CASE INFORMATION

Case ID: SCH-2025-01
Case Name: John Matthews
Age: 25
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: P72 (Schizophrenia)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages effectively with a patient with psychotic symptoms 1.2 Uses patient-centred language to build rapport and assess insight 1.5 Negotiates a shared management plan
2. Clinical Information Gathering and Interpretation	2.1 Elicits a thorough psychiatric history, including positive and negative symptoms 2.4 Assesses risk to self or others 2.6 Identifies substance use as a potential contributor
3. Diagnosis, Decision-Making and Reasoning	3.1 Formulates a working diagnosis of schizophrenia based on DSM-5 criteria 3.5 Differentiates schizophrenia from other psychotic disorders 3.6 Recognises first-episode psychosis and need for urgent intervention
4. Clinical Management and Therapeutic Reasoning	4.1 Initiates appropriate pharmacological management 4.2 Provides psychoeducation to patient and family 4.6 Coordinates care with mental health services
5. Preventive and Population Health	5.2 Provides preventive health advice on lifestyle, smoking cessation, and metabolic monitoring
6. Professionalism	6.1 Maintains a non-judgmental, compassionate approach
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate referral to a psychiatrist and community mental health team 7.3 Documents assessment and management plan in line with medico-legal standards
9. Managing Uncertainty	9.2 Manages diagnostic uncertainty in a young patient with emerging psychosis
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises schizophrenia as a serious mental illness requiring ongoing care

CASE FEATURES

25-year-old male with first-episode psychosis.
Paranoid delusions and auditory hallucinations.
Social withdrawal, decline in functioning.
Possible cannabis use disorder.
Requires risk assessment and urgent psychiatric referral.
Needs psychoeducation and long-term follow-up.

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: John Matthews
Age: 25
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

None currently

Past History

No prior psychiatric diagnoses
No significant medical history

Social History

Lives with parents
Unemployed, recent withdrawal from university
No partner, few social contacts

Family History

Maternal uncle diagnosed with schizophrenia

Smoking

Smokes cannabis daily

Alcohol

Occasional binge drinking

Vaccination and Preventative Activities

Up to date with vaccinations

SCENARIO

John Matthews, a 25-year-old male, is brought to your general practice clinic by his mother. She reports that he has become increasingly withdrawn over the past six months, avoiding family interactions and neglecting his personal hygiene.

John has been speaking to himself and expressing fears that “the government is tracking him through his phone.” His mother notes that he often laughs inappropriately and appears to be responding to voices. She has also found him staring at the mirror for long periods, saying he sees something moving behind him.

He recently dropped out of university, citing “conspiracies in the education system,” and refuses to leave the house. He has no known history of medical or psychiatric conditions but has been using cannabis daily since his late teens.

During the consultation, John is guarded but agrees to speak with you. He avoids eye contact, has blunted affect, and provides vague, tangential answers. He denies suicidal thoughts but appears preoccupied with unseen threats.

EXAMINATION FINDINGS

General Appearance: Dishevelled, poor eye contact, suspicious
Temperature: 36.8°C
Blood Pressure: 120/80 mmHg
Heart Rate: 72 bpm
Respiratory Rate: 16 breaths per minute
Oxygen Saturation: 98% RA
BMI: 24 kg/m²
Mental State Examination:

Appearance & Behaviour: Dishevelled, poor self-care, limited engagement
Speech: Slow, vague, and tangential
Mood & Affect: Blunted affect, suspicious demeanor
Thought Content: Paranoid delusions about government tracking
Perception: Auditory hallucinations (“hearing whispers about me”)
Insight: Poor – does not recognise illness
Judgment: Impaired – does not see need for treatment

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses, and what is your working diagnosis?

Prompt: How does this presentation align with schizophrenia?
Prompt: What other conditions must be excluded?

Q2. How would you assess John’s risk?

Prompt: What factors indicate a risk of harm to self or others?
Prompt: How would you ensure his safety?

Q3. How would you explain the diagnosis and management plan to John and his mother?

Prompt: What key points would you cover in psychoeducation?
Prompt: How do you address treatment adherence concerns?

Q4. What pharmacological and non-pharmacological treatments would you initiate?

Prompt: What medication would you consider first-line?
Prompt: What supportive interventions should be implemented?

Q5. How would you coordinate ongoing care for John?

Prompt: What referrals would be appropriate?
Prompt: How would you involve community mental health services?

THE COMPETENT CANDIDATE

Q1: What are your differential diagnoses, and what is your working diagnosis?

A structured approach to differential diagnosis is critical in evaluating a young male with psychotic symptoms. Based on the history and mental state examination, the most likely diagnosis is schizophrenia, as per DSM-5 criteria, characterised by delusions, hallucinations, disorganised thinking, and functional impairment persisting for at least six months.

Differential Diagnoses

Schizophrenia (most likely)
- Persistent paranoid delusions (government tracking him)
- Auditory hallucinations (hearing whispers)
- Negative symptoms (social withdrawal, poor hygiene)
- Functional decline (withdrawal from university, unemployment)
Substance-Induced Psychotic Disorder
- Daily cannabis use is a known risk factor for psychosis.
- Requires urine drug screening and clinical correlation.
- Symptoms may persist beyond intoxication or withdrawal.
Delusional Disorder
- Presents with fixed, non-bizarre delusions.
- Absence of hallucinations or significant disorganisation.
- Less likely due to significant functional decline.
Bipolar Disorder with Psychotic Features
- Grandiosity, pressured speech, or mood elevation would be expected.
- No clear manic or depressive episode in the history.
Major Depressive Disorder with Psychotic Features
- Low mood, hopelessness, and anhedonia must be prominent.
- Delusions are usually mood-congruent.
Organic Causes (Medical/Neurological Conditions)
- Thyroid dysfunction, CNS infection, epilepsy, or metabolic disorders.
- Investigations should include blood tests, neuroimaging (if indicated), and EEG.

Working Diagnosis

The presentation is most consistent with first-episode schizophrenia, considering the prolonged duration of symptoms, presence of delusions and hallucinations, and significant functional decline. Immediate psychiatric assessment and risk management are essential.

SUMMARY OF A COMPETENT ANSWER

Identifies schizophrenia as the most likely diagnosis based on DSM-5 criteria.
Considers substance-induced psychosis and the impact of cannabis use.
Differentiates schizophrenia from other psychotic disorders (e.g., delusional disorder, bipolar disorder).
Rules out organic causes (e.g., thyroid dysfunction, neurological conditions).
Emphasises need for urgent psychiatric evaluation and risk assessment.

PITFALLS

Failing to explore substance use thoroughly and its contribution to symptoms.
Not considering alternative diagnoses, such as mood disorders with psychotic features.
Overlooking functional decline as a key diagnostic criterion for schizophrenia.
Not acknowledging the need for further investigations to exclude organic causes.

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

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulates a working diagnosis of schizophrenia based on DSM-5 criteria.
3.5 Differentiates schizophrenia from other psychotic disorders.
3.6 Recognises first-episode psychosis and need for urgent intervention.

Competency at Fellowship Level

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