Case ID: SIN-001
Case Name: Laura Mitchell
Age: 35 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: R75 (Sinusitis), R83 (Allergic Rhinitis), A77 (Upper Respiratory Tract Infection)

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 self-care and symptom management 5.3 Discusses strategies to prevent recurrent sinus infections
6. Professionalism	6.2 Demonstrates a professional and non-judgmental approach
7. General Practice Systems and Regulatory Requirements	7.2 Understands appropriate antibiotic prescribing guidelines and Medicare billing for respiratory consultations
8. Procedural Skills	8.1 Recognises when imaging (e.g., sinus CT) is necessary
9. Managing Uncertainty	9.1 Identifies when referral to an ENT specialist is warranted
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises complications such as orbital cellulitis or chronic sinusitis

CASE FEATURES

Judicious antibiotic use in accordance with Australian guidelines.
Adult patient presenting with sinus-related symptoms.
Determining viral vs bacterial sinusitis to avoid unnecessary antibiotics.
Identifying underlying triggers such as allergic rhinitis, recent upper respiratory infection (URTI), or anatomical issues.
Exploring red flags for complications such as orbital cellulitis or chronic sinusitis.
Patient concerns about persistent congestion and recurrent infections.
Providing evidence-based management, including nasal irrigation, intranasal corticosteroids, and analgesia.

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 the patient’s concerns

SCENARIO

Laura Mitchell, a 35-year-old marketing consultant, presents with facial pressure, nasal congestion, and headaches for the past 12 days. She initially developed a runny nose and sore throat after a cold, but her symptoms have worsened instead of improving. She describes thick yellow nasal discharge, worsening facial pain (especially around her cheeks and forehead), and a persistent blocked nose.

PATIENT RECORD SUMMARY

Patient Details

Name: Laura Mitchell
Age: 35 years
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Occasional over-the-counter decongestants (oxymetazoline nasal spray)
Antihistamines (loratadine) for seasonal allergies

Past Medical History

Recurrent acute sinusitis (2-3 episodes per year)
Allergic rhinitis (seasonal and dust mite sensitivity)

Family History

Mother has asthma and hay fever

Social History

Works in an office with air conditioning, sometimes triggers her allergies.
Non-smoker, drinks socially (1-2 drinks per week).

Vaccination and Preventative Activities

Up to date with routine vaccinations, including flu and COVID-19 vaccines.

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 sinuses have been completely blocked for nearly two weeks, and it’s getting worse. Do I need antibiotics?”

General Information

(Freely Given if Asked Open-Ended Questions):

You had a cold about two weeks ago, which started with a runny nose, sore throat, and mild cough.
Instead of improving, your symptoms worsened after a few days.
You now have a blocked nose, thick yellow mucus, facial pressure, and headaches.

Specific Information

(Only Given If Asked Directly):

Symptoms and Progression:

Your ears feel blocked, but there’s no significant ear pain or hearing loss.
You feel mildly fatigued, but you’re still managing to go to work.
You don’t have a fever, visual disturbances, or severe headaches.
You have tried decongestants (Drixine) and saline rinses, but they haven’t helped much.
You have been using the decongestants for 5 days.
You feel frustrated because this keeps happening—you get sinus infections 2-3 times a year.
The first few days felt like a normal cold, but then your nasal congestion worsened instead of improving.
Your facial pressure is mainly around your cheeks and forehead and is worse when you bend forward.
You have a postnasal drip that makes your throat feel irritated.
You feel completely blocked in your nose, which is making it hard to breathe.

Triggers and Risk Factors:

You have allergic rhinitis, especially in spring and dusty environments.
You work in an air-conditioned office, which sometimes dries out your nasal passages.
You use oxymetazoline nasal spray occasionally, but not for more than 3 days in a row because you know it can cause rebound congestion.
You do not smoke, but your partner smokes occasionally, which sometimes irritates your nose and throat.

Concerns About Antibiotics:

You are not sure if this is a bacterial infection, but you’ve heard that yellow mucus means infection and that antibiotics might help.
You’ve had sinus infections before, and sometimes you were given antibiotics, which seemed to help.
You want to know how to tell the difference between a viral and bacterial infection.
You are worried about developing chronic sinusitis if this keeps happening.

