Case ID: ATSI-AST-002
Case Name: Lily Johnson
Age: 7 years
Gender: Female
Indigenous Status: Aboriginal
Year: 2025
ICPC-2 Codes: R96 – Asthma, A98 – Indigenous Health Issue

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Communicates effectively with the caregiver and child, addressing concerns empathetically 1.3 Uses culturally safe communication techniques with Aboriginal and Torres Strait Islander families
2. Clinical Information Gathering and Interpretation	2.1 Takes a thorough history, including social and environmental factors impacting health 2.3 Identifies triggers and severity indicators for asthma exacerbation
3. Diagnosis, Decision-Making and Reasoning	3.1 Recognises clinical features of asthma and differentiates from other causes of wheeze
4. Clinical Management and Therapeutic Reasoning	4.2 Provides appropriate acute management of asthma 4.3 Develops an individualised asthma action plan
5. Preventive and Population Health	5.2 Identifies modifiable risk factors such as smoking exposure, allergens, and respiratory infections
6. Professionalism	6.3 Engages with local Aboriginal health workers for culturally safe care
7. General Practice Systems and Regulatory Requirements	7.4 Utilises appropriate Medicare-funded Aboriginal health services (e.g., 715 health check)
9. Managing Uncertainty	9.2 Ensures appropriate follow-up and education to manage asthma long term
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises when an asthma exacerbation requires urgent escalation
11. Aboriginal Health Context (AH)	AH1.2 Considers social determinants of health impacting asthma management in Aboriginal children AH1.3 Utilises culturally appropriate resources for education and support
12. Rural Health Context (RH)	RH1.2 Manages asthma in a remote setting with limited resources RH1.4 Coordinates care with regional paediatric services for escalation if required

CASE FEATURES

Need for clear safety-netting, education, and preventive strategies
Aboriginal child with recurrent asthma exacerbations in a remote community
Concerned mother with limited health literacy regarding asthma management
Environmental triggers, including household smoking and dust exposure
Limited local resources (e.g., no paediatric respiratory specialist, reliance on telehealth and retrieval services if needed)

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 focused history
Assess the severity of the asthma exacerbation
Explain your diagnosis and management plan
Provide culturally appropriate education on asthma prevention and long-term management.

SCENARIO

Lily Johnson, a 7-year-old Aboriginal girl, is brought to the clinic by her mother, Karen. Karen is worried because Lily has had worsening wheezing and shortness of breath over the past two days. She has been using her blue puffer (salbutamol) more often but is still struggling to breathe, especially at night.

Lily has a history of asthma, diagnosed two years ago, but has never had a formal asthma action plan. She usually gets wheezy when she has a cold, runs around, or when the weather changes. Her mother reports that her symptoms have been getting worse over the past year, requiring multiple visits to the clinic.

On arrival, Lily has mild respiratory distress, with a respiratory rate of 30 breaths per minute, mild intercostal recession, and oxygen saturation of 95% on room air. She is able to talk in full sentences but is noticeably tired.

PATIENT RECORD SUMMARY

Patient Details

Name: Lily Johnson
Age: 7 years
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Aboriginal

Allergies and Adverse Reactions

Nil known

Medications

Salbutamol (Ventolin) puffer PRN
No preventer medication prescribed

Past History

Asthma diagnosed at age 5
Multiple presentations with wheeze, no hospital admissions

Social History

Lives with mother, father, and three siblings in a remote Aboriginal community

Family History

Mother has asthma
No other known chronic conditions in the family

Smoking Exposure

Father smokes inside the house

Alcohol

Nil relevant

Vaccination and Preventive Activities

Up to date with childhood vaccinations

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

“I don’t know what else to do, Doctor. Lily’s been getting worse, and I feel like we’re always back here with the same problem.”

General Information

Karen Johnson is a 31-year-old Aboriginal mother who has brought her 7-year-old daughter, Lily, to the clinic due to worsening asthma symptoms. Karen is deeply concerned and frustrated because Lily’s asthma keeps flaring up despite using her blue puffer. She feels like she doesn’t fully understand how to manage it properly.

Lily was diagnosed with asthma two years ago, but Karen has never received proper education on what asthma is, how it works, or how to prevent attacks. She has been giving Lily the blue puffer more often, but she isn’t sure if she is using it the right way or often enough.

Specific Information

(Only reveal when asked relevant questions)

Background Information

Lily’s symptoms tend to get worse when she runs around, when it’s cold, or when she gets sick. Over the past few months, Karen has noticed that Lily’s asthma is becoming more frequent and severe, requiring multiple visits to the clinic. She is worried this could be harming Lily’s health and feels guilty that she might be doing something wrong.

