CASE INFORMATION

Case ID: 001
Case Name: Thomas Jangala
Age: 6
Gender: Male
Indigenous Status: Aboriginal
Year: 2025
ICPC-2 Codes: S74 (Scabies), S84 (Impetigo)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Demonstrates culturally safe communication 1.2 Elicits concerns and expectations of the caregiver 1.4 Provides clear and simple health education
2. Clinical Information Gathering and Interpretation	2.1 Obtains a focused history to identify risk factors and household contacts 2.2 Recognises characteristic clinical features of scabies and impetigo
3. Diagnosis, Decision-Making and Reasoning	3.1 Formulates a working diagnosis based on history and presentation 3.6 Considers differential diagnoses including eczema and fungal infections
4. Clinical Management and Therapeutic Reasoning	4.2 Provides appropriate first-line treatment 4.5 Advises on symptomatic relief and prevention of transmission
5. Preventive and Population Health	5.1 Identifies environmental and social contributors to recurrent infections 5.3 Provides community-focused health education
6. Professionalism	6.2 Maintains culturally appropriate and respectful engagement
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and follow-up 7.7 Liaises with public health services if necessary
8. Procedural Skills	8.1 Demonstrates knowledge of appropriate specimen collection for secondary bacterial infection
9. Managing Uncertainty	9.3 Identifies when escalation or referral is needed
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises complications such as cellulitis or rheumatic fever
11. Aboriginal Health Context	AH1.1 Demonstrates understanding of cultural and environmental factors affecting health AH1.3 Adapts management strategies to be effective in a remote setting
12. Rural Health Context	RH1.2 Works within the limitations of rural healthcare resources

CASE FEATURES

Highlights cultural competence and collaboration with community health workers
Aboriginal child living in a remote community
Presents with scabies and impetigo, common in remote settings
Risk factors include overcrowded living conditions and limited access to healthcare
Emphasises the importance of family-wide treatment and community education
Addresses potential complications such as post-streptococcal glomerulonephritis and rheumatic fever

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 a focused history
Explain your diagnosis and outline a differential diagnosis.
Develop a safe and effective management plan
Provide appropriate preventive health advice

SCENARIO

Thomas Jangala, a 6-year-old Aboriginal boy from a remote community, is brought in by his grandmother due to worsening itchy sores on his arms, legs, and torso. The sores started as small, itchy bumps but have become crusted and spreading.

Thomas has been scratching a lot, especially at night, making it difficult for him to sleep.

PATIENT RECORD SUMMARY

Patient Details

Name: Thomas Jangala
Age: 6
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Aboriginal

Allergies and Adverse Reactions

None known

Medications

None

Past History

Recurrent skin infections in the past year

Social History

Attends local school

Family History

Siblings and cousins also affected by similar rash
Grandmother has diabetes and is worried about infections spreading

Vaccination and Preventative Activities

Up to date with childhood immunisations

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

“I don’t know what to do, Doctor. Thomas is scratching all night, and his sores just keep getting worse.”

General Information

Thomas, my grandson, has been having this itchy skin for about two weeks now.
It started as little bumps, but then they turned into sores. Some of them are covered in yellow crusts now, and more are popping up on his arms, legs, and tummy.
He keeps scratching, especially at night. He wakes up crying and scratching, poor thing.
I’ve seen this before with the other kids. It seems to go around, and it keeps coming back.
A few of the other kids in our house are scratching too. My youngest granddaughter has some sores starting now as well.

Specific Information

(Only Reveal When Asked)

Your name is Darana
This is your country
You, and your family, have lived here as long as you can remember

History of Presenting Complaint

The itching started around two weeks ago, first on his hands and between his fingers.
The sores appeared a few days after the itching began.
Thomas keeps scratching them, and some have started to ooze a little bit.
He says the itching is worse at night, and he’s not been sleeping well.
No fever or chills, but he’s been a bit grumpy from not sleeping enough.

Family and Household Situation

We live in a house with about 10 people—Thomas, his siblings, cousins, and me.
It’s been hard to keep up with washing clothes and bedding. Sometimes, we don’t have enough water for washing everything properly.
Other kids in the house have been scratching too, and some have sores like Thomas.
I’ve seen this before in the community—seems like lots of kids get these itchy rashes.
We don’t have a doctor here all the time, just a nurse who visits.
The school sent a note home about some kids having skin sores.

Past Management and Current Concerns

We tried using some bush medicine—putting tea tree oil and some other things on his skin—but it hasn’t really helped.
I don’t know if he needs antibiotics. The nurse gave antibiotics to my nephew a while ago when he had something similar.
I’m worried this will just keep coming back.
One of the aunties in town told me that bad sores can cause kidney problems. Is that true?
I don’t want the other kids to get sick.

Emotional Cues and Body Language

Looks concerned and tired from looking after Thomas.
Expresses frustration about how hard it is to keep everyone clean.
Becomes more worried when talking about the sores getting worse or spreading.
When talking about kidney problems, looks particularly anxious and leans in, seeking reassurance.
Softens when the doctor gives clear explanations but may seem sceptical if the advice sounds unrealistic for their situation.

Patient Expectations

Wants to know what is causing the problem and whether it’s serious.
Hopes for something that will stop Thomas from itching and make the sores go away.
Wants to know if the whole family needs treatment.
Needs practical advice on how to prevent this from happening again, especially given the challenges in their living conditions.

Questions for the Candidate

“What’s causing this? Is it dangerous?”
“Do we need medicine for everyone in the house?”
“How can we stop this from coming back?”
“Is there anything we can do if we don’t have enough water for washing everything?”
“Do we need to go to the hospital for this?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history from Thomas’s caregiver, ensuring you explore social and environmental risk factors.

