CCE-CE-038 - GP Exams

CASE INFORMATION

Case ID: CCE-2025-001
Case Name: Joanne Matthews
Age: 52
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: X11 – Menopause/Climacteric; X09 – Premenstrual symptoms/complaints; A44 – Preventive immunisation/medication-general

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages the patient 1.2 Elicits and explores the patient’s concerns and expectations 1.3 Provides clear, empathetic explanations of diagnosis and management
2. Clinical Information Gathering and Interpretation	2.1 Takes a targeted history, including symptoms, medical history, and impact on quality of life 2.2 Interprets relevant risk factors and clinical findings
3. Diagnosis, Decision-Making and Reasoning	3.1 Uses clinical reasoning to identify key issues 3.2 Formulates a problem list and differential diagnoses
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a safe, evidence-based management plan 4.2 Explores pharmacological and non-pharmacological options for symptom relief
5. Preventive and Population Health	5.1 Assesses risk factors for osteoporosis and cardiovascular disease 5.2 Provides lifestyle advice for menopause management
6. Professionalism	6.1 Maintains patient-centred care and respects patient autonomy
7. General Practice Systems and Regulatory Requirements	7.1 Adheres to prescribing guidelines for Menopausal Hormone Therapy (MHT)
8. Procedural Skills	8.1 Selects appropriate investigations, such as bone mineral density testing, where indicated
9. Managing Uncertainty	9.1 Manages uncertainty related to varied menopause presentations and patient concerns
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and addresses red flags such as abnormal vaginal bleeding or severe mood disturbances

CASE FEATURES

A 52-year-old woman presents with symptoms of menopause, including hot flushes, mood swings, and sleep disturbances.
She is concerned about risks associated with Menopausal Hormone Therapy (MHT).
She is unsure about lifestyle changes that may help.
The case includes shared decision-making regarding MHT and non-hormonal options.
She has a family history of osteoporosis and cardiovascular disease.

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
Explain the diagnosis and differentiate from other conditions
Provide an evidence-based management plan
Address the patient’s concerns.

SCENARIO

Joanne Matthews, a 52-year-old office worker, presents to your general practice with concerns about symptoms that have worsened over the past year. She describes frequent hot flushes, night sweats disrupting her sleep, mood swings, and increased anxiety. She also reports vaginal dryness, leading to discomfort during intercourse.

Joanne is uncertain about treatment options and has heard conflicting advice about Menopausal Hormone Therapy (MHT). She is particularly worried about breast cancer and cardiovascular disease risks, as her mother had a heart attack at age 60 and osteoporosis at 70.

PATIENT RECORD SUMMARY

Patient Details

Name: Joanne Matthews
Age: 52
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular medications

Past History

Nil significant

Social History

Occupation: Office worker
Drinks 2 glasses of wine per night
No smoking history

Family History

Mother: Osteoporosis diagnosed at 70, myocardial infarction at 60
Father: Type 2 diabetes, hypertension
Sister: Breast cancer at age 55

Smoking

Never smoked

Alcohol

2 standard drinks per night

Vaccination and Preventative Activities

Cervical screening up to date
Mammogram normal (last year)

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 think I’m going through menopause, and it’s been terrible. I don’t know what to do.”

General Information

(Freely Given Information)

You are Joanne Matthews, a 52-year-old office worker who has been experiencing symptoms of menopause for the past year.
You have frequent hot flushes, which feel like an intense wave of heat spreading across your face and upper body, happening several times a day.
Night sweats wake you up, making it hard to get back to sleep. You often wake up feeling exhausted.
Your mood swings have worsened. You find yourself getting irritated at small things, sometimes feeling tearful for no reason.

Specific Information

(Only Provided When Asked)

Background Information

You’ve become more anxious, which is unusual for you. You worry about your health and the future.
You have vaginal dryness, which makes intercourse with your partner uncomfortable. You feel embarrassed about it and worry it might affect your relationship.
You are gaining weight, especially around your abdomen, despite not eating more than usual.
You’ve heard a lot of different things about Menopausal Hormone Therapy (MHT) and are unsure if it’s safe for you.
You are worried about osteoporosis, as your mother was diagnosed with it in her 70s, and you want to know if you should be tested.
You have no other major health problems and take no regular medications.

