CASE INFORMATION

Case ID: SLP-001
Case Name: James Carter
Age: 42 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: P06 (Sleep disturbance), R81 (Obstructive sleep apnoea), P20 (Generalised anxiety disorder)

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 sleep hygiene and mental health strategies 5.3 Discusses lifestyle factors contributing to sleep disorders
6. Professionalism	6.2 Demonstrates a professional and non-judgmental approach
7. General Practice Systems and Regulatory Requirements	7.2 Understands Medicare item numbers for sleep studies and mental health care plans
8. Procedural Skills	8.1 Recognises indications for a sleep study referral
9. Managing Uncertainty	9.1 Identifies when referral to a sleep physician or psychologist is warranted
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises complications such as untreated sleep apnoea and mental health deterioration

CASE FEATURES

Referral decisions, including sleep study, mental health care plan, or lifestyle interventions.
Middle-aged man presenting with sleep disturbance.
Multiple possible causes including obstructive sleep apnoea (OSA), anxiety, poor sleep hygiene, and stress-related insomnia.
Significant daytime impact, including fatigue, mood changes, and difficulty concentrating.
Exploration of lifestyle factors, including caffeine/alcohol intake, screen use, and bedtime routine.
Addressing potential underlying anxiety or mental health concerns.

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 and justify your reasoning.
Develop a management plan.
Address the patient’s concerns.

SCENARIO

James Carter, a 42-year-old office worker, presents to the clinic complaining of difficulty sleeping over the past 6 months.

His BMI is 36, and his neck circumference is 44cm.

PATIENT RECORD SUMMARY

Patient Details

Name: James Carter
Age: 42 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

None currently

Past Medical History

Hypertension

Family History

Father had type 2 diabetes and hypertension

Social History

Works in an office.

Vaccination and Preventative Activities

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, I just can’t sleep properly, and it’s making my life miserable. I feel exhausted all the time.”

General Information

(Freely Given if Asked Open-Ended Questions):

You struggle to fall asleep and wake up multiple times during the night.
You wake up feeling unrefreshed even after 7–8 hours of sleep.
You feel tired throughout the day.

Specific Information

(Only Given If Asked Directly):

Sleep Patterns:

Your job is stressful, and you often feel on edge or irritable.
You snore loudly, and your wife has mentioned you sometimes gasp for air during sleep.
You rely on coffee throughout the day to stay awake and sometimes have a glass of wine to help you sleep.
You use your phone in bed, scrolling through news or social media before trying to sleep.
You usually go to bed between 10:30 PM and 1 AM, depending on your workload.
You wake up at 6:30 AM because of work, regardless of when you fall asleep.
You often wake up 3-4 times per night, sometimes feeling restless.
You feel tired throughout the day, which affects your work performance and mood.
Your wife has noticed your snoring is getting worse, and she sometimes moves to another room because of the noise.

Daytime Symptoms:

You feel fatigued and groggy in the morning, struggling to get out of bed.
You struggle to focus at work, and your boss recently commented on your lower productivity.
You feel more irritable and anxious than usual, and small things frustrate you easily.
You have occasional headaches in the morning and mild palpitations at times.
You feel like you are in a constant cycle of exhaustion and stress, which worsens your sleep.

Lifestyle Factors:

Caffeine: You drink 3-4 cups of coffee per day, usually one in the morning and another in the afternoon.
Alcohol: You have a glass of wine 2-3 nights per week to help unwind but aren’t sure if this is helping or making things worse.
Exercise: You don’t have a regular exercise routine and often feel too tired to work out.
Diet: You eat a lot of takeaway food due to your busy schedule and often snack late at night.
Screen Time: You use your phone in bed, sometimes for up to an hour before trying to sleep.

Work and Stress:

You work in a demanding office job and often take work home with you.
You feel pressure to perform, and lately, you have been worried about your job security.
You feel that work stress is affecting your sleep, but you don’t know how to manage it.

Emotional and Behavioural Cues:

You appear frustrated and exhausted, often rubbing your temples or sighing when discussing your symptoms.
If the doctor validates your concerns and offers practical solutions, you seem hopeful and open to suggestions.
If the doctor minimises your sleep issues or suggests simplistic solutions, you appear irritated or disengaged.
If the doctor suggests reducing caffeine or alcohol, you may hesitate and ask if there are alternatives.
You are reluctant about lifestyle changes but willing to try something if it seems achievable and practical.

Potential Questions for the Candidate:

“Could this be something serious, like sleep apnoea?”
“Why do I feel so tired even after sleeping all night?”
“Is there a medication that could help me sleep?”
“Do I need a sleep study?”
“Could stress or anxiety be making this worse?”
“Should I stop drinking coffee altogether?”
“Do I need to see a specialist?”
“Is this just part of getting older?”
“Should I take melatonin or another supplement?”
“What can I do to feel more rested without making huge changes?”

Guidance for Role-Player Responses:

If the candidate suggests a sleep study, you should express some concerns about the cost and inconvenience but be open to discussion.
If the candidate suggests medication, you should ask whether it’s safe and if it’s something you’d have to take long-term.
If the candidate explains sleep hygiene, you should acknowledge that some habits (like phone use and caffeine) might be an issue but express difficulty in making major changes.
If the candidate suggests stress management, you should ask if therapy or relaxation techniques would actually help.
If the candidate dismisses your concerns, you should become more frustrated and sceptical.

