CASE INFORMATION

Case ID: SD-006
Case Name: Emily Clarke
Age: 35 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: S99 (Skin Disease, Other)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Effectively gathers history about skin symptoms and their impact on daily life. 1.2 Explains diagnosis and management options in simple, patient-friendly language. 1.3 Addresses patient concerns about appearance, chronicity, and possible triggers.
2. Clinical Information Gathering and Interpretation	2.1 Takes a thorough dermatological history, including onset, progression, associated symptoms, and potential triggers. 2.2 Assesses for systemic involvement or underlying conditions.
3. Diagnosis, Decision-Making and Reasoning	3.1 Forms a differential diagnosis based on history and examination findings. 3.2 Identifies red flags requiring referral (e.g., suspected malignancy, systemic involvement, severe impact on quality of life).
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a personalised treatment plan including pharmacological and non-pharmacological options. 4.2 Provides guidance on long-term management, lifestyle changes, and when to seek further medical review.
5. Preventive and Population Health	5.1 Discusses preventive strategies, including skin care, sun protection, and avoiding triggers.
6. Professionalism	6.1 Demonstrates empathy and professionalism in addressing patient distress and cosmetic concerns.
7. General Practice Systems and Regulatory Requirements	7.1 Documents the skin condition, treatment plan, and follow-up plan appropriately.
9. Managing Uncertainty	9.1 Recognises when further investigations or dermatology referral is required.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies cases that may indicate underlying systemic disease or require more urgent intervention.

CASE FEATURES

Consideration of long-term management, treatment options, and the need for referral if the condition is severe or unresponsive.
A 35-year-old woman presents with itchy, red patches on her face and neck that have been persistent for six months.
The case involves differentiating between common dermatological conditions (eczema, rosacea, contact dermatitis, seborrhoeic dermatitis, psoriasis).
The patient has tried multiple over-the-counter creams without success and is frustrated by the ongoing symptoms.
Discussion about potential triggers (allergens, skincare products, stress, diet, environmental factors).

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 of the onset, progression, triggers, and impact of the skin condition.
Explain your assessment, including the likely diagnosis and differential diagnoses.
Provide an individualised management plan, including treatment options, preventive strategies, and follow-up.
Address patient concerns about cosmetic impact, chronicity, and the need for referral if required.

SCENARIO

Emily Clarke is a 35-year-old office worker who presents with red, itchy patches on her face and neck, which have persisted for the past six months. She has noticed that the rash flares up intermittently but has never completely resolved. It often worsens with stress and after using certain skincare products.

She has tried various over-the-counter creams, including moisturisers, hydrocortisone, and antihistamines, but none have provided lasting relief. She is feeling frustrated and self-conscious about the appearance of her skin, especially in professional and social settings.

She has no history of allergies or known skin conditions, but she had asthma as a child. She does not have any significant systemic symptoms such as fever, joint pain, or weight loss.

Your role is to assess the skin condition, determine a likely diagnosis, and provide a treatment and management plan.

PATIENT RECORD SUMMARY

Patient Details

Name: Emily Clarke
Age: 35 years
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular

Past History

Childhood asthma (resolved)

Social History

Works as an office administrator in a stressful work environment
Uses cosmetic skincare and makeup daily
No smoking, drinks socially

Family History

Mother has rosacea
No family history of autoimmune or chronic skin conditions

Smoking & Alcohol

Non-smoker
Drinks alcohol 1-2 times per week

Vaccination and Preventive Activities

Up to date with routine health checks

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, my skin has been a mess for months now. It’s red, itchy, and flares up all the time. I’ve tried everything, but nothing seems to work.”

General Information

Your name is Emily Clarke, and you are a 35-year-old office worker. Over the past six months, you have developed a persistent rash on your face and neck. The rash is red, itchy, and sometimes flaky, and it seems to flare up randomly. You feel self-conscious about your appearance, and the condition is starting to affect your confidence at work and in social situations.

You have tried multiple over-the-counter treatments, including moisturisers, hydrocortisone, and antihistamines, but nothing has provided long-term relief. You are frustrated and worried that this could be something serious, and you want a clear diagnosis and an effective treatment plan.

You don’t recall having any skin problems as a child, but you did have asthma when you were younger. Your mother has rosacea, so you wonder if you might have it too.

You haven’t changed your diet significantly, but you have noticed that the rash sometimes gets worse after drinking alcohol or eating spicy food.

You are also concerned about steroid creams, as you have read online that they can thin the skin and cause damage.

