Case ID: CCE-2025-001
Case Name: Margaret Wilson
Age: 78
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A88 (Dizziness and Giddiness), K86 (Hypertension), T92 (Medication Side Effects)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their concerns and expectations. 1.2 Explains diagnosis and management in an understandable way. 1.5 Negotiates a shared management plan.
2. Clinical Information Gathering and Interpretation	2.1 Takes a comprehensive medication history, including adherence and side effects. 2.2 Identifies polypharmacy and potential medication interactions.
3. Diagnosis, Decision-Making and Reasoning	3.2 Recognises postural hypotension as a possible cause of falls. 3.5 Formulates a differential diagnosis considering polypharmacy and comorbidities.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an appropriate medication management plan. 4.3 Initiates deprescribing where appropriate. 4.5 Recommends Webster packing or other adherence aids.
5. Preventive and Population Health	5.1 Addresses fall prevention strategies. 5.3 Provides education on medication safety.
6. Professionalism	6.1 Ensures shared decision-making and patient autonomy.
7. General Practice Systems and Regulatory Requirements	7.1 Coordinates care with a pharmacist or aged care team.
9. Managing Uncertainty	9.2 Recognises and manages uncertainty related to polypharmacy and symptom attribution.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and addresses high-risk factors for falls and medication-related adverse effects.

CASE FEATURES

Involvement of multidisciplinary care team (pharmacist, aged care services).
Elderly patient experiencing confusion and falls, likely related to polypharmacy.
Possible postural hypotension contributing to dizziness and falls.
Medication management issue, including potential for deprescribing and Webster packing.
Need for fall prevention and patient education.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take a detailed history
Outline the differential diagnosis and key investigations required.
Address the patient’s concerns.
Develop a safe and patient-centred management plan.

SCENARIO

Margaret Wilson, a 78-year-old woman, presents to your clinic with her daughter, who is concerned about her recent confusion and frequent falls at home. Margaret reports feeling dizzy, especially when standing up, and has difficulty remembering whether she has taken her medications. She has multiple chronic conditions, including hypertension, osteoarthritis, and type 2 diabetes. She takes several medications, including an antihypertensive, a statin, metformin, and a benzodiazepine for sleep.

PATIENT RECORD SUMMARY

Patient Details

Name: Margaret Wilson
Age: 78
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Amlodipine 10mg daily
Metformin 1000mg BD
Atorvastatin 40mg nocte
Temazepam 10mg nocte
Paracetamol 1g PRN

Past History

Hypertension
Type 2 diabetes
Osteoarthritis
Insomnia

Social History

Lives alone, daughter visits regularly

Family History

Mother had dementia in her late 80s

Smoking

Ex-smoker, quit 15 years ago

Alcohol

Drinks occasionally, 1-2 drinks per week

Vaccination and Preventative Activities

Influenza and pneumococcal vaccines up to date

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

Opening Line

“Doctor, my daughter keeps saying I’ve been getting confused, but I feel fine most of the time. I do keep falling over, though.”

General Information

(Provide this information if the candidate asks general, open-ended questions such as “Can you tell me more about that?”)

You are Margaret Wilson, a 78-year-old woman living alone in your own home.
Your daughter, Sarah, visits regularly, and a community nurse comes once a week.
You have had a few falls recently, but you don’t remember exactly how many.
You sometimes feel dizzy, especially when you stand up too quickly.

Specific Information

(Reveal these only if the candidate asks relevant questions.)

Background Information

You don’t think you have memory problems, but your daughter says you keep asking the same questions.
You take several medications but sometimes forget whether you’ve taken them.
You try to stay independent and don’t want to be seen as someone who “needs looking after.”
You enjoy watching TV, reading, and knitting but have been feeling more tired lately.

Falls and Dizziness

You have fallen about five times in the past six months.
The most recent fall happened two weeks ago when you got up from the couch too quickly.
You sometimes feel lightheaded when standing up but didn’t think much of it.
You hit your head once on a table but didn’t go to the hospital.
You use a walking stick but don’t always feel steady.
You feel more off-balance in the morning.
You worry about falling in the shower but don’t want to use a shower chair.

Memory and Confusion

Your daughter says you repeat yourself but you don’t think you have memory issues.
You sometimes forget why you walked into a room.
You occasionally misplace things, like your glasses or keys.
You have trouble remembering if you took your morning tablets, so you sometimes take another dose, “just in case.”
You are worried about dementia because your mother had it, but you don’t think you have it yet.

Medication Use

You take Amlodipine for blood pressure, Metformin for diabetes, Atorvastatin for cholesterol, Temazepam for sleep, and Paracetamol for knee pain.
You sometimes take extra Paracetamol when your knees hurt but don’t exceed the recommended dose.
You only take Temazepam on nights when you really can’t sleep.
You don’t like asking for help with your medications because it makes you feel like you’re losing independence.
You don’t use a pill organiser because you find it confusing.
You’re not sure why you need so many medications but assume they are all necessary.

Concerns and Expectations

You are worried that the doctor will take away your medications.
You don’t want to be put in aged care and fear losing your independence.
You are open to suggestions but don’t want to feel like you’re being treated as incapable.
You’re worried about falling again and hurting yourself badly.
You don’t want your daughter to worry too much about you.

Emotional Cues and Body Language

You appear slightly defensive at first, as you don’t believe you’re “confused.”
You look embarrassed when talking about forgetting your medications.
You show frustration when your daughter interrupts or speaks on your behalf.
You seem worried when discussing your falls.
You relax if the doctor reassures you and explains things in a way that makes sense.

Questions for the Candidate

(Ask these at appropriate moments in the conversation.)