Impact on Daily Life:

You are struggling to focus at work because of headaches and congestion.
You are waking up at night because you can’t breathe properly.
You feel more tired than usual, but you’re still functioning.
You’re worried about your productivity at work because your job involves talking to clients, and you feel stuffy and congested all the time.

Emotional and Behavioural Cues:

You appear frustrated and tired, rubbing your forehead and nose when describing symptoms.
If the doctor explains why antibiotics may not be needed, you seem skeptical but open to discussion.
If the doctor dismisses your concerns too quickly, you may push back and ask for antibiotics.
If the doctor suggests long-term prevention strategies, you are receptive and eager to try new approaches.
If the doctor explains how to manage symptoms effectively, you seem relieved and more engaged in the conversation.

Potential Questions for the Candidate:

“How do I know if this is viral or bacterial sinusitis?”
“Will antibiotics help me get better faster?”
“Why do I keep getting these sinus infections?”
“Is there anything I can do to prevent this from happening again?”
“Do I need any tests or scans?”
“Should I see an ENT specialist?”
“Could allergies be causing this?”
“Is nasal irrigation safe? I’ve read conflicting advice online.”
“Could this be something serious like a sinus tumour?”
“What should I do if this doesn’t get better in the next few days?”

Guidance for Role-Player Responses:

If the candidate suggests symptomatic management, you should ask whether antibiotics would work faster.
If the candidate explains that most cases are viral, you should express concern about your thick yellow mucus and the possibility of bacterial infection.
If the candidate suggests using a steroid nasal spray, you should ask, “Is that safe to use long term?”
If the candidate mentions allergy control, you should mention that you already take loratadine but still get congested sometimes.
If the candidate explains the criteria for a bacterial infection, you should ask whether you should get an X-ray or CT scan.
If the candidate recommends a specialist referral, you should ask, “How do I know if I really need that?”

Key Learning Points for the Candidate:

This case evaluates the candidate’s ability to:

Differentiate between viral and bacterial sinusitis using appropriate clinical criteria.
Provide evidence-based management, including nasal corticosteroids, saline rinses, and analgesia.
Educate the patient on antibiotic stewardship, addressing misconceptions about yellow mucus and bacterial infections.
Discuss long-term prevention strategies, such as allergy management, nasal irrigation, and avoiding nasal decongestant overuse.
Recognise red flags for complications, such as orbital cellulitis or chronic sinusitis, and determine when further investigation or referral is warranted.
Use a patient-centred approach, addressing the patient’s concerns and expectations while guiding them towards best-practice management.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, focusing on symptom duration, severity, and potential triggers.

The competent candidate should:

Use open-ended questions to explore the patient’s presenting symptoms, including:
- Duration and progression of symptoms (e.g., worsening facial pain, persistent nasal congestion).
- Character and severity of nasal discharge (e.g., clear vs. yellow/green).
- Presence of associated symptoms, such as headache, postnasal drip, cough, or ear blockage.
Differentiate between viral and bacterial sinusitis:
- Viral: Symptoms lasting <10 days, no worsening after initial improvement.
- Bacterial: Symptoms lasting >10 days, worsening after initial improvement, severe facial pain.
Assess for underlying triggers, including:
- History of allergic rhinitis (seasonal, environmental exposures).
- Frequent upper respiratory infections.
- Structural factors (nasal polyps, deviated septum).
Identify red flags suggesting complications:
- Visual changes, periorbital swelling, altered mental state (concern for orbital or intracranial spread).
Clarify medication use, including over-the-counter decongestants, antihistamines, and nasal sprays.
Explore patient concerns and expectations, particularly regarding antibiotics and recurrence prevention.

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

The competent candidate should:

Most likely diagnosis: Acute sinusitis, likely bacterial (symptoms lasting >10 days with worsening facial pain).
Consider alternative diagnoses:
- Viral upper respiratory tract infection (URTI) – if symptoms had not persisted or worsened.
- Allergic rhinitis – if symptoms were chronic, seasonal, and associated with sneezing/itchy eyes.
- Rhinitis medicamentosa – rebound congestion due to overuse of decongestants
- Migraine or tension headache – if headaches were the predominant symptom without congestion.
- Dental infection (odontogenic sinusitis) – if associated with recent dental work or tooth pain.
Justify the need for further investigation only if red flags are present, such as orbital swelling (consider sinus CT scan or ENT referral).

