CCE-CE-034

CASE INFORMATION

Case ID: AOM-001
Case Name: Ethan Williams
Age: 3 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: H71 (Acute Otitis Media)


COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages effectively with parent/caregiver to gather history and provide explanations.
1.2 Uses age-appropriate communication strategies.
1.3 Addresses parental concerns empathetically and provides reassurance.
2. Clinical Information Gathering and Interpretation2.1 Elicits a targeted history of ear pain, fever, irritability, and other relevant symptoms.
2.2 Identifies red flags for complications such as mastoiditis or perforation.
3. Diagnosis, Decision-Making and Reasoning3.1 Formulates a diagnosis of acute otitis media based on clinical findings.
3.2 Differentiates between bacterial and viral causes of AOM.
4. Clinical Management and Therapeutic Reasoning4.1 Develops a management plan that includes appropriate use of antibiotics following Australian guidelines.
4.2 Provides symptomatic treatment options for pain and fever.
5. Preventive and Population Health5.1 Discusses preventive measures such as vaccination and reducing passive smoke exposure.
6. Professionalism6.1 Demonstrates professionalism in responding to parental concerns and expectations.
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate documentation and follow-up recommendations.
9. Managing Uncertainty9.1 Explains the role of watchful waiting in non-severe AOM cases.
10. Identifying and Managing the Patient with Significant Illness10.1 Recognises when referral to ENT or hospital is necessary for complications.

CASE FEATURES

  • Explanation of when to seek further medical attention.
  • A 3-year-old boy presents with ear pain, fever, and irritability.
  • Concerned parent seeking antibiotic treatment.
  • Clinical assessment and decision-making regarding management.
  • Discussion of preventive strategies (vaccination, passive smoke exposure).

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. Provide a clear management plan
  4. Address the parent’s concerns.

SCENARIO

Ethan Williams is a 3-year-old boy brought in by his mother, Sarah. She reports that Ethan has been irritable and pulling at his left ear for the past two days. He has had a fever (38.5°C) and a runny nose for the past three days. He has been sleeping poorly and refuses to eat solid foods but is still drinking fluids. Sarah is concerned because he had a similar episode six months ago, and she was advised at that time that antibiotics might not be needed. She is worried about complications and wants to know if Ethan needs antibiotics now.

On examination:

  • Temperature: 38.2°C
  • Heart Rate: 110 bpm
  • Respiratory Rate: 22/min

PATIENT RECORD SUMMARY

Patient Details

Name: Ethan Williams
Age: 3 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • None known

Medications

  • Salbutamol inhaler

Past History

  • One prior episode of suspected acute otitis media
  • Mild asthma

Social History

  • Lives with mother (Sarah) and father (Mark)

Family History

  • No significant family history of recurrent ear infections or hearing issues

Smoking

  • No household smokers

Alcohol

  • Not applicable

Vaccination and Preventive Activities

  • Up to date, including pneumococcal and influenza 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.


ROLE-PLAYER SCRIPT

Opening Line

“Doctor, Ethan has been pulling at his ear and crying a lot. I think he has another ear infection, and I want to know if he needs antibiotics.”


General Information

You are Sarah Williams, a 32-year-old mother of Ethan, a 3-year-old boy. You have brought him to the GP today because he has been unwell for a few days. He has had a fever, runny nose, and has been unusually irritable. He started pulling at his left ear yesterday and was crying a lot during the night. You are concerned that he might have another ear infection, as he had a similar episode six months ago.


Specific Information

(Only Provide if Asked Relevant Questions)

Background Information

Ethan has been fussy with food and has not been eating much, though he is still drinking fluids. He has been waking up frequently at night and seems uncomfortable when lying down. You are also worried about whether he should go to daycare tomorrow, as he normally attends three days a week.

You remember that last time Ethan had an ear infection, the doctor suggested waiting instead of using antibiotics. However, you are unsure whether this is the right thing to do again. You want to know if this infection could cause complications like hearing problems.

You are a non-smoker, and no one in your household smokes. Ethan’s vaccinations are up to date, including pneumococcal and flu vaccines. He has mild asthma but hasn’t needed his inhaler recently.

