CCE-CE-025

Case ID: CT-002
Case Name: David Thompson
Age: 58
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A91 (Abnormal Test Results, Investigations NOS), R84 (Abnormal Imaging of the Chest)

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to understand their concerns and expectations
1.2 Communicates effectively regarding test results and implications
1.4 Demonstrates empathy and reassurance regarding uncertainty and next steps
2. Clinical Information Gathering and Interpretation2.1 Gathers an appropriate history focusing on risk factors (smoking, occupational exposure, symptoms)
2.2 Interprets abnormal imaging findings in the context of the patient’s history
3. Diagnosis, Decision-Making and Reasoning3.1 Considers a broad differential diagnosis for incidental lung findings
3.2 Justifies the need for further investigations and specialist referral
4. Clinical Management and Therapeutic Reasoning4.1 Provides a structured approach to investigation and follow-up
4.2 Outlines management options, balancing urgency and patient concerns
5. Preventive and Population Health5.1 Discusses smoking cessation and lung cancer screening (if applicable)
5.2 Educates on risk reduction for lung disease
6. Professionalism6.1 Manages patient concerns with sensitivity and professionalism
7. General Practice Systems and Regulatory Requirements7.1 Explains appropriate use of Medicare-funded imaging and referrals
9. Managing Uncertainty9.1 Communicates appropriately when a diagnosis is uncertain and outlines a structured follow-up plan
10. Identifying and Managing the Patient with Significant Illness10.1 Recognises potential serious pathology and ensures timely investigation and referral

CASE FEATURES

  • Emphasis on communication skills—delivering abnormal results with empathy and clear next steps.
  • Incidental lung lesion on CT ordered for another reason (e.g., persistent cough, weight loss, or as part of a routine workup).
  • Patient has risk factors (smoking history, occupational exposure, or a family history of lung cancer).
  • Requires appropriate diagnostic workup, balancing the need for urgency and avoiding unnecessary alarm.
  • Managing uncertainty and addressing patient anxiety regarding the possibility of cancer.

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:

  1. Take an appropriate history.
  2. Outline the differential diagnosis and key investigations required.
  3. Address the patient’s concerns.
  4. Develop a safe and patient-centred management plan.

SCENARIO

David Thompson, a 58-year-old former construction worker, visits your clinic to discuss the results of his recent chest CT scan, which was ordered after he presented with a persistent cough lasting eight weeks.

The CT report describes a 1.8 cm solitary pulmonary nodule (SPN) in the right upper lobe. The radiologist has recommended further assessment due to the patient’s history of smoking (15 pack-years) and age.

David is anxious about the possibility of lung cancer, as his older brother was diagnosed with lung cancer last year. He wants to know what the results mean and what will happen next.

PATIENT RECORD SUMMARY

Patient Details

Name: David Thompson
Age: 58
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Amlodipine 5mg daily (hypertension)
  • Atorvastatin 20mg nocte (hypercholesterolaemia)

Past History

  • Hypertension
  • Hypercholesterolaemia
  • Chronic lower back pain (previous workplace injury)

Social History

  • Works as a part-time handyman (retired from full-time construction work).
  • Smoked 15 pack-years, quit five years ago.
  • Drinks alcohol socially (1-2 standard drinks on weekends).

Family History

  • Brother diagnosed with lung cancer at age 62.
  • Father had COPD (long-term smoker).

Smoking

  • Smoked 15 pack-years, quit at age 53.

Alcohol

  • Social drinker.

Vaccination and Preventative Activities

  • Up to date with standard 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

“Doctor, I got a message to come in about my CT scan. Is everything alright?”

General Information

  • You had a chest CT scan because of a persistent cough for eight weeks.
  • The doctor called you back to discuss the results.
  • You feel nervous about the scan, especially because of your brother’s lung cancer.

Specific Information

(Only provide if asked relevant questions)

Background Information

  • You have had no weight loss, night sweats, or coughing up blood.
  • You quit smoking five years ago but smoked for a long time before that.
  • You have never had a CT scan before and are unsure how serious this could be.

Symptoms & Concerns

  • Cough: Dry, occasional. No mucus or blood.
  • Fatigue: No change.
  • Breathlessness: Mild, mostly when exerting.
  • Chest pain: None.
  • Weight loss: No.
  • Appetite: Normal.

Medical & Lifestyle History

  • Smoking history: Smoked for 15 pack-years, quit at age 53.
  • Occupation: Worked as a construction worker, now works part-time as a handyman.
  • Family history: Brother diagnosed with lung cancer at 62, father had COPD.
  • Exercise: Walks occasionally but gets short of breath on hills.

Patient’s Concerns & Emotional Reactions

Concern About Cancer

  • If the candidate mentions cancer early, become visibly tense and ask:
    “Does this mean I have lung cancer? What are the chances?”
  • If the candidate explains that further tests are needed, you still look concerned but say:
    “So, you don’t know yet? How long will it take to find out?”

Frustration With Uncertainty

  • If the candidate is vague or avoids answering directly, become frustrated and say:
    “I just want to know what I’m dealing with, doctor. Should I be preparing for bad news?”
  • If the candidate explains possible benign causes, appear slightly reassured, but still ask:
    “So, what’s the next step? Can we rule cancer out completely?”

