Case ID: ECZ-CHILD-001
Case Name: Noah Williams
Age: 4 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S87 (Atopic dermatitis/eczema)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes a patient-centred approach 1.2 Uses active listening and questioning skills 1.4 Demonstrates empathy and sensitivity
2. Clinical Information Gathering and Interpretation	2.1 Gathers a relevant and focused history 2.2 Identifies red flags and risk factors
3. Diagnosis, Decision-Making and Reasoning	3.1 Formulates appropriate differential diagnoses 3.3 Considers common and serious conditions
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan 4.2 Uses shared decision-making in treatment options
5. Preventive and Population Health	5.1 Provides education on eczema triggers and skincare 5.3 Discusses strategies to prevent complications
6. Professionalism	6.2 Demonstrates a professional and non-judgmental approach
7. General Practice Systems and Regulatory Requirements	7.2 Understands appropriate Medicare item numbers for childhood eczema management
8. Procedural Skills	8.1 Recognises and assesses skin integrity and signs of secondary infection
9. Managing Uncertainty	9.1 Identifies when referral to a specialist (e.g., dermatologist) is warranted
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises complications such as secondary bacterial infection or severe eczema

CASE FEATURES

Addressing secondary infection risks and ensuring appropriate follow-up.
Child presenting with chronic eczema symptoms (itching, dry skin, redness).
Parental concerns about flare-ups, sleep disturbances, and possible food allergies.
Exploration of environmental triggers (soaps, allergens, weather, clothing).
Balancing effective treatment (topical corticosteroids, emollients) with parental hesitancy regarding steroid use.

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 an appropriate history.
Formulate a differential diagnosis.
Develop a management plan.
Address parental concerns.

SCENARIO

Noah Williams, a 4-year-old boy, presents to the clinic with his mother, Sarah, who is concerned about his worsening eczema. She reports persistent itching, redness, and dry patches, particularly affecting his elbows, knees, and cheeks. Over the past two weeks, the condition has flared up significantly, leading to scratching at night, disturbed sleep, and discomfort.

PATIENT RECORD SUMMARY

Patient Details

Name: Noah Williams
Age: 4 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

None known

Medications

Emollient (fragrance-free lotion) – applied once daily

Past History

Diagnosed with atopic eczema at 6 months
Previous mild asthma symptoms but no recent wheezing
No history of food allergies or anaphylaxis

Family History

Father has asthma and hay fever
Mother has mild eczema

Social History

Lives with both parents and a 2-year-old sibling

Vaccination and Preventative 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:

“Noah’s eczema has been really bad lately, and nothing we’re doing seems to help. I’m worried it might be something he’s eating.”

General Information

(Freely Given if Asked Open-Ended Questions):

You are Sarah Williams, a 32-year-old mother of two. You have brought your 4-year-old son, Noah, to the GP today because his eczema has worsened over the past two weeks. You are frustrated and worried because despite your efforts, his skin remains dry, itchy, and inflamed, and now you’ve noticed some scabbing and oozing in areas where he has been scratching.

Specific Information

(Only Given If Asked Directly):

Background Information

You have tried using moisturiser daily, but it doesn’t seem to be making a difference. You are hesitant about using steroid creams because you have read that they can cause skin thinning. You are also worried that Noah’s eczema might be caused by a food allergy, especially dairy, as you recently read an article online that linked eczema to milk consumption. You have been considering cutting out dairy from his diet but aren’t sure if that’s necessary.

Noah has had eczema since he was six months old, and flare-ups tend to happen every few months. You have noticed that his skin gets worse in cold weather and when he is sick with a cold. He also scratches a lot at night, which has been disrupting his sleep and making him irritable during the day.

Eczema Symptoms:

Noah’s eczema mostly affects his elbows, knees, and cheeks.
His skin feels dry, rough, and bumpy, and when he scratches, it turns red and inflamed.
You’ve noticed some small scabs and yellow crusting on his arms, which worries you.
His itching has been keeping him up at night, and he often wakes up scratching.

