CCE-CE-042 - GP Exams

CASE INFORMATION

Case ID: CE-XXX
Case Name: Jacob Reynolds
Age: 7 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: R76 – Tonsillitis, acute; R90 – Hypertrophy; tonsils/adenoids.

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages with the patient and parent to explore concerns and expectations 1.2 Uses clear, age-appropriate communication for the child and parent 1.4 Provides appropriate reassurance and education
2. Clinical Information Gathering and Interpretation	2.1 Obtains a focused history, including symptom onset, duration, severity, and associated symptoms 2.2 Interprets clinical features to differentiate viral vs bacterial tonsillitis
3. Diagnosis, Decision-Making and Reasoning	3.1 Forms a differential diagnosis considering common and serious causes of sore throat 3.2 Uses clinical scoring tools (e.g., Centor/McIsaac) to guide antibiotic use
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a management plan appropriate for viral vs bacterial tonsillitis 4.2 Provides appropriate antibiotic stewardship and symptomatic relief advice
5. Preventive and Population Health	5.1 Provides education on infection prevention (e.g., hand hygiene, school exclusion guidelines)
6. Professionalism	6.1 Maintains a professional and empathetic approach when addressing parental concerns
7. General Practice Systems and Regulatory Requirements	7.1 Provides appropriate guidance on medical certificates/school absence requirements
9. Managing Uncertainty	9.1 Recognises when further assessment or referral is needed (e.g., recurrent tonsillitis, airway obstruction risk)
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises red flag symptoms that may indicate complications (e.g., peritonsillar abscess, airway obstruction)

CASE FEATURES

Addressing preventive measures and when to follow up
Young child presenting with fever, sore throat, and difficulty swallowing
Differentiating viral vs bacterial tonsillitis using clinical features and scoring systems
Parental concerns about antibiotic need and school absence
Providing safe, evidence-based management and recognising red flags

INSTRUCTIONS

You have 15 minutes to complete this case.

This consultation 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.
Outline the differential diagnosis and key investigations required.
Address the patient’s concerns.
Develop a safe and patient-centred management plan.

SCENARIO

Jacob Reynolds, a 7-year-old boy, is brought in by his mother, Sarah, due to a sore throat and fever for the past 3 days. Sarah is concerned it may be strep throat and is requesting antibiotics. Jacob has had difficulty swallowing and reduced appetite but is still drinking small amounts of fluid.

Sarah mentions that Jacob’s best friend recently had tonsillitis and was given antibiotics, so she is worried he has the same.

PATIENT RECORD SUMMARY

Patient Details

Name: Jacob Reynolds
Age: 7 years
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Past History

Nil significant

Social History

Attends primary school, lives with parents and younger sister

Family History

No significant history of ENT conditions

Smoking

Nil exposure

Alcohol

Not applicable

Vaccination and Preventive Activities

Up to date, including influenza and COVID-19 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.

Opening Line

“Doctor, Jacob has had a terrible sore throat and fever for the last three days. I think he needs antibiotics.”

General Information (Can be shared freely if asked an open-ended question like, “Can you tell me more?”)

Jacob has been complaining of throat pain since three days ago.
His fever started on the same day, and the highest temperature recorded was 38.5°C.
He has difficulty swallowing and is eating much less than usual but is still managing small sips of water.
He has been more tired than usual, lying on the couch most of the day.

Specific Information

(Should only be provided if the candidate asks targeted questions)

History of Presenting Complaint

Jacob first complained of a sore throat in the morning three days ago. By that afternoon, he felt worse and had a fever.
The sore throat worsened over the past two days, making it painful for him to eat.
He has been able to drink small amounts of water, and Sarah has been encouraging fluids.
He has not had any antibiotics recently and has never had tonsillitis before.
He has taken paracetamol, which helped slightly but didn’t fully relieve the pain.
No difficulty breathing, no drooling, and no change in his voice.
He has no cough, runny nose, or conjunctivitis, which Sarah believes means it’s not just a cold.
He has no ear pain, rash, or vomiting.
His voice sounds a little different than normal, but there is no hoarseness or muffling.
Sarah has not noticed any swollen glands in his neck, but Jacob complains of his neck feeling “sore.”
He has not had a similar illness in the past.

Parental Concerns

Sarah is worried it is Strep throat because Jacob’s best friend had tonsillitis last week and was prescribed antibiotics.
She wants antibiotics to “nip it in the bud” before it gets worse.
She is concerned about school absence because Jacob has already missed two days.
She has read online that untreated Strep can lead to serious complications like rheumatic fever and is anxious about potential risks.
She heard that children with frequent tonsillitis need their tonsils removed and wants to know if Jacob might need surgery in the future.

Social Context

Jacob is in Year 2 at primary school and normally enjoys school, but today he is too unwell to play.
He has a younger sister, aged 4, and Sarah wants to prevent the infection from spreading to her.
Sarah works part-time as an admin assistant and has already had to take two days off work.
She wants to know how long he will be contagious and if he can return to school soon.