Symptoms and History

  • The fever started three days ago and was around 38.5°C last night. You gave him paracetamol, which helped a little. This morning, his temperature was 38.2°C.
  • He has had a runny nose for three days, with clear mucus at first, but now it looks slightly yellow.
  • His ear pain started yesterday, mainly in his left ear. He was crying a lot and pulling at his ear.
  • He has been more irritable than usual and wakes up frequently at night, crying.
  • He has not been eating much solid food, but he is still drinking milk and water.
  • He hasn’t had vomiting or diarrhoea.
  • You haven’t noticed any ear discharge.
  • He has had a mild cough, but no wheezing or trouble breathing.
  • He has no known allergies.
  • He had a similar ear infection six months ago, but antibiotics weren’t prescribed at the time.

Concerns and Expectations

  • Concerned about antibiotics:
    • You are not sure whether Ethan needs antibiotics this time. You don’t want him to suffer, but you also don’t want to give unnecessary medication.
    • You have heard mixed advice about whether antibiotics are needed for ear infections and want clarification.
  • Worried about complications:
    • You are worried about Ethan’s hearing and whether repeated infections could cause damage.
    • You have read that ear infections can lead to speech or developmental delays and want to know if this is a risk.
  • Daycare concerns:
    • You are wondering if going to daycare makes Ethan sick more often.
    • You want to know if he should stay home from daycare until he is completely better.
  • Prevention:
    • You want to know how to prevent future ear infections.
    • You have heard that some kids need grommets (ear tubes) and are wondering if Ethan might need them.

Emotional Cues and Behaviour

  • You are worried and slightly frustrated, but open to discussion.
  • If the doctor suggests delaying antibiotics, you may express concern and say: “But what if he gets worse? I don’t want him to be in pain for days.”
  • If the doctor reassures you that pain relief is the best approach for now, you relax slightly, but still want a clear explanation.
  • If the doctor explains signs of complications, you listen carefully and ask about what to watch for.
  • If the doctor provides information about preventing ear infections, you seem interested and engaged, asking for practical advice.
  • If the doctor acknowledges your concerns and explains things clearly, you trust their recommendation and follow their advice.

Questions for the Candidate

You should naturally ask these questions during the consultation:

  1. “Does he need antibiotics this time? How do we know if it’s bacterial or viral?”
  2. “What can I do to prevent him from getting more ear infections?”
  3. “How will I know if it’s getting worse? When should I come back?”
  4. “Could this affect his hearing? Will repeated infections cause problems later?”
  5. “Should I keep him home from daycare? Will being around other kids make this worse?”
  6. “Are there any natural remedies or things I can do at home to help him feel better?”
  7. “What if his fever doesn’t go down in the next day or two?”

Final Behaviour and Conclusion

  • If the doctor gives a clear plan, including watchful waiting, pain relief, and follow-up advice, you feel more reassured.
  • If antibiotics are not recommended, you hesitate at first, but accept the decision if it is well explained.
  • If the doctor explains complications clearly, you appreciate their thoroughness.
  • If they offer preventive strategies, you show genuine interest and ask further questions.
  • You thank the doctor and say: “Okay, I’ll keep an eye on him. I’ll bring him back if he’s not improving.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:


Task 1: Take a focused history from the parent regarding Ethan’s symptoms and medical background.

The competent candidate should:

  • Use open-ended questions to gather key details about Ethan’s ear pain, fever, irritability, sleep disturbances, and feeding difficulties.
  • Ask about the onset, duration, severity, and progression of symptoms.
  • Explore associated symptoms such as nasal congestion, cough, ear discharge, vomiting, or behavioural changes.
  • Inquire about medication use (e.g., paracetamol or ibuprofen) and its effect.
  • Assess Ethan’s past medical history, including previous ear infections, asthma, allergies, and vaccination status.
  • Obtain a family history of recurrent ear infections, hearing issues, or other ENT concerns.
  • Discuss Ethan’s daycare attendance, recent illnesses, and exposure to sick contacts.
  • Identify any parental concerns, including fears about hearing loss or need for antibiotics.
  • Provide empathetic reassurance while summarising key findings back to the parent.

Task 2: Explain your assessment and outline a reasonable differential diagnosis.