Karen and her family live in a remote Aboriginal community. Their house is crowded and dusty, and Karen’s partner, Lily’s father, smokes inside the home, although Karen has asked him not to. She isn’t sure if this is making Lily’s asthma worse, but she feels uncomfortable bringing it up again.

Karen also worries about the distance to the nearest hospital. If Lily needs urgent care, she doesn’t know how she will get there, as she doesn’t own a car and would need to rely on someone else. She is scared that one day Lily might have a really bad attack, and she won’t know what to do.

Symptoms and Timeline

Day 1 (Two days ago): Lily developed a mild cough and some wheezing but was still active and playing.
Day 2 (Yesterday): Lily’s wheezing worsened, and she started getting breathless after running. She woke up at night coughing and struggling to breathe.
Day 3 (Today): She has been using her blue puffer every 3-4 hours, but it only helps for a little while. She is still breathless and wheezing, especially after activity.

Breathing Concerns

Lily is breathing faster than usual, especially at night.
She is waking up coughing and struggling to catch her breath.
She can talk but sometimes pauses to take a breath.
Karen hasn’t noticed any blue lips but thinks Lily’s face looks pale.

Medication Use

Salbutamol (blue puffer) every few hours over the last two days.
No preventer medication prescribed before.
Unsure if Lily is using the spacer correctly.

Triggers

Gets worse with colds, cold air, exercise, and dust.
Father smokes inside the house, but Karen doesn’t feel comfortable confronting him.
House is dusty, and they don’t have air conditioning.

Emotional Cues

(Role-player should respond with appropriate emotions)

Anxious and overwhelmed: “I feel like I’m failing her because she keeps getting sick.”
Frustrated: “Why is this happening again? What can I do to stop it?”
Fearful: “Is this going to get worse? Could she stop breathing?”
Guilt-ridden: If smoking is mentioned, Karen may become defensive or sad, saying, “I know smoking isn’t good, but I can’t stop my partner.”

Questions for the Candidate

(Ask these naturally during the conversation)

“Does she need to go to the hospital?” – Karen is scared about how serious this could be.
“Why does she keep getting asthma attacks?” – She doesn’t understand asthma well and is looking for clear explanations.
“How do I know when to use the puffer?” – She isn’t sure when or how often to use it.
“Is there something in the house making it worse?” – She suspects smoking might be an issue but feels powerless to stop it.
“Can she still play with her friends and do sports?” – Karen wants Lily to live a normal life but is worried about activity triggering her asthma.
“What do I do if she has another attack at home?” – She wants a clear plan for what to do in an emergency.

Expectations

(What Karen Wants from the Consultation)

Clear advice on whether Lily needs hospitalisation or if she can be managed at home.
A step-by-step guide on how to manage Lily’s asthma, including how to use the puffer properly.
A long-term plan to stop these attacks from happening so often.
Education on asthma triggers and what she can do at home to reduce them.
Supportive, culturally safe communication – she doesn’t want to feel judged or blamed, especially regarding household smoking.

Potential Challenges for the Candidate

Karen may become defensive if smoking is discussed in a way that feels blaming.
She may be hesitant to go to the hospital due to transport and distance concerns.
She may be frustrated if she feels she isn’t getting clear answers.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history from the caregiver and child, ensuring a culturally safe approach.

The competent candidate should:

Elicit details about Lily’s current symptoms, including onset, duration, severity, and progression of wheeze, shortness of breath, and cough.
Assess medication use, including frequency of reliever (salbutamol) use, technique, and adherence.
Identify triggers such as exercise, cold weather, respiratory infections, allergens, or smoke exposure.
Explore past asthma history, including previous exacerbations, hospitalisations, or intensive care admissions.
Take a thorough social history, considering household smoking, dust exposure, and housing conditions.
Engage in culturally safe communication, using a non-judgemental and supportive approach, particularly when discussing smoking.
Explore caregiver concerns, including understanding of asthma, fears regarding hospitalisation, and access to healthcare.

Task 2: Assess the severity of the asthma exacerbation and determine if escalation is required.