Key Learning Points for the Candidate:

This case evaluates the candidate’s ability to:

Take a comprehensive sleep history, including patterns, lifestyle habits, and mental health factors.
Recognise symptoms of obstructive sleep apnoea (OSA) and explain the need for a sleep study if warranted.
Provide education on sleep hygiene, including caffeine reduction, alcohol avoidance, and screen-time management.
Address underlying stress and anxiety, offering realistic and achievable solutions.
Discuss treatment options, including lifestyle changes, cognitive behavioural therapy for insomnia (CBT-I), and potential referral to a sleep specialist.
Ensure a patient-centred approach, considering feasibility and patient concerns when recommending changes.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, focusing on sleep patterns, lifestyle factors, and mental health.

The competent candidate should:

Establish rapport and create a non-judgmental environment to encourage open discussion.
Explore sleep history, including:
- Sleep onset and maintenance issues (difficulty falling/staying asleep, early waking).
- Snoring, witnessed apnoeas, or gasping (suggestive of obstructive sleep apnoea).
- Daytime fatigue and impact on daily function.
Assess lifestyle factors:
- Caffeine and alcohol intake, particularly before bedtime.
- Exercise and diet habits.
- Screen use and bedtime routine.
Screen for mental health conditions, including:
- Anxiety or stress contributing to sleep difficulties.
- Depression (low mood, anhedonia, early morning wakening).
Identify red flags such as unintentional weight loss, neurological symptoms, or significant cognitive impairment.
Asks the STOP-BANG questions:
- STOP (Symptoms & Risk Factors)
  - Snoring – Do you snore loudly (louder than talking or heard through doors)?
  - Tiredness – Do you often feel tired, fatigued, or sleepy during the daytime?
  - Observed apnoeas – Has anyone observed you stop breathing during sleep?
  - Pressure – Are you having or being treated for high blood pressure?
- BANG (Physical Characteristics)
  - Body Mass Index (BMI) – Is your BMI > 35 kg/m²?
  - Age – Are you older than 50 years?
  - Neck Circumference – Is your neck circumference > 40 cm?
  - Gender – Are you male?

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

The competent candidate should:

Primary diagnosis:
- Insomnia, secondary to poor sleep hygiene and lifestyle factors.
Other possible diagnoses:
- Obstructive sleep apnoea (OSA) – based on snoring, witnessed gasping, daytime fatigue, BMI ~29.
- Generalised anxiety disorder (GAD) – work-related stress, irritability, palpitations.
- Primary insomnia – if there is no clear secondary cause.
- Medication-related or substance-induced sleep disturbance (if using stimulants, alcohol, or sedatives).
Justify investigations:
- Home sleep study if OSA is suspected.
- Mental health screening tools (e.g., GAD-7, DASS-21).

Task 3: Develop a management plan, including sleep hygiene strategies, potential investigations, and mental health considerations.

The competent candidate should:

Educate on sleep hygiene:
- Regular bedtime and wake time (even on weekends).
- Reduce screen use before bed.
- Avoid caffeine after midday and alcohol before bedtime.
- Encourage relaxation techniques (e.g., mindfulness, reading).
Address potential OSA:
- Refer for a sleep study, given snoring and gasping episodes.
- Encourage weight loss and regular exercise.
Manage anxiety/stress:
- Consider a mental health care plan and referral to a psychologist.
- Cognitive behavioural therapy for insomnia (CBT-I) if primary insomnia is suspected.
Medication considerations:
- Avoid sedative-hypnotics unless absolutely necessary.
- Consider short-term melatonin if needed.

Task 4: Address the patient’s concerns, particularly regarding daytime fatigue, long-term health risks, and available treatment options.

The competent candidate should:

Validate concerns and explain the link between sleep and overall health.
Discuss risks of untreated sleep disorders, including:
- Cognitive impairment and workplace performance decline.
- Increased cardiovascular risk (if undiagnosed OSA is present).
Provide realistic, patient-centred solutions:
- Gradual lifestyle modifications rather than drastic changes.
- Stepwise approach to sleep hygiene and mental health management.
Ensure follow-up, with a review in 2-4 weeks to assess progress.

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, assessing sleep patterns, lifestyle, mental health, and red flags.
Considers a broad differential diagnosis, including OSA, anxiety, insomnia, and lifestyle-related factors.
Provides a clear, evidence-based management plan, incorporating sleep hygiene, mental health support, and referrals if needed.
Addresses patient concerns empathetically, offering achievable solutions and reassurance.
Ensures appropriate follow-up to monitor progress and adjust treatment.

PITFALLS

Failing to explore lifestyle factors, such as caffeine, alcohol, and screen use.
Overlooking potential OSA despite snoring, gasping, and high BMI.
Prescribing sedative-hypnotics too readily without addressing underlying causes.
Not screening for anxiety despite significant work stress and irritability.
Providing generic advice without tailoring recommendations to the patient’s lifestyle.
Neglecting follow-up, leading to ongoing untreated sleep disturbance.

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 sleep hygiene and mental health strategies.
5.3 Discusses lifestyle factors contributing to sleep disorders.

6. Professionalism

6.2 Demonstrates a professional and non-judgmental approach.

7. General Practice Systems and Regulatory Requirements

7.2 Understands Medicare item numbers for sleep studies and mental health care plans.

8. Procedural Skills

8.1 Recognises indications for a sleep study referral.

9. Managing Uncertainty

9.1 Identifies when referral to a sleep physician or psychologist is warranted.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises complications such as untreated sleep apnoea and mental health deterioration.

Competency at Fellowship Level

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