“Could my dizziness be caused by my blood pressure tablets?”
“Do I need to change my medications, or is there another way to fix this?”
“What can I do to stop falling so much?”
“Is there a way to make taking my medications easier without feeling like I’m being treated like a child?”
“Do you think I have dementia?”

Final Notes for the Role-Player

You are not openly resistant but need reassurance about any changes to your medication.
You want to stay independent but are starting to realise you may need help.
You appreciate a doctor who listens and explains things clearly.
If the candidate is empathetic and patient, you gradually become more open to suggestions.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a detailed history, including medication use, adherence, and symptoms.

The competent candidate should:

Elicit a thorough history of falls: Identify the frequency, circumstances, and any preceding symptoms such as dizziness, lightheadedness, or confusion.
Assess for postural hypotension: Ask whether dizziness occurs upon standing, how quickly symptoms resolve, and if there are any near-syncope episodes.
Explore medication use and adherence:
- Identify polypharmacy issues, including medication duplications or unnecessary prescriptions.
- Determine adherence patterns (e.g., missed or extra doses).
- Ask about recent changes in medications that might contribute to side effects.
Assess cognitive function and memory concerns:
- Ask about forgetfulness, missed medications, repetitive questioning, or getting lost.
- Screen for possible mild cognitive impairment or early dementia, considering family history.
Evaluate risk factors for falls:
- Recent changes in mobility, strength, or balance.
- Use of mobility aids (stick or walker) and their effectiveness.
- Environmental hazards at home (e.g., rugs, poor lighting, stairs).
Assess psychosocial factors:
- Understand patient’s concerns about independence and medication reduction.
- Explore support systems (family, carers, community nurse).

Task 2: Identify possible causes for the patient’s symptoms and formulate a differential diagnosis.

The competent candidate should:

Prioritise postural hypotension due to antihypertensive use and possible overmedication.
Consider medication side effects, particularly from:
- Amlodipine (hypotension, dizziness).
- Temazepam (confusion, drowsiness, increased fall risk).
- Polypharmacy and potential drug interactions.
Assess for cognitive impairment or early dementia:
- Differentiate between normal ageing, mild cognitive impairment, and dementia.
Rule out metabolic causes:
- Check for hypoglycaemia or electrolyte disturbances due to metformin use.
Consider other neurological conditions:
- Cerebrovascular disease (previous small strokes).
- Parkinsonism or peripheral neuropathy.
Investigate cardiovascular causes:
- Underlying cardiac arrhythmias.
- Orthostatic intolerance from autonomic dysfunction.

Task 3: Explain your findings to the patient and discuss potential management options, including deprescribing and Webster packing.

The competent candidate should:

Use clear, non-judgmental language to explain possible causes of symptoms.
Acknowledge patient concerns about confusion and falls while emphasising safety.
Explain the risk of postural hypotension and its link to blood pressure medications.
Introduce the concept of deprescribing:
- Gradual reduction of Temazepam to improve cognitive function and reduce fall risk.
- Reassess the necessity of Amlodipine.
Discuss Webster packing or alternative medication management strategies.
Provide fall prevention strategies, including:
- Home modifications (handrails, adequate lighting).
- Physiotherapy for strength and balance training.
- Regular monitoring and follow-up.

Task 4: Develop a management plan that prioritises safety, fall prevention, and appropriate medication use.

The competent candidate should:

Optimise medication safety:
- Trial deprescribing Temazepam under supervision.
- Consider dose reduction or alternative to Amlodipine if postural hypotension persists.
Implement fall prevention measures:
- Refer to physiotherapist for balance exercises.
- Organise a home safety assessment.
Monitor cognitive function:
- Schedule a follow-up cognitive assessment (e.g., MMSE or MoCA).
Coordinate care with pharmacist and aged care services:
- Webster packing for medications.
- Involve a geriatrician if needed for medication review.
Follow-up plan:
- Review medication changes in 2–4 weeks.
- Reassess falls risk and cognitive symptoms at next visit.

SUMMARY OF A COMPETENT ANSWER

Thorough history covering falls, medications, adherence, cognitive function, and support systems.
Differential diagnosis prioritising postural hypotension, medication side effects, cognitive impairment, and metabolic causes.
Clear communication addressing patient concerns while promoting shared decision-making.
Evidence-based management plan incorporating deprescribing, Webster packing, fall prevention, and multidisciplinary care.
Follow-up arrangements ensuring ongoing monitoring and adjustments.

PITFALLS

Failure to recognise postural hypotension as a primary contributor to falls.
Ignoring medication adherence issues, leading to continued polypharmacy and risks.
Not addressing cognitive concerns despite family history and reported forgetfulness.
Lack of patient-centred communication, dismissing the patient’s fear of losing independence.
Overlooking fall prevention strategies, missing an opportunity for early intervention.
Failure to involve allied health services (pharmacist, physiotherapist, aged care support).

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, and expectations.
1.5 Negotiates a shared management plan.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive medication history, including adherence and side effects.
2.2 Identifies polypharmacy and potential medication interactions.

3. Diagnosis, Decision-Making and Reasoning

3.2 Recognises postural hypotension as a possible cause of falls.
3.5 Formulates a differential diagnosis considering polypharmacy and comorbidities.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate medication management plan.
4.3 Initiates deprescribing where appropriate.
4.5 Recommends Webster packing or other adherence aids.

5. Preventive and Population Health

5.1 Addresses fall prevention strategies.
5.3 Provides education on medication safety.

6. Professionalism

6.1 Ensures shared decision-making and patient autonomy.

7. General Practice Systems and Regulatory Requirements

7.1 Coordinates care with a pharmacist or aged care team.

9. Managing Uncertainty

9.2 Recognises and manages uncertainty related to polypharmacy and symptom attribution.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and addresses high-risk factors for falls and medication-related adverse effects.

Competency at Fellowship Level

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