Specific Information (Only Provide if Asked Relevant Questions)

Symptoms and Functional Impact

The rash started six months ago, appearing on your cheeks, nose, chin, and neck.
It is red and sometimes flaky, but there are no blisters, pus, or open wounds.
It itches mildly but is more irritating than painful.
It worsens with heat, stress, alcohol, and certain skincare products.
No fever, weight loss, or joint pain.

Triggers and Lifestyle Factors

The rash gets worse in hot weather or when your face gets sweaty.
It seems to react to certain skincare products and makeup, but you haven’t identified a specific ingredient that causes a reaction.
Stressful days at work seem to trigger flare-ups.
Alcohol (especially red wine) and spicy food sometimes make the redness worse.

Previous Treatments Tried

You have used moisturisers, but they don’t seem to soothe the redness.
You tried antihistamines, but they didn’t make a difference.
A pharmacist recommended hydrocortisone cream, which helped a little but didn’t stop it from coming back.

Concerns and Expectations

You want to know what this is and whether it will go away.
You worry that it could be a chronic condition like rosacea.
You are concerned about using steroid creams long-term because you’ve heard they thin the skin.
You wonder if this could be related to diet, hormones, or an allergy.
You are looking for a solution that works and won’t make things worse.

Emotional Cues and Behaviour

You start the consultation feeling frustrated and concerned, as you feel like nothing has helped so far.
If the doctor acknowledges your concerns and provides reassurance, you relax and become more receptive to advice.
If the doctor suggests a chronic skin condition like rosacea, you become slightly anxious and ask:
- “So does that mean I’ll have this forever? Is there a cure?”
If the doctor recommends lifestyle changes, you seem skeptical and say:
- “I already try to eat pretty well. Do I really need to change my diet?”
If the doctor mentions prescription treatments, you ask:
- “Will this actually fix it, or will it just come back once I stop using the medication?”

Questions for the Candidate

You should naturally ask these questions during the consultation:

“What do you think this is? Could it be rosacea like my mum has?”
“Do I need any tests, or can you diagnose this just by looking at it?”
“Is there a treatment that will actually work long-term?”
“Should I stop wearing makeup or using skincare products?”
“Is this something I’ll have to deal with forever?”
“Could this be caused by my diet, stress, or something in the environment?”
“Do I need to see a dermatologist, or can this be managed here?”

Possible Responses to the Doctor’s Suggestions

If the Doctor Diagnoses Rosacea or Contact Dermatitis:

You look worried and ask:
- “So does this mean it won’t go away completely? Will I always have flare-ups?”
If the doctor explains long-term management, you listen carefully but still seem concerned about recurrence.

If the Doctor Recommends Topical or Oral Medication:

You seem cautious and ask:
- “Are there any side effects? How long will I need to use it?”
If they suggest a short-term trial, you nod and agree to try it.

If the Doctor Suggests Avoiding Triggers (e.g., Alcohol, Spicy Food, Stress):

You look frustrated and say:
- “But I enjoy wine and spicy food—do I really have to cut them out completely?”
If the doctor suggests moderation rather than elimination, you seem relieved.

If the Doctor Recommends a Referral to a Dermatologist:

You ask:
- “Is this necessary, or can we manage it here?”
If the doctor explains that referral is only needed if first-line treatments fail, you agree to try treatment first.

Final Behaviour and Conclusion

If the doctor explains things clearly and gives a structured plan, you feel reassured and more positive about managing your skin condition.
If the doctor fails to provide a clear diagnosis or plan, you remain frustrated and may ask for a referral to a dermatologist.
You leave the consultation feeling more informed about your condition and with a plan to follow.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history of the onset, progression, triggers, and impact of the skin condition.

The competent candidate should:

Use open-ended questions to establish the onset, duration, and progression of the skin condition.
Ask about associated symptoms, including itching, pain, burning, scaling, or discharge.
Explore triggers, such as heat, stress, alcohol, skincare products, makeup, or diet.
Inquire about previous treatments tried, including moisturisers, corticosteroids, antihistamines, or prescription medications.
Assess daily impact, including effects on work, social confidence, and mental health.
Identify past skin conditions, family history of dermatological diseases (e.g., rosacea, eczema, psoriasis), and history of allergies or asthma.
Summarise findings and acknowledge the patient’s concerns about appearance, chronicity, and treatment failure.

Task 2: Explain your assessment, including the likely diagnosis and differential diagnoses.

