CCE-CBD-212 - GP Exams

CASE INFORMATION

Case ID: CFS-001
Case Name: Emily Dawson
Age: 29 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: A04 (Chronic fatigue syndrome)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Creates a safe and empathetic space for discussing chronic symptoms 1.2 Uses clear and supportive explanations about chronic fatigue syndrome 1.3 Addresses patient concerns and expectations about diagnosis and management
2. Clinical Information Gathering and Interpretation	2.1 Takes a thorough history of fatigue, associated symptoms, and functional impact 2.2 Conducts a focused physical examination 2.3 Recognises red flags suggesting alternative diagnoses
3. Diagnosis, Decision-Making and Reasoning	3.1 Applies the Institute of Medicine (IOM) criteria for diagnosing chronic fatigue syndrome 3.2 Differentiates CFS from other causes of fatigue (thyroid disease, anaemia, autoimmune conditions) 3.3 Recognises psychiatric comorbidities that may overlap with CFS
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an individualised management plan with a graded exercise and pacing approach 4.2 Explains pharmacological and non-pharmacological treatment options 4.3 Sets realistic goals for symptom control and functional improvement
5. Preventive and Population Health	5.1 Screens for depression, anxiety, and sleep disorders 5.2 Encourages lifestyle modifications to improve energy and function
6. Professionalism	6.1 Validates the patient’s experience and ensures a non-dismissive approach
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate referrals (e.g., physiotherapy, psychology, sleep specialist) 7.2 Provides structured follow-up and chronic condition support
9. Managing Uncertainty	9.1 Recognises that CFS is a diagnosis of exclusion and requires ongoing assessment
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and manages comorbid conditions, such as fibromyalgia or post-viral syndrome

CASE FEATURES

Young woman with persistent fatigue, brain fog, and post-exertional malaise.
Excludes alternative medical and psychiatric causes of fatigue.
Discussion around symptom pacing, activity management, and non-pharmacological treatments.
Long-term management and multidisciplinary care approach.

CANDIDATE INFORMATION

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: Emily Dawson
Age: 29 years
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Melatonin 2 mg nightly (for sleep disturbance)
Sertraline 50 mg daily (for mild anxiety)

Past History

Fatigue for 8 months, worsening after a viral illness.
Post-exertional malaise: Energy crashes after minor physical or mental exertion.
Cognitive dysfunction (“brain fog”): Difficulty concentrating at work.
Sleep disturbances: Unrefreshing sleep, frequent awakenings.
No significant autoimmune, endocrine, or infectious disease history.

Social History

Works as a graphic designer but recently reduced work hours due to fatigue.
Lives alone, strong family support.
Minimal physical activity due to energy limitations.
No smoking, occasional alcohol use.

Family History

No family history of autoimmune disease or chronic fatigue syndrome.
Mother has generalised anxiety disorder.

Vaccination and Preventative Activities

Recent viral illness (suspected glandular fever 8 months ago, never formally diagnosed).
No prior chronic disease screenings.

SCENARIO

Emily, a 29-year-old woman, presents with ongoing fatigue, brain fog, and post-exertional malaise that began after a viral illness 8 months ago. She reports waking unrefreshed, struggling to maintain her workload, and experiencing extreme exhaustion after minimal activity.

She has seen multiple doctors, with normal blood tests and no identified cause for her fatigue. She is frustrated and worries she will never feel normal again. She asks, “Do I have chronic fatigue syndrome, and what can I do about it?”

Your role is to assess Emily’s symptoms, confirm the diagnosis, discuss management options, and provide long-term self-management strategies.

EXAMINATION FINDINGS

General Appearance: Tired-looking but engaged in conversation
Vital Signs: Normal
Musculoskeletal Examination: No joint swelling or muscle weakness
Neurological Examination: Normal reflexes, strength, and coordination
Cognitive Function: Mild concentration difficulties but no focal deficits
Mental Health Screening: Mild anxiety, no major depressive features

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess Emily to confirm a diagnosis of chronic fatigue syndrome?

Prompt: What diagnostic criteria apply?
Prompt: How would you differentiate CFS from other causes of fatigue?

Q2. What investigations would you consider, and why?

Prompt: What conditions should be ruled out?
Prompt: How do you ensure appropriate but not excessive testing?

Q3. What management options would you discuss with Emily?

Prompt: What lifestyle modifications and non-pharmacological treatments are effective?
Prompt: What pharmacological options can be considered?

Q4. How would you counsel Emily about the long-term nature of chronic fatigue syndrome and realistic expectations?

Prompt: How do you validate her symptoms while setting realistic goals?
Prompt: What strategies can help her manage work and daily activities?

Q5. What long-term follow-up and referral strategies would you recommend?

Prompt: What multidisciplinary support can be beneficial?
Prompt: How often should she be reviewed?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess Emily to confirm a diagnosis of chronic fatigue syndrome?