Management So Far:

Moisturiser: You use a fragrance-free lotion once a day, but you don’t think it’s helping much.
Steroid creams: You were prescribed hydrocortisone 1% cream a while ago, but you’ve only used it a few times because you are worried about side effects.
Bathing habits: Noah bathes every night, and sometimes you use bubble bath or scented soaps, but you haven’t noticed if it makes a difference.
Clothing: You dress Noah in cotton clothing, but he sometimes wears wool jumpers when it’s cold.

Environmental Factors:

You recently moved into a new house with carpeted floors instead of tiles.
Noah sleeps with a soft toy that he insists on keeping in bed with him.
The family has a cat, but Noah doesn’t seem to react to it.

Family and Medical History:

Noah has mild asthma symptoms occasionally but hasn’t needed regular treatment.
His father has asthma and hay fever.
You had mild eczema as a child, but it went away.

Parental Concerns:

Food allergies: You believe dairy might be triggering his eczema because you read an article about it. You are considering eliminating dairy from his diet and want to know if this is necessary.
Steroid creams: You have heard that steroids can thin the skin and are worried about long-term effects. You want to avoid using them if possible.
Long-term prognosis: You are concerned that Noah’s eczema will get worse as he gets older or that it might lead to other health issues like asthma.
Possible infection: You are worried about the scabs and yellow crusting and wonder if this could be a skin infection.

Emotional and Behavioural Cues:

You start the consultation appearing frustrated and worried. You feel like you’ve tried everything, and nothing seems to work.
You hesitate when discussing steroid creams, showing reluctance and uncertainty.
If the doctor reassures you that eczema is common and manageable, you begin to relax and open up more.
If the doctor dismisses your concerns about food allergies, you might appear defensive or push back by saying you’ve read a lot about it online.
If the doctor explains things clearly and provides a structured management plan, you will feel relieved and more confident about treating Noah’s eczema.
You are grateful for practical advice and keen to learn how to prevent future flare-ups.

Potential Questions for the Candidate:

“Do you think dairy is causing this? Should we cut it out?”
“Is there a cure for eczema, or will Noah have this forever?”
“Are steroid creams really safe? I’ve heard they can thin the skin.”
“Could this be an infection? His skin looks worse than usual.”
“Should we see an allergy specialist?”
“What can I do to stop him from scratching so much?”
“Could his bedding or our carpets be making it worse?”
“What else can I do to prevent these flare-ups?”
“How long does it usually take for eczema to get better once we start treatment?”
“Would probiotics or special diets help?”

Guidance for Role-Player Responses:

If the candidate provides clear explanations about eczema triggers and management, you should appear reassured and appreciative.
If the candidate avoids addressing food allergy concerns, you should continue to bring it up and express frustration.
If the candidate recommends steroid creams, you should show hesitation at first but be willing to listen if they explain the safety and benefits well.
If the candidate acknowledges your worries and provides a clear treatment plan, you should appear relieved and more trusting of their advice.

Key Learning Points for the Candidate:

This case evaluates the candidate’s ability to:

Conduct a comprehensive history focused on eczema symptoms, triggers, and treatment.
Educate and reassure the parent about eczema, particularly addressing steroid safety concerns.
Provide clear management advice on emollients, topical steroids, and lifestyle modifications.
Identify and manage secondary bacterial infection if suspected.
Offer practical strategies to reduce itching and prevent further flare-ups.
Approach parental concerns sensitively, particularly regarding food allergies and long-term prognosis.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including eczema triggers, symptom control strategies, and impact on the child’s wellbeing.

The competent candidate should:

Use open-ended questions to gather information about Noah’s eczema, including duration, affected areas, severity, and progression.
Assess symptom impact, including itchiness, sleep disturbance, school/daycare attendance, and emotional well-being.
Explore parental management strategies:
- Frequency and type of moisturisers and emollients used.
- Use of topical steroids (adherence, concerns, effectiveness).
- Bathing habits (water temperature, soap use, bubble baths).
- Clothing and environmental factors (dust mites, carpet, pets, weather).
Identify triggers such as seasonal changes, illness, stress, allergens, and food-related concerns.
Evaluate for secondary infection: signs of weeping, crusting, pain, fever, or swelling.
Screen for atopic conditions (asthma, hay fever, family history of atopy).
Acknowledge and address parental concerns, particularly about food allergies and steroid use.