The competent candidate should:

Explain that the presentation is consistent with a chronic inflammatory skin condition.
Discuss possible diagnoses, including:
- Rosacea (flushing, persistent redness, worsens with triggers like alcohol, heat, stress, and spicy food).
- Seborrhoeic dermatitis (red, scaly patches, affects oily areas of the face and scalp).
- Contact dermatitis (reaction to skincare products, allergens, or irritants).
- Eczema (atopic or irritant) (itchy, dry patches, possible childhood history of asthma or allergies).
Discuss that further examination (e.g., close skin inspection, dermoscopy) may help differentiate conditions.
Reassure that most chronic skin conditions are manageable, but treatment requires ongoing care and trigger avoidance.

Task 3: Provide an individualised management plan, including treatment options, preventive strategies, and follow-up.

The competent candidate should:

Tailor treatment based on the likely diagnosis:
- For rosacea: Avoid triggers, prescribe topical metronidazole or azelaic acid, consider oral doxycycline if severe.
- For seborrhoeic dermatitis: Use antifungal creams (ketoconazole), mild corticosteroids for flares.
- For contact dermatitis: Identify and avoid irritants, use emollients and mild topical steroids.
Advise on skincare modifications:
- Use gentle, fragrance-free moisturisers and cleansers.
- Avoid harsh exfoliants, alcohol-based products, and excessive sun exposure.
Address lifestyle factors:
- Stress management (relaxation techniques, mindfulness).
- Diet modifications (if rosacea suspected, avoid alcohol and spicy food).
Set realistic expectations:
- Explain that chronic conditions require long-term management.
- Encourage consistent use of treatment and trigger avoidance.
Plan follow-up:
- Review in 4-6 weeks to assess treatment response.
- Refer to dermatology if no improvement or diagnostic uncertainty.

Task 4: Address patient concerns about cosmetic impact, chronicity, and the need for referral if required.

The competent candidate should:

Validate the patient’s distress about appearance, social confidence, and frustration with past treatments.
Reassure that effective treatments exist and that long-term control is achievable.
Clarify misconceptions about steroid creams:
- Short-term, low-potency topical steroids are safe if used correctly.
Discuss the importance of sun protection to prevent worsening of skin inflammation.
If concerned about a long-term condition like rosacea, provide education on symptom control rather than cure.
Offer referral to a dermatologist if:
- Symptoms are severe or resistant to initial treatment.
- There is diagnostic uncertainty.
- The patient requests specialist input.

SUMMARY OF A COMPETENT ANSWER

Takes a thorough dermatological history, identifying onset, triggers, and treatment history.
Forms a differential diagnosis, explaining the likely condition and other possibilities.
Provides a structured treatment plan, including topical, oral, and lifestyle strategies.
Addresses cosmetic concerns, treatment fears, and prognosis in an empathetic manner.
Offers clear follow-up and specialist referral if necessary.

PITFALLS

Failing to take a complete history, missing triggers, skincare routines, or past treatments.
Not considering differential diagnoses, leading to incorrect or delayed treatment.
Overprescribing corticosteroids without explaining safe use and risks.
Not addressing psychological impact, ignoring patient distress about cosmetic appearance.
Providing inadequate follow-up, failing to monitor treatment response.
Missing referral indications, particularly for treatment failure or diagnostic uncertainty.

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 Effectively gathers history about skin symptoms and their impact on daily life.
1.2 Explains diagnosis and management options in simple, patient-friendly language.
1.3 Addresses patient concerns about appearance, chronicity, and possible triggers.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough dermatological history, including onset, progression, associated symptoms, and potential triggers.
2.2 Assesses for systemic involvement or underlying conditions.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms a differential diagnosis based on history and examination findings.
3.2 Identifies red flags requiring referral (suspected malignancy, systemic involvement, severe impact on quality of life).

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a personalised treatment plan including pharmacological and non-pharmacological options.
4.2 Provides guidance on long-term management, lifestyle changes, and when to seek further medical review.

5. Preventive and Population Health

5.1 Discusses preventive strategies, including skin care, sun protection, and avoiding triggers.

6. Professionalism

6.1 Demonstrates empathy and professionalism in addressing patient distress and cosmetic concerns.

7. General Practice Systems and Regulatory Requirements

7.1 Documents the skin condition, treatment plan, and follow-up plan appropriately.

9. Managing Uncertainty

9.1 Recognises when further investigations or dermatology referral is required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies cases that may indicate underlying systemic disease or require more urgent intervention.

Competency at Fellowship Level

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