CASE INFORMATION

Case ID: NAEV-2025-03
Case Name: Daniel Roberts
Age: 34
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S82 (Naevus/mole)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages effectively with the patient to assess concerns about a mole 1.3 Explains the significance of suspicious features in simple terms 1.5 Uses shared decision-making regarding further investigation or referral
2. Clinical Information Gathering and Interpretation	2.1 Conducts a thorough dermatological history and examination 2.3 Applies the ABCDE criteria to assess the mole 2.4 Identifies risk factors for melanoma
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between benign and suspicious naevi 3.5 Recognises when urgent referral is needed
4. Clinical Management and Therapeutic Reasoning	4.2 Advises on monitoring, biopsy, or excision as appropriate 4.5 Provides clear follow-up instructions and skin cancer prevention advice
5. Preventive and Population Health	5.1 Educates on sun safety and skin surveillance 5.3 Encourages regular skin checks for at-risk individuals
6. Professionalism	6.1 Provides reassurance while addressing the patient’s concerns
7. General Practice Systems and Regulatory Requirements	7.1 Documents clinical findings and management plan clearly 7.2 Ensures appropriate referral pathways for suspected malignancy
9. Managing Uncertainty	9.1 Addresses diagnostic uncertainty by considering dermatoscopy or biopsy
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises when a lesion requires urgent specialist review

CASE FEATURES

Male patient presenting with concern about a mole that has changed.
History of fair skin, frequent sunburns, and outdoor work.
No personal or family history of melanoma.
Patient is anxious about skin cancer.
Needs an assessment of whether biopsy, excision, or monitoring is appropriate.

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: Daniel Roberts
Age: 34
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

None currently

Past History

No history of melanoma or other skin cancers

Social History

Works as a landscaper, with high sun exposure
Often forgets to apply sunscreen
Frequently experiences sunburn

Family History

No known family history of melanoma

Smoking

Non-smoker

Alcohol

Drinks 3–4 standard drinks per week

Vaccination and Preventative Activities

No history of routine skin checks

SCENARIO

Daniel Roberts, a 34-year-old landscaper, presents with a mole on his upper back that has changed over the past six months. His partner noticed that it looks darker and slightly larger than before.

Daniel has never had a full skin check and is worried about melanoma. He has a history of frequent sun exposure and sunburns, often working outdoors without sunscreen.

On examination, the mole is approximately 8mm in diameter, asymmetrical, and has irregular borders with colour variation. There is no ulceration or bleeding.

Daniel is concerned about the next steps and wants to know whether he needs a biopsy or removal.

EXAMINATION FINDINGS

General Appearance: Well, no acute distress
Dermatological Exam (Upper Back Mole):

Size: ~8mm
Asymmetry: Present
Border: Irregular
Colour: Multiple shades of brown
Diameter: Increased over six months
Evolving features: Recently changed in size and colour

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What aspects of history and examination are critical in assessing this mole?

Prompt: What risk factors increase the suspicion of melanoma?
Prompt: How do you apply the ABCDE criteria in this case?

Q2. Based on the findings, what is your differential diagnosis, and what is your working diagnosis?

Prompt: How do you differentiate between benign and malignant lesions?
Prompt: What makes this mole concerning?

Q3. What investigations or management steps would you recommend?

Prompt: When is biopsy versus excision appropriate?
Prompt: Would you refer this patient for specialist assessment?

Q4. How would you counsel Daniel about his risk and next steps?

Prompt: How do you explain the need for biopsy or excision?
Prompt: What lifestyle modifications and preventive strategies should he adopt?

Q5. What follow-up plan would you implement?

Prompt: When should he return for review?
Prompt: What ongoing skin cancer surveillance is recommended?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What aspects of history and examination are critical in assessing this mole?

A structured approach is essential when assessing a changing mole. The history and clinical examination should determine risk factors for malignancy and guide management.

1. History

Timeline of changes: Assess duration, rate of growth, colour changes, and symptoms (itching, bleeding, ulceration).
Previous skin cancer history: Personal or family history of melanoma increases risk.
Sun exposure history: High UV exposure, outdoor work, past sunburns, and tanning bed use are significant risk factors.
Skin type: Fair skin, freckles, and difficulty tanning increase melanoma susceptibility.
Immune status: Immunosuppression (e.g., post-organ transplant, immunosuppressive therapy) raises melanoma risk.

2. Clinical Examination

ABCDE criteria (for melanoma suspicion):
- Asymmetry: One half differs from the other.
- Border irregularity: Uneven or scalloped edges.
- Colour variation: Multiple colours (brown, black, blue, red, white).
- Diameter: >6mm is concerning.
- Evolving: Changes in size, shape, or symptoms.
Dermatoscopy assessment:
- Atypical network, blue-white veil, irregular globules, or streaks raise suspicion.
- Benign features include uniform pigment, regular network, and symmetry.
Regional lymph nodes: Assess for lymphadenopathy, indicating potential metastasis.

This structured approach ensures early detection of malignant lesions and allows for appropriate triage and referral.

SUMMARY OF A COMPETENT ANSWER

Comprehensive history, including mole changes, sun exposure, and skin cancer risk factors.
Applies ABCDE criteria to assess melanoma risk.
Uses dermatoscopy to enhance diagnostic accuracy.
Evaluates lymph nodes to assess for metastatic spread.

PITFALLS

Failing to ask about mole evolution and relying solely on current appearance.
Not applying the ABCDE criteria, leading to missed melanoma detection.
Ignoring sun exposure history, an important risk factor.
Overlooking dermatoscopy, which improves diagnostic accuracy.

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

2. Clinical Information Gathering and Interpretation

2.1 Conducts a thorough dermatological history and examination.
2.3 Applies the ABCDE criteria to assess the mole.
2.4 Identifies risk factors for melanoma.

Competency at Fellowship Level

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