Task 3: Develop a management plan, including symptom relief, antibiotic considerations, and follow-up.

The competent candidate should:

Reassure the patient that most cases of acute sinusitis are viral and self-limiting within 10 days.
First-line management (symptomatic relief):
- Saline nasal irrigation (to clear secretions).
- Intranasal corticosteroids (e.g., budesonide or fluticasone for inflammation).
- Analgesia (paracetamol, ibuprofen) for facial pain and headache.
- Steam inhalation/humidifiers for congestion relief.
- Short-term nasal decongestants (e.g., oxymetazoline for ≤3 days to avoid rebound congestion).
When to consider antibiotics (based on Australian guidelines):
- Symptoms persisting >10 days with no improvement or worsening.
- Severe symptoms (high fever, purulent nasal discharge, intense facial pain).
- First-line antibiotic: Amoxicillin-clavulanate (or doxycycline if penicillin-allergic).
Discuss prevention strategies:
- Managing allergic rhinitis with intranasal corticosteroids and antihistamines.
- Avoiding overuse of decongestants.
- Hydration and nasal hygiene.
Arrange follow-up in 1–2 weeks to assess improvement.

Task 4: Address the patient’s concerns, particularly regarding symptom persistence and risk of chronic sinusitis.

The competent candidate should:

Acknowledge the patient’s frustration with recurrent infections and validate concerns about symptom duration.
Explain the natural course of sinusitis, distinguishing between viral and bacterial cases.
Address antibiotic concerns:
- Emphasise that antibiotics are not always necessary and do not speed up recovery in viral sinusitis.
- Reassure the patient that symptomatic treatment is effective for most cases.
Discuss recurrence prevention:
- Optimising allergy control (intranasal steroids, antihistamines).
- Saline rinses as a long-term strategy to maintain nasal hygiene.
- Lifestyle modifications, such as avoiding dry air exposure and improving indoor air quality.
Explain when further investigation is needed, such as:
- Persistent sinusitis lasting >12 weeks (consider chronic sinusitis workup).
- Frequent episodes with structural concerns (ENT referral for nasal endoscopy or CT scan).

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, differentiating viral vs bacterial sinusitis and assessing for risk factors.
Considers alternative diagnoses, including allergic rhinitis and migraine.
Provides an evidence-based management plan, focusing on symptomatic relief, nasal hygiene, and judicious antibiotic use.
Effectively addresses patient concerns, ensuring realistic expectations about symptom resolution and recurrence prevention.
Recognises when specialist referral or imaging is warranted, avoiding unnecessary investigations.

PITFALLS

Failing to differentiate between viral and bacterial sinusitis, leading to unnecessary antibiotic use.
Overlooking red flags, such as orbital swelling or persistent severe headache, which may indicate complications.
Not considering allergic rhinitis as an underlying cause for recurrent symptoms.
Not considering rhinitis medicamentosa as an underlying cause for recurrent symptoms.
Recommending prolonged use of nasal decongestants, increasing the risk of rebound congestion.
Neglecting to educate the patient on prevention strategies, such as intranasal corticosteroids for allergic rhinitis.
Lack of structured follow-up, particularly in recurrent or persistent cases.

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 self-care and symptom management.
5.3 Discusses strategies to prevent recurrent sinus infections.

6. Professionalism

6.2 Demonstrates a professional and non-judgmental approach.

7. General Practice Systems and Regulatory Requirements

7.2 Understands appropriate antibiotic prescribing guidelines and Medicare billing for respiratory consultations.

8. Procedural Skills

8.1 Recognises when imaging (e.g., sinus CT) is necessary.

9. Managing Uncertainty

9.1 Identifies when referral to an ENT specialist is warranted.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises complications such as orbital cellulitis or chronic sinusitis.

Competency at Fellowship Level

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