Worry About Next Steps

  • If the candidate explains the need for further tests, ask:
    “What kind of tests? Are they painful? How soon can I get them?”
  • If biopsy is mentioned, react with concern:
    “A biopsy? That sounds serious. Does that mean it’s cancer?”

Concern About Family Impact

  • If the candidate reassures you that the nodule may not be cancer, express continued concern:
    “I’ve seen what my brother went through. I need to know exactly what’s going on.”

Emotional and Body Language Cues

  • At the start: Slightly anxious but composed.
  • When cancer is mentioned: Shift uncomfortably, cross arms, tense facial expression.
  • When discussing further tests: Appear worried but willing to listen.
  • If reassured well: Nod and relax slightly, but still ask about follow-up steps.
  • If poorly reassured: Become frustrated, lean forward, and demand clarity.

Questions to Ask the Candidate

  • “What exactly did the scan show?” (Prompting the candidate to explain findings clearly).
  • “Is this something serious? Could it be cancer?”
  • “What do I need to do next?”
  • “How long do I have to wait to find out for sure?”
  • “What happens if it is cancer? What are my options?”
  • “Should I tell my wife to come with me to the next appointment?”

Closing Prompt

(If Next Steps Are Not Discussed)

“So, what happens now? Do I need another scan or something more?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Explain the abnormal chest CT result to David in a clear and empathetic manner.

The competent candidate should:

  • Deliver the result clearly, using non-alarming language while ensuring accuracy.
  • Explain that the CT scan showed a 1.8 cm solitary pulmonary nodule (SPN) in the right upper lobe, which requires further assessment.
  • Acknowledge the patient’s anxiety, particularly regarding lung cancer, and address concerns empathetically.
  • Explain that while SPNs can be due to many benign causes, including infections and inflammation, they can also be early signs of malignancy, requiring further testing.
  • Outline the importance of risk factors, such as the patient’s smoking history and family history of lung cancer, in guiding next steps.
  • Check for patient understanding and allow space for questions.

Task 2: Discuss the possible differential diagnoses and justify the need for further investigation.

The competent candidate should:

  • Provide a structured differential diagnosis, including:
    • Benign: Granulomas (due to past infections like tuberculosis or histoplasmosis), hamartomas, or inflammatory nodules.
    • Malignant: Primary lung cancer (non-small cell or small cell carcinoma), metastatic disease from another primary cancer.
    • Other causes: Pulmonary abscess, vascular abnormalities.
  • Explain that risk stratification is based on factors like nodule size, growth, patient age, and smoking history.
  • Justify why further investigations (e.g., repeat CT, PET scan, biopsy) are necessary to determine the nature of the nodule.
  • Discuss the importance of a structured approach, referencing guidelines such as the Fleischner Society guidelines for pulmonary nodules.

Task 3: Address David’s concerns regarding the results and outline the next steps, including management and follow-up.

The competent candidate should:

  • Reassure David that most SPNs are benign, but further testing is required to rule out serious conditions.
  • Address his anxiety about lung cancer, balancing reassurance with realistic discussion of risks.
  • Outline a stepwise approach, including:
    • Low-risk nodules: Serial CT surveillance (e.g., in 3-6 months).
    • Higher-risk nodules: PET scan or biopsy.
    • Very high-risk nodules: Referral to a respiratory physician or thoracic surgeon.
  • Discuss smoking cessation and risk reduction strategies.
  • Provide clear follow-up plans and ensure the patient understands the importance of ongoing monitoring.

SUMMARY OF A COMPETENT ANSWER

  • Clearly communicates abnormal results, avoiding unnecessary alarm.
  • Provides a structured differential diagnosis, covering both benign and malignant possibilities.
  • Uses shared decision-making to explain the need for further investigations.
  • Addresses patient concerns empathetically, particularly regarding cancer.
  • Outlines a clear management plan, including investigations, follow-up, and smoking cessation.

PITFALLS

  • Providing vague or overly technical explanations, leading to confusion or distress.
  • Failing to acknowledge the patient’s concerns, particularly anxiety about cancer.
  • Over-reassuring or downplaying the significance of the finding, leading to a lack of follow-up.
  • Not explaining the rationale for further tests, leaving the patient feeling uncertain.
  • Ignoring preventive health measures, such as smoking cessation and lung cancer screening discussions.

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 an appropriate history focusing on risk factors and symptomatology.
2.2 Interprets abnormal imaging findings in the context of the patient’s history.

3. Diagnosis, Decision-Making and Reasoning

3.1 Considers a broad differential diagnosis for incidental lung findings.
3.2 Justifies the need for further investigations and specialist referral.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides a structured approach to investigation and follow-up.
4.2 Outlines management options, balancing urgency and patient concerns.

5. Preventive and Population Health

5.1 Discusses smoking cessation and lung cancer screening (if applicable).
5.2 Educates on risk reduction for lung disease.

6. Professionalism

6.1 Manages patient concerns with sensitivity and professionalism.

7. General Practice Systems and Regulatory Requirements

7.1 Explains appropriate use of Medicare-funded imaging and referrals.

9. Managing Uncertainty

9.1 Communicates appropriately when a diagnosis is uncertain and outlines a structured follow-up plan.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises potential serious pathology and ensures timely investigation and referral.

Competency at Fellowship Level

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