Menstrual and Gynaecological History

Your periods became irregular about two years ago. They gradually became lighter, and your last period was about 10 months ago.
Before this, you occasionally had heavy periods and some spotting between cycles, but that has stopped.
You had a normal Pap smear last year and a normal mammogram a year ago.

Family History

Your mother had a heart attack at 60 and was diagnosed with osteoporosis at 70.
Your father had type 2 diabetes and hypertension.
Your sister was diagnosed with breast cancer at 55, and this makes you worried about MHT increasing your risk.

Concerns About Hormone Therapy

You have read online and heard from friends that MHT can cause breast cancer.
You are scared that if you take hormones, you might develop cancer like your sister.
You also heard that hormones can cause blood clots and heart disease, which concerns you because of your mother’s heart attack.

Lifestyle and Non-Pharmacological Measures

You exercise once or twice a week, usually walking, but feel too tired some days.
You drink two glasses of wine most nights.
You are open to trying natural remedies, and you’ve already tried black cohosh and evening primrose oil, but they didn’t help much.
You are unsure if changing your diet would help but would be willing to try if it could improve your symptoms.

Mental and Emotional Health

You feel more anxious than usual, sometimes over small things.
You occasionally feel overwhelmed and teary, but you are not depressed.
You worry about getting older and how this will affect your quality of life.

Sexual Health and Relationship Concerns

You love your partner, but you avoid intimacy because of vaginal dryness and discomfort.
You feel self-conscious about your body changes, and this has affected your confidence.
You haven’t talked to your partner much about this, but you worry it could create distance between you.

Emotional and Non-Verbal Cues

Anxious and hesitant at first, especially when discussing MHT and cancer risks.
Frustrated when talking about weight gain and sleep issues.
Sad and slightly embarrassed when discussing vaginal dryness and its effect on your relationship.
Hopeful and interested when discussing possible solutions.

Questions for the Candidate

(Ask Naturally During the Consultation)

“Is there anything I can do to manage this naturally?”
“I’ve heard hormone therapy can cause cancer. Is that true?”
“Do I need any tests or scans for my bones?”
“Will menopause affect my heart health?”
“What happens if I just do nothing and wait it out?”
“Are there any lifestyle changes that can help with weight gain and sleep?”

Challenging Statements

(Only If the Candidate Does Not Address Concerns Well)

“I don’t want to take medications if they might harm me. Is there a safer way?”
“I feel like no one talks about this, and I don’t know what’s normal anymore.”
“I don’t feel like myself. Will I ever feel normal again?”

Expectations from the Consultation

You want clear, evidence-based advice on managing menopause.
You want to know if MHT is safe for you and whether it increases your risk of breast cancer.
You would like lifestyle and natural strategies to help improve symptoms before committing to medication.
You want reassurance that what you’re going through is normal.
You would appreciate practical advice about improving your sleep and reducing anxiety.

Key Takeaways for the Role-Player

Be engaged and expressive, showing frustration, worry, and relief as the consultation progresses.
If the candidate provides a clear, empathetic explanation, be receptive and relieved.
If they fail to address concerns, stay doubtful and ask more probing questions.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, considering the patient’s symptoms, concerns, and risk factors.

The competent candidate should:

Elicit details of menopause symptoms: Hot flushes, night sweats, mood changes, sleep disturbances, vaginal dryness, and impact on daily life.
Assess menstrual history: Last menstrual period, cycle changes, and any abnormal bleeding.
Explore psychological and emotional impact: Assess anxiety, depression, and mood swings, including their effect on relationships and work.
Clarify lifestyle factors: Exercise, diet, alcohol intake, smoking status, and stress levels.
Take a comprehensive family history: History of osteoporosis, cardiovascular disease, and breast cancer.
Discuss previous treatments tried: Over-the-counter remedies, lifestyle changes, and any prior medical interventions.
Assess patient’s concerns: Address myths and fears regarding menopause treatments, including MHT.