1. Comprehensive History-Taking

Fatigue characteristics: Duration (>6 months), severity, post-exertional malaise.
Associated symptoms:
- Cognitive impairment (“brain fog”).
- Unrefreshing sleep and sleep disturbances.
- Muscle/joint pain without inflammation.
- Autonomic symptoms (dizziness, palpitations).
Impact on daily function: Work, social life, exercise tolerance.
Psychosocial factors: Anxiety, depression, stress.

2. Application of the Institute of Medicine (IOM) Criteria for CFS

Diagnosis requires all three core symptoms:

Significant, unexplained fatigue lasting >6 months.
Post-exertional malaise (PEM).
Unrefreshing sleep. AND at least one of the following:

Cognitive impairment or
Orthostatic intolerance.

3. Differentiating from Other Conditions

Hypothyroidism, diabetes (test TSH, fasting glucose).
Iron deficiency anaemia (check ferritin).
Autoimmune disease (screen for SLE, rheumatoid arthritis if suggestive features).
Depression/anxiety (assess PHQ-9, GAD-7).

Conclusion: Emily meets the clinical criteria for CFS, with post-viral onset, PEM, and cognitive symptoms.

Q2: What investigations would you consider, and why?

1. Essential Baseline Tests

FBC, iron studies: Rule out anaemia.
TSH, free T4: Exclude thyroid dysfunction.
U&E, LFTs, glucose: Screen for metabolic issues.
CRP, ESR: Identify inflammatory conditions.
Vitamin D, B12: Assess for deficiencies.

2. Optional Tests (If Red Flags Present)

Autoimmune markers (ANA, RF, ENA) if joint pain or rash.
Sleep study if significant sleep disturbances.
ECG if palpitations or postural dizziness.

3. Avoid Over-Investigation

No specific test confirms CFS.
Unnecessary testing may increase patient anxiety.

Conclusion: Investigations help exclude other causes, but CFS remains a clinical diagnosis.

Q3: What management options would you discuss with Emily?

1. Non-Pharmacological Management (First-Line)

Pacing strategies: Energy conservation to prevent post-exertional crashes.
Graded exercise therapy (if tolerated): Low-intensity movement (yoga, stretching).
Cognitive-behavioural therapy (CBT): Helps reframe thoughts around fatigue.
Sleep hygiene measures: Fixed wake times, limiting stimulants.

2. Pharmacological Management (Symptom Control)

Pain relief: Paracetamol, pregabalin if neuropathic pain.
Sleep aid: Melatonin, amitriptyline (low dose).
Address comorbid anxiety/depression: SSRIs (if indicated).

3. Supportive Care

Referral to physiotherapy, psychology, pain management if needed.
Encouraging social support and workplace accommodations.

Conclusion: Multidisciplinary care with an emphasis on self-management is essential.

Q4: How would you counsel Emily about the long-term nature of chronic fatigue syndrome and realistic expectations?

1. Validate Her Experience

Acknowledge symptoms: “I understand this has been frustrating for you.”
Explain CFS mechanism: Likely related to dysregulation of the nervous and immune systems.

2. Set Realistic Goals

Symptoms improve over time but may fluctuate.
Focus on managing energy, rather than “pushing through”.
Encourage small, achievable lifestyle changes.

3. Address Emotional Impact

Monitor for depression/anxiety.
Encourage self-compassion and stress reduction strategies.

Conclusion: A patient-centred, supportive approach helps reduce distress and improve long-term outcomes.

Q5: What long-term follow-up and referral strategies would you recommend?

1. Regular GP Reviews

Monitor symptom progression.
Screen for new comorbidities (e.g., depression, fibromyalgia).
Adjust treatment plan as needed.

2. Multidisciplinary Referrals

Physiotherapy: For pacing and movement therapy.
Psychology: CBT for coping strategies.
Sleep specialist: If ongoing unrefreshing sleep.
Occupational therapy: Workplace accommodations.

3. Patient Education and Self-Management

Encourage peer support groups.
Provide reliable resources (e.g., Emerge Australia, RACGP guidelines).

Conclusion: A long-term management plan with structured follow-up optimises patient well-being.

SUMMARY OF A COMPETENT ANSWER

Applies the Institute of Medicine criteria to confirm CFS diagnosis.
Orders appropriate investigations to exclude other causes.
Uses a multimodal, patient-centred approach to management.
Provides realistic counselling on prognosis and self-management.
Implements long-term follow-up with allied health referrals.

PITFALLS

Over-investigating despite clinical diagnosis of CFS.
Failing to validate symptoms, leading to patient frustration.
Recommending high-intensity exercise, worsening post-exertional malaise.
Not screening for comorbid mental health conditions.
Neglecting long-term follow-up and support options.

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

Competency at Fellowship Level

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