The competent candidate should:

Assess key clinical indicators of severity, including:
- Respiratory rate (30/min)
- Ability to speak in full sentences
- Oxygen saturation (95% on room air)
- Presence of intercostal recession
Classify severity based on Australian asthma guidelines:
- Mild: No increased work of breathing, occasional wheeze.
- Moderate: Increased work of breathing, speaks in phrases.
- Severe: Marked increased work of breathing, can only speak in single words.
- Life-threatening: Silent chest, exhaustion, cyanosis.
Determine that Lily’s presentation suggests a moderate asthma exacerbation, requiring close monitoring and further intervention.
Consider whether hospitalisation is necessary, factoring in:
- Response to initial treatment (salbutamol via spacer)
- Distance to tertiary care and transport challenges
- Caregiver’s ability to monitor symptoms at home
Discuss next steps with the caregiver, ensuring she understands when to escalate to emergency care.

Task 3: Explain your diagnosis and management plan to the caregiver using clear, understandable language.

The competent candidate should:

Explain that Lily has a moderate asthma exacerbation, caused by airway inflammation and narrowing.
Clarify that asthma is a chronic condition, requiring both acute treatment and long-term management.
Educate on appropriate medication use:
- Reliever (salbutamol) for symptom relief – correct dosing via spacer.
- Preventer therapy (e.g., inhaled corticosteroids) to reduce frequency and severity of attacks.
Develop an asthma action plan, outlining:
- Green zone: No symptoms – continue preventer if prescribed.
- Yellow zone: Mild symptoms – use salbutamol as needed.
- Red zone: Severe symptoms – seek urgent medical attention.
Provide culturally safe education on triggers and prevention strategies, including:
- Reducing household smoke exposure.
- Managing dust and allergen exposure in the home.
- Ensuring Lily remains active but with appropriate precautions.
Address the mother’s concerns about hospitalisation, ensuring she knows when and how to seek emergency care.

Task 4: Provide culturally appropriate education on asthma prevention and long-term management.

The competent candidate should:

Empower the caregiver with knowledge and resources, ensuring she understands how to manage asthma at home.
Discuss smoking in a non-judgemental way, offering practical support (e.g., referrals for smoking cessation support).
Encourage regular GP follow-ups, including spirometry and reviewing preventer use.
Refer to local Aboriginal health services for ongoing education and support.
Provide written materials in a format suitable for the caregiver’s health literacy level.
Reinforce the importance of vaccination, including annual flu vaccines to prevent respiratory infections.

SUMMARY OF A COMPETENT ANSWER

Takes a comprehensive asthma history, assessing symptom severity, triggers, and medication use.
Recognises signs of a moderate asthma exacerbation, determining if escalation is needed.
Provides clear, jargon-free education about asthma and its management.
Develops a personalised asthma action plan, ensuring caregiver understanding.
Engages in culturally safe communication, addressing caregiver concerns and social determinants of health.
Offers practical prevention strategies, including smoking reduction and environmental modifications.

PITFALLS

Failing to classify the severity of the exacerbation appropriately.
Not assessing medication adherence or inhaler technique, missing an opportunity for intervention.
Overlooking social and environmental factors, such as household smoking and housing conditions.
Using complex medical terminology, leading to caregiver misunderstanding.
Not addressing caregiver concerns, particularly around hospitalisation and long-term asthma management.
Failing to provide an asthma action plan, leaving the caregiver without a clear framework for management.

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.
1.3 Uses culturally safe communication techniques with Aboriginal and Torres Strait Islander families.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough history, including social and environmental factors impacting health.
2.3 Identifies triggers and severity indicators for asthma exacerbation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises clinical features of asthma and differentiates from other causes of wheeze.

4. Clinical Management and Therapeutic Reasoning

4.2 Provides appropriate acute management of asthma.
4.3 Develops an individualised asthma action plan.

5. Preventive and Population Health

5.2 Identifies modifiable risk factors such as smoking exposure, allergens, and respiratory infections.

6. Professionalism

6.3 Engages with local Aboriginal health workers for culturally safe care.

7. General Practice Systems and Regulatory Requirements

7.4 Utilises appropriate Medicare-funded Aboriginal health services (e.g., 715 health check).

9. Managing Uncertainty

9.2 Ensures appropriate follow-up and education to manage asthma long term.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises when an asthma exacerbation requires urgent escalation.

11. Aboriginal Health Context (AH)

AH1.2 Considers social determinants of health impacting asthma management in Aboriginal children.
AH1.3 Utilises culturally appropriate resources for education and support.

12. Rural Health Context (RH)

RH1.2 Manages asthma in a remote setting with limited resources.
RH1.4 Coordinates care with regional paediatric services for escalation if required.

Competency at Fellowship Level

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