Task 2: Explain the diagnosis and differentiate from other conditions.

The competent candidate should:

Confirm the likely diagnosis of perimenopause based on history (age, symptomatology, and absence of menstruation for 10 months).
Discuss perimenopause as a transition phase to menopause and its variable symptomatology.
Differentiate from other conditions:
- Thyroid dysfunction (ask about weight changes, heat/cold intolerance, palpitations).
- Depression/anxiety disorders (screen for major depressive symptoms beyond mood swings).
Explain the natural progression of menopause and reassure the patient about the expected course.
Address misconceptions about menopause and clarify what is normal versus what needs medical attention.

Task 3: Provide an evidence-based management plan, including lifestyle, pharmacological, and non-pharmacological options.

The competent candidate should:

Explain lifestyle interventions:
- Regular exercise, a Mediterranean diet, weight management.
- Reducing alcohol and caffeine intake to manage hot flushes.
- Sleep hygiene strategies for night sweats and insomnia.
Discuss non-hormonal pharmacological options:
- SSRIs/SNRIs for mood disturbances and vasomotor symptoms.
- Gabapentin or clonidine for severe hot flushes.
Outline Menopausal Hormone Therapy (MHT) options:
- Benefits and risks based on patient profile.
- Local vaginal oestrogen for urogenital symptoms.
- Lowest effective dose for the shortest duration.
- Contraindications: Personal/family history of breast cancer, thromboembolism, or uncontrolled hypertension.
Preventive health strategies:
- Bone health: Calcium, vitamin D, weight-bearing exercises, and consider DEXA scan if indicated.
- Cardiovascular risk assessment and lifestyle modifications.

Task 4: Address the patient’s concerns regarding treatment risks and benefits.

The competent candidate should:

Acknowledge and validate concerns about MHT and breast cancer risk.
Clarify evidence-based risk assessment:
- MHT slightly increases breast cancer risk after 5 years of use.
- No significant cardiovascular risk increase with early initiation (<60 years or within 10 years of menopause).
- Vaginal oestrogen is safe and effective for local symptoms.
Discuss benefits versus risks tailored to her history and symptoms.
Empower the patient to make an informed choice by engaging in shared decision-making.

SUMMARY OF A COMPETENT ANSWER

Takes a structured and empathetic history, covering physical, emotional, and lifestyle factors.
Considers differential diagnoses and explains them clearly.
Provides a patient-centred management plan, balancing lifestyle, non-hormonal, and hormonal options.
Explains risks and benefits of MHT using evidence-based guidelines.
Engages in shared decision-making to address patient concerns.

PITFALLS

Failing to consider differential diagnoses like thyroid dysfunction or depression.
Overemphasising or underplaying risks of MHT, leading to unnecessary anxiety or missed treatment benefits.
Not discussing non-hormonal options, limiting the patient’s choices.
Failing to assess psychological and emotional impact, missing key concerns affecting the patient’s well-being.
Providing vague or non-specific advice, rather than individualised recommendations.

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.
1.3 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a targeted history, including symptoms, medical history, and impact on quality of life.
2.2 Interprets relevant risk factors and clinical findings.

3. Diagnosis, Decision-Making and Reasoning

3.1 Uses clinical reasoning to identify key issues.
3.2 Formulates a problem list and differential diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a safe, evidence-based management plan.
4.2 Explores pharmacological and non-pharmacological options for symptom relief.

5. Preventive and Population Health

5.1 Assesses risk factors for osteoporosis and cardiovascular disease.
5.2 Provides lifestyle advice for menopause management.

6. Professionalism

6.1 Maintains patient-centred care and respects patient autonomy.

7. General Practice Systems and Regulatory Requirements

7.1 Adheres to prescribing guidelines for Menopausal Hormone Therapy (MHT).

8. Procedural Skills

8.1 Selects appropriate investigations, such as bone mineral density testing, where indicated.

9. Managing Uncertainty

9.1 Manages uncertainty related to varied menopause presentations and patient concerns.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and addresses red flags such as abnormal vaginal bleeding or severe mood disturbances.

Competency at Fellowship Level

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