Task 2: Formulate a differential diagnosis and justify your reasoning.

The competent candidate should:

Primary diagnosis: Atopic eczema, given chronicity, distribution (elbows, knees, cheeks), and history of atopy.
Consider differential diagnoses:
- Contact dermatitis – if there is exposure to irritants (e.g., new soap, detergent).
- Seborrhoeic dermatitis – if involvement of scalp, behind ears, and greasy appearance.
- Psoriasis – if well-demarcated, silvery plaques.
- Fungal infection (tinea corporis) – if ring-like lesions with central clearing.
- Scabies – if severe itch and family members are affected.
- Impetigo (secondary infection) – if yellow crusting and spreading lesions.
Justify investigations (if needed): skin swabs for infection, allergy testing only if eczema is severe and not responding to standard treatments.

Task 3: Develop a management plan, including treatment, prevention strategies, and parent education.

The competent candidate should:

Emphasise first-line treatment:
- Regular use of emollients (thick, fragrance-free, applied frequently).
- Short, lukewarm baths with soap substitutes.
- Avoid triggers (e.g., dust mites, wool, overheating).
Topical corticosteroids:
- Explain correct use: apply once or twice daily during flare-ups, then taper.
- Address concerns about skin thinning, reinforcing safe use under medical guidance.
Manage secondary infection:
- If weeping/crusting present, consider topical antibiotics (mupirocin) or oral antibiotics if extensive.
Control itching:
- Short-term antihistamines may help sleep if severe.
- Keep nails short, use cotton mittens at night.
Parental education:
- Explain chronic but manageable nature of eczema.
- Reassure about steroid safety and provide a written plan.
Follow-up:
- Review in 2–4 weeks for response.
- Consider referral to a dermatologist if severe or unresponsive.

Task 4: Address parental concerns, particularly regarding long-term steroid use and potential allergies.

The competent candidate should:

Acknowledge concerns empathetically, particularly regarding steroid safety and food allergies.
Explain steroid use:
- Correct use minimises risks (applied thinly, short-term bursts).
- Untreated eczema is more harmful than appropriate steroid use.
Discuss food allergies rationally:
- Food is not a common cause of eczema.
- Allergy testing is only needed if there is a clear reaction (e.g., hives, vomiting after eating).
Provide reassurance:
- Eczema often improves with age, though may persist.
- Focus on good skin care rather than dietary restriction.

SUMMARY OF A COMPETENT ANSWER

Takes a structured history focusing on symptoms, triggers, treatments, and impact on quality of life.
Provides a clear, evidence-based differential diagnosis, considering other skin conditions.
Explains a stepwise management plan, prioritising emollients, topical steroids, trigger avoidance, and infection management.
Uses effective communication skills to address parental concerns about steroids and allergies.
Arranges follow-up and escalation if needed, ensuring continuity of care.

PITFALLS

Failing to explore parental concerns about steroids and food allergies, leading to distrust.
Not assessing for secondary infection, which may require antibiotics.
Providing incorrect or vague information about steroid safety or allergy testing.
Overlooking the need for follow-up, particularly in cases of poor symptom control.
Recommending unnecessary allergy testing without clear clinical indicators.
Neglecting preventive measures, such as trigger avoidance and skin hydration.

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, expectations of healthcare and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers a relevant and focused history.
2.2 Identifies red flags and risk factors.

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulates appropriate differential diagnoses.
3.3 Considers common and serious conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.2 Uses shared decision-making in treatment options.

5. Preventive and Population Health

5.1 Provides education on eczema triggers and skincare.
5.3 Discusses strategies to prevent complications.

6. Professionalism

6.2 Demonstrates a professional and non-judgmental approach.

7. General Practice Systems and Regulatory Requirements

7.2 Understands appropriate Medicare item numbers for childhood eczema management.

8. Procedural Skills

8.1 Recognises and assesses skin integrity and signs of secondary infection.

9. Managing Uncertainty

9.1 Identifies when referral to a specialist (e.g., dermatologist) is warranted.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises complications such as secondary bacterial infection or severe eczema.

Competency at Fellowship Level

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