The competent candidate should:

Start by introducing themselves, having a yarn, and finding out the name of the caregiver – Darana – and that this is her country
Elicit details about Thomas’s symptoms, including the onset, progression, and associated features of his rash (e.g., itching, nocturnal worsening, presence of sores, and secondary infection signs).
Assess the family and community context, including whether other household members or schoolmates have similar symptoms.
Explore hygiene and living conditions, including access to running water, soap, overcrowding, and bedding/washing frequency.
Identify any previous treatments used (e.g., bush medicine, prior antibiotics) and their effectiveness.
Explore caregiver concerns and expectations, particularly fears about complications such as kidney disease or rheumatic fever.
Demonstrate culturally safe communication, ensuring empathy and rapport with Thomas’s grandmother.

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

The competent candidate should:

Clearly communicate that Thomas has scabies and secondary impetigo, explaining that scabies is a mite infestation, while impetigo is a bacterial skin infection.
Explain that scratching scabies lesions can introduce bacteria, leading to impetigo, which presents as crusted sores.
Discuss the contagious nature of both conditions and the need for household-wide treatment.
Outline differential diagnoses, including:
- Eczema: Chronic, itchy rash with a history of dry skin.
- Fungal infections: Tinea (ringworm) can cause itchy, scaly patches.
- Allergic/contact dermatitis: May present with widespread itching but lacks burrows or secondary infection.
- Insect bites: Can mimic scabies but usually resolve faster without progression.
Acknowledge the grandmother’s concerns, ensuring reassurance and opportunities for questions.

Task 3: Develop a safe and effective management plan, including treatment, household measures, and follow-up.

The competent candidate should:

Prescribe either:
- permethrin 5% cream for Thomas and all household members, explaining correct application and washing off after 8-12 hours.
- weight based Ivermectin
Note that both treatments need repeating a week later to kill newly hatched mites
Prescribe oral antibiotics (e.g., cephalexin) for impetigo, especially due to the risk of post-streptococcal complications.
Advise environmental control measures:
- Hot washing or sealing bedding and clothing for 3 days to kill mites.
- Regular handwashing and short nails to reduce bacterial spread.
- Encouraging improved hygiene practices given the limitations of water access.
Provide education on symptoms of complications, including signs of cellulitis, abscess formation, or post-streptococcal glomerulonephritis (dark urine, swelling).
Arrange follow-up in 1-2 weeks to ensure resolution, check for new cases, and reinforce prevention.

Task 4: Provide appropriate preventive health advice to reduce recurrence in the community.

The competent candidate should:

Discuss long-term strategies to reduce recurrent scabies and skin infections, including:
- Community-wide education on recognising symptoms early.
- Regular skin checks for children and early treatment of itching before sores develop.
- Liaison with public health services to explore support for improved hygiene infrastructure.
Acknowledge systemic barriers, such as overcrowding and limited water access, and provide realistic hygiene strategies (e.g., prioritising cleaning of clothes and bedding of affected individuals).
Encourage school-based health education programs to prevent reinfestation cycles.
Consider contacting Aboriginal Health Services for community-led solutions and government support.

SUMMARY OF A COMPETENT ANSWER

Starts the consultation with a yarn and finds out the caregiver name and that this is her country.
Elicits a thorough history, including social and environmental risk factors.
Clearly explains the diagnosis and differential diagnoses in a patient-centred manner.
Provides a structured, practical management plan, including pharmacological and non-pharmacological interventions.
Emphasises household and community treatment to prevent reinfection.
Demonstrates cultural competence, recognising challenges in remote Aboriginal communities.
Identifies and mitigates risks for complications (e.g., post-streptococcal glomerulonephritis).
Includes appropriate follow-up and escalation of care if needed.

PITFALLS

Failing to consider the household and community context, leading to incomplete management.
Overlooking the risk of complications, such as rheumatic fever and post-streptococcal glomerulonephritis.
Not offering treatment for all household members, increasing the risk of recurrence.
Lack of culturally appropriate communication, not acknowledging barriers to hygiene or caregiver concerns.
Neglecting preventive strategies, such as public health involvement or environmental hygiene measures.
Not arranging timely follow-up, missing ongoing transmission or complications.

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 Obtains a focused history to identify risk factors and household contacts.
2.2 Recognises characteristic clinical features of scabies and impetigo.

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulates a working diagnosis based on history and presentation.
3.6 Considers differential diagnoses including eczema and fungal infections.

4. Clinical Management and Therapeutic Reasoning

4.2 Provides appropriate first-line treatment.
4.5 Advises on symptomatic relief and prevention of transmission.

5. Preventive and Population Health

5.1 Identifies environmental and social contributors to recurrent infections.
5.3 Provides community-focused health education.

6. Professionalism

6.2 Maintains culturally appropriate and respectful engagement.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up.
7.7 Liaises with public health services if necessary.

8. Procedural Skills

8.1 Demonstrates knowledge of appropriate specimen collection for secondary bacterial infection.

9. Managing Uncertainty

9.3 Identifies when escalation or referral is needed.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises complications such as cellulitis or rheumatic fever.

11. Aboriginal Health Context (AH)

AH1.1 Demonstrates understanding of cultural and environmental factors affecting health.
AH1.3 Adapts management strategies to be effective in a remote setting.

12. Rural Health Context (RH)

RH1.2 Works within the limitations of rural healthcare resources.

Competency at Fellowship Level

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