The competent candidate should:

  • Explain that Ethan’s symptoms are consistent with acute otitis media (AOM) based on fever, ear pain, and tympanic membrane findings.
  • Discuss the likely viral or bacterial aetiology, highlighting that many cases resolve without antibiotics.
  • Provide a differential diagnosis, including:
    • Acute otitis media (most likely diagnosis)
    • Otitis media with effusion (if symptoms are milder and persistent without fever)
    • Otitis externa (if ear pain is severe, with tenderness and discharge)
    • Pharyngitis or viral upper respiratory tract infection (URTI) contributing to symptoms)
    • Mastoiditis (if signs of postauricular swelling, redness, or worsening pain)
  • Address parental concerns about hearing loss, recurrence, and complications.

Task 3: Provide a patient-centred management plan, including the appropriate use of antibiotics.

The competent candidate should:

  • Explain the watchful waiting approach for mild to moderate cases, as per Australian guidelines.
  • Recommend pain relief with paracetamol or ibuprofen for symptom control.
  • Advise on nasal saline drops and adequate hydration.
  • Educate the parent on signs requiring urgent review, such as:
    • Worsening symptoms beyond 48 hours
    • Persistent high fever
    • Otorrhoea or swelling behind the ear (suggesting mastoiditis)
  • Discuss when antibiotics may be appropriate:
    • Severe symptoms (fever >39°C, severe pain, bilateral AOM in children <2 years)
    • High-risk groups (Indigenous children, immunocompromised, recurrent infections)
    • Delayed antibiotic prescription strategy if symptoms persist or worsen
  • Provide a follow-up plan to reassess Ethan in 48 hours if no improvement.

Task 4: Address the parent’s concerns, provide education, and discuss follow-up recommendations.

The competent candidate should:

  • Acknowledge parental anxiety about complications and reassure them that AOM is common and self-limiting in most cases.
  • Provide information on when antibiotics are necessary and when they are not.
  • Reassure that hearing loss is usually temporary and that recurrent infections may require ENT review.
  • Discuss preventive strategies, including:
    • Reducing passive smoke exposure
    • Encouraging breastfeeding (if applicable)
    • Timely vaccinations (pneumococcal and influenza)
    • Daycare hygiene practices
  • Advise that Ethan can return to daycare once fever-free for 24 hours and symptoms are improving.
  • Provide a clear safety-net plan and encourage follow-up if symptoms worsen or persist beyond expected timeframe.

SUMMARY OF A COMPETENT ANSWER

  • Demonstrates structured and empathetic history-taking, exploring all relevant biopsychosocial aspects.
  • Identifies acute otitis media as the most likely diagnosis while considering appropriate differentials.
  • Explains the rationale for watchful waiting, pain relief, and antibiotic use in line with Australian guidelines.
  • Addresses parental concerns thoroughly, providing education on prevention, complications, and follow-up.
  • Uses clear and accessible language, ensuring the parent understands management and red flags.

PITFALLS

  • Failure to take a comprehensive history, missing key details such as previous infections, risk factors, or parental concerns.
  • Overprescribing antibiotics without clinical justification, disregarding watchful waiting recommendations.
  • Not considering alternative diagnoses, such as otitis externa or mastoiditis, when relevant.
  • Inadequate safety-netting, failing to explain when to return for review.
  • Lack of reassurance or education, leaving the parent feeling uncertain or anxious.

REFERENCES


MARKING

Each competency area is assessed on the following scale:

☐ 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 sociocultural context
1.2 Engages the parent to gather information about symptoms, concerns, and expectations
1.3 Addresses parental concerns empathetically and provides reassurance

2. Clinical Information Gathering and Interpretation

2.1 Elicits a targeted history of ear pain, fever, irritability, and associated symptoms
2.2 Identifies red flags for complications such as mastoiditis or perforation

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulates a diagnosis of acute otitis media based on clinical findings
3.2 Differentiates between bacterial and viral causes of AOM

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a management plan including watchful waiting, pain relief, and antibiotic stewardship
4.2 Provides clear guidance on follow-up and escalation if symptoms worsen

5. Preventive and Population Health

5.1 Discusses preventive measures such as vaccination and reducing passive smoke exposure

6. Professionalism

6.1 Demonstrates professionalism in responding to parental concerns and expectations

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up recommendations

9. Managing Uncertainty

9.1 Explains the role of watchful waiting in non-severe AOM cases

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises when referral to ENT or hospital is necessary for complications


Competency at Fellowship Level

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