepine use and provides alternative management options.
- Recommends non-pharmacological strategies, including CBT, lifestyle changes, and sleep hygiene.
- Adheres to safe prescribing regulations, limits benzodiazepine use, and implements a deprescribing plan if needed.
- Recognises when specialist referral (psychiatry or addiction medicine) is required.
PITFALLS
- Prescribing benzodiazepines without assessing dependency risk.
- Failing to screen for underlying anxiety, depression, or substance use.
- Not offering safer alternatives (CBT, SSRIs, sleep hygiene).
- Ignoring PBS and regulatory requirements for long-term prescribing.
REFERENCES
- RACGP Benzodiazepine Prescribing Guidelines
- Australian Prescriber on Psychotropic Medications
- MindSpot (Free Online CBT Program)
MARKING
Each competency area is 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 Engages in a patient-centred discussion about prescription risks.
2. Clinical Information Gathering and Interpretation
2.1 Takes a structured medication and mental health history.
3. Diagnosis, Decision-Making and Reasoning
3.1 Evaluates the appropriateness of benzodiazepine prescribing.
4. Clinical Management and Therapeutic Reasoning
4.1 Implements safe prescribing and alternative treatment strategies.
5. Preventive and Population Health
5.2 Encourages non-drug approaches for anxiety and sleep issues.
6. Professionalism
6.3 Adheres to ethical and regulatory guidelines for prescribing.
7. General Practice Systems and Regulatory Requirements
7.2 Documents rationale for prescribing or deprescribing benzodiazepines.
9. Managing Uncertainty
9.1 Recognises when further assessment or referral is required.
10. Identifying and Managing the Patient with Significant Illness
10.3 Identifies red flags for addiction or psychiatric comorbidities.
Competency at Fellowship Level
☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD