CCE-CBD-071

CASE INFORMATION

Case ID: SC-001
Case Name: Michael Peterson
Age: 58
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S26 – Fear of Skin Cancer / S82 – Nevus/Mole

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their concerns and expectations.
1.4 Communicates effectively in routine and difficult situations.
2. Clinical Information Gathering and Interpretation2.1 Obtains relevant clinical information, including personal and family history of skin cancer.
2.2 Performs comprehensive skin examination.
3. Diagnosis, Decision-Making and Reasoning3.1 Identifies suspicious lesions and differentiates benign from malignant lesions.
4. Clinical Management and Therapeutic Reasoning4.1 Develops an evidence-based management plan, including surveillance or biopsy.
5. Preventive and Population Health5.1 Advises on sun protection and skin cancer prevention.
6. Professionalism6.1 Demonstrates ethical practice, including informed consent for procedures and patient confidentiality.
7. General Practice Systems and Regulatory Requirements7.1 Uses appropriate referral pathways (e.g., dermatology, surgical).
7.2 Documents findings according to clinical guidelines.
9. Managing Uncertainty9.1 Explains uncertainty and rationale for surveillance versus intervention.
10. Identifying and Managing the Patient with Significant Illness10.1 Recognises potentially serious presentations requiring urgent intervention (e.g., melanoma).

CASE FEATURES

  • No systemic symptoms like weight loss, fatigue, or lymphadenopathy.
  • Presents for a routine full skin check at his wife’s request.
  • Has a family history of melanoma (mother diagnosed at 65).
  • Works as a gardener, with significant sun exposure over 30 years.
  • Fair-skinned, blue eyes, history of childhood sunburns.
  • Wears sunscreen “sometimes”, mostly wears a hat.
  • Noticed a new dark mole on his upper back, changing over the past 6 months.

INSTRUCTIONS

Review the following patient record summary and scenario.
Your examiner will ask you a series of questions based on this information.
You have 15 minutes to complete this case.

The time for each question will be managed by the examiner.
The time allocation for each question is roughly as follows:

  • 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: Michael Peterson
Age: 58
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

  • Atorvastatin 20 mg daily (hyperlipidaemia)
  • No other medications

Past History

  • Hyperlipidaemia (diagnosed 3 years ago)
  • No previous skin cancers or biopsies

Social History

  • Occupation: Gardener
  • Smoker: Never smoked
  • Alcohol: 1-2 standard drinks on weekends
  • Exercise: Active due to work
  • Lives with wife

Family History

  • Mother: Melanoma at 65
  • Father: Hypertension

Vaccination and Preventive Activities

  • Influenza vaccine: Up to date
  • COVID-19: Completed primary course, no recent boosters
  • No previous skin checks documented

SCENARIO

Michael Peterson presents for his first-ever skin check at the request of his wife. He has a personal concern about a new mole on his upper back that he believes has changed in size and colour over the past six months.

He spends most of his time outdoors due to his gardening work and reports frequent sun exposure, though he wears a hat and occasionally uses sunscreen. He recalls multiple severe sunburns during childhood and adolescence.

He reports no symptoms such as pain, bleeding, or ulceration of the mole but is worried because of his mother’s history of melanoma. He has no palpable lymphadenopathy or systemic symptoms.

EXAMINATION FINDINGS

General Appearance: Well, alert
Skin Exam:

  • Multiple solar lentigines on face and arms
  • Actinic keratoses on forearms
  • A single 6 mm asymmetric dark brown lesion with irregular borders on the upper back
    • Colours vary from dark brown to black
    • Slightly raised
    • No ulceration or bleeding noted
  • No other suspicious lesions identified
    Lymph nodes: No regional lymphadenopathy

INVESTIGATION FINDINGS

  • None yet performed.
    Dermoscopic examination of the upper back lesion shows:
  • Blue-grey veil
  • Asymmetry
  • Irregular pigment network
  • Areas of regression

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. Take a focused history and explain your findings to the patient.

  • Prompt: Explore risk factors for skin cancer
  • Prompt: Address patient concerns about family history

Q2. Describe your examination findings and explain their significance to the patient.

  • Prompt: Discuss features of concern in the mole
  • Prompt: Discuss dermoscopic findings

Q3. Outline your management plan for this lesion and other preventive measures.

  • Prompt: Biopsy/referral decision
  • Prompt: Ongoing skin surveillance and sun protection advice

Q4. Explain how you would manage patient anxiety regarding melanoma risk.

  • Prompt: Address patient’s fears and provide reassurance
  • Prompt: Outline follow-up and ongoing support

Q5. Discuss the role of the GP in early detection and management of skin cancers in Australia.

  • Prompt: Importance of skin checks in high-risk individuals
  • Prompt: GP role in education, prevention, and early intervention

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: Take a focused history and explain your findings to the patient.

The competent candidate should:

  • Begin by acknowledging the patient’s concern regarding the new mole on his back.
  • Explore key risk factors for skin cancer:
    • Personal history: First skin check, never had skin cancers or biopsies before.
    • Family history: Mother diagnosed with melanoma at 65.
    • Sun exposure: Works outdoors as a gardener with long-term sun exposure; had multiple childhood sunburns.
    • Skin type: Fair skin, blue eyes, higher susceptibility.
    • Sun protection habits: Wears a hat but inconsistent sunscreen use.
  • Explore concerns and expectations:
    • Patient’s anxiety about melanoma due to family history.
    • Desire for reassurance and understanding of potential next steps.
  • Summarise findings:
    • Identified a new, changing mole (size, colour) on the upper back, which warrants further assessment.
  • Provide clear, empathetic explanations about the significance of his risk factors and why thorough examination is essential.

Q2: Describe your examination findings and explain their significance to the patient.

The competent candidate should:

  • Provide an overview of the skin check:
    • No suspicious lesions found elsewhere.
    • Multiple solar lentigines and actinic keratoses (sun-related damage).
  • Discuss the concerning features of the mole:
    • Size: 6 mm.
    • Asymmetry, irregular borders, colour variation (dark brown to black).
    • Dermoscopic features: Asymmetry, irregular pigment network, blue-grey veil—features suspicious for melanoma.
  • Explain the need for further investigation (biopsy/excision).
  • Use patient-friendly language, avoid jargon, and check understanding.

Q3: Outline your management plan for this lesion and other preventive measures.

The competent candidate should:

  • Explain the next step is an excisional biopsy with a narrow margin to establish a histological diagnosis.
  • Discuss possible outcomes and next steps:
    • If melanoma, staging investigations and referral to a melanoma specialist.
    • If benign, regular surveillance.
  • Provide sun protection advice:
    • Daily use of SPF 50+ sunscreen.
    • Wearing protective clothing, sunglasses, hat.
    • Seeking shade between 10 am and 4 pm.
  • Recommend routine skin checks every 6–12 months due to high risk.
  • Offer information on self-skin examination techniques.

Q4: Explain how you would manage patient anxiety regarding melanoma risk.

The competent candidate should:

  • Acknowledge and normalise the patient’s concerns.
  • Provide factual, balanced information about melanoma prognosis when caught early.
  • Offer reassurance about the thoroughness of the approach.
  • Encourage active participation in health management through prevention and regular checks.
  • Provide written resources and recommend a melanoma support service if needed.

Q5: Discuss the role of the GP in early detection and management of skin cancers in Australia.

The competent candidate should:

  • Highlight Australia’s high rates of skin cancer and the critical role of primary care in early detection.
  • Explain that GPs perform opportunistic and systematic skin checks, identify high-risk individuals, and initiate early management.
  • Discuss coordination of care, including referrals to dermatologists, surgeons, and oncology teams.
  • Educate patients on prevention, sun safety, and self-examination.
  • Emphasise the importance of accurate documentation, monitoring, and follow-up.

SUMMARY OF A COMPETENT ANSWER

  • Comprehensive history-taking addressing personal risk factors, family history, and lifestyle.
  • Clear explanation of examination findings, focusing on the significance of dermatoscopic features.
  • Management plan includes biopsy, sun protection, regular follow-ups, and referrals as needed.
  • Addresses patient concerns empathetically, with a focus on education and reassurance.
  • Explains the GP’s role in skin cancer prevention, early detection, and coordination of care.

PITFALLS

  • Failing to identify and explain the significance of the high-risk features of the lesion.
  • Omitting shared decision-making regarding biopsy and management.
  • Providing inadequate education about skin cancer prevention and sun safety.
  • Not addressing the patient’s anxiety and fears empathetically.
  • Failing to explain follow-up plans clearly.

REFERENCES

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 Communication is appropriate 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 on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Obtains relevant clinical information, including personal and family history of skin cancer.
2.2 Performs comprehensive skin examination.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies suspicious lesions and differentiates benign from malignant lesions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan, including surveillance or biopsy.

5. Preventive and Population Health

5.1 Advises on sun protection and skin cancer prevention.

6. Professionalism

6.1 Demonstrates ethical practice, including informed consent for procedures and patient confidentiality.

7. General Practice Systems and Regulatory Requirements

7.1 Uses appropriate referral pathways (e.g., dermatology, surgical).
7.2 Documents findings according to clinical guidelines.

9. Managing Uncertainty

9.1 Explains uncertainty and rationale for surveillance versus intervention.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises potentially serious presentations requiring urgent intervention (e.g., melanoma).

Competency at Fellowship Level

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