Emotional Cues and Body Language

Mildly anxious and concerned but not overly aggressive.
She leans slightly forward when discussing the need for antibiotics.
She crosses her arms when the doctor suggests antibiotics may not be needed but remains open to discussion.
If reassured effectively, she relaxes and nods in agreement.
She sighs when discussing work absence, clearly feeling frustrated.
She touches Jacob’s head while speaking about his fever, showing concern.
If given clear guidance on what to watch for and how to manage symptoms, she visibly eases.

Questions Sarah Might Ask the Doctor

(These should be asked if the candidate does not proactively address them.)

“How do you know if it’s viral or bacterial?”
“If it’s bacterial, why shouldn’t he get antibiotics straight away?”
“I read that untreated Strep can cause heart problems. Shouldn’t we treat it just in case?”
“When should I be worried enough to bring him back?”
“How long will he be contagious? When can he go back to school?”
“Could this be a sign that he needs his tonsils removed?”
“How do I stop my daughter from getting sick too?”

If the Candidate Does Not Provide Clear Management Advice

If the doctor does not give safety-netting advice, Sarah should ask: “So if we don’t give antibiotics, what should I do to help him feel better?”
If they do not explain the importance of fluids, she should ask: “What if he stops drinking completely?”
If they do not mention when to return, she should ask: “So when should I worry enough to bring him back?”

Possible Responses to the Candidate’s Explanations

If the candidate explains antibiotic stewardship well, Sarah nods slowly and says: “Okay, I see what you mean about not overusing antibiotics, but I still worry about complications. Are you sure it’s safe to wait?”
If the candidate provides clear safety-netting and follow-up advice, Sarah relaxes and says: “That makes sense. So, if he gets worse, I should bring him back?”
If the candidate explains viral vs bacterial causes well, Sarah accepts it but may still push slightly: “But if it’s bacterial, wouldn’t it be safer to treat now?”
If the candidate does not provide a confident answer, Sarah frowns slightly and looks uncertain, pressing further: “But what if it gets worse? Shouldn’t we just be cautious?”
If the candidate explains when a tonsillectomy is necessary, Sarah sighs in relief and says: “Oh, so it’s only needed if it keeps happening a lot?”

Key Behaviours the Candidate Should Demonstrate

Active listening: If Sarah feels heard, she is more likely to accept advice.
Empathy: She responds well if the doctor acknowledges her concerns, e.g., “I can see why you’d be worried.”
Clear explanations: She is more likely to accept viral vs bacterial differentiation if it is explained simply.
Reassurance: If the doctor reassures her about complications, she is less insistent on antibiotics.
Patient-centred care: She appreciates advice on symptom relief and preventing spread.

Final Thoughts

If the candidate communicates effectively, reassures Sarah, and provides a clear plan, she accepts the decision and feels reassured. However, if the explanation is unclear or dismissive, she remains worried and unconvinced.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a relevant history from the parent and child.

The competent candidate should:

Use open-ended and specific questions to obtain a focused history.
Explore the onset, duration, and progression of symptoms.
Assess associated symptoms (e.g., fever, difficulty swallowing, voice changes, rash, ear pain, cough, and runny nose).
Differentiate viral vs bacterial tonsillitis using key features (e.g., Centor/McIsaac criteria).
Address the impact on oral intake and hydration status.
Explore parental concerns and expectations regarding antibiotics and school absence.
Identify red flag symptoms suggesting complications (e.g., peritonsillar abscess, stridor, difficulty breathing).
Take a brief medical and social history, including vaccination status and past episodes of tonsillitis.

Task 2: Differentiate between viral and bacterial tonsillitis based on clinical presentation.

The competent candidate should:

Apply clinical scoring tools, such as the Centor or McIsaac criteria, to guide antibiotic use.
Recognise features suggestive of bacterial tonsillitis (e.g., fever >38°C, absence of cough, swollen anterior cervical lymph nodes, tonsillar exudate).
Identify features more suggestive of viral infection (e.g., cough, rhinorrhoea, conjunctivitis, coryzal symptoms).
Understand that Group A Streptococcus (GAS) is uncommon in children under 3 years and self-limiting in many cases.
Recognise that throat swabs are not routinely required in primary care unless there is diagnostic uncertainty.
Consider the risk of complications (e.g., rheumatic fever, post-streptococcal glomerulonephritis) in certain populations.

Task 3: Explain your diagnosis and management plan to the parent, including antibiotic stewardship.

The competent candidate should:

Clearly communicate the likely diagnosis (viral or bacterial tonsillitis).
Explain why antibiotics may not be necessary, using evidence-based reasoning.
Reassure the parent about the natural course of viral tonsillitis and provide supportive care advice (e.g., adequate hydration, analgesia).
If antibiotics are indicated, discuss the choice of antibiotic, duration, and side effects (e.g., phenoxymethylpenicillin for 10 days).
Provide safety-netting advice, including when to return (e.g., worsening symptoms, dehydration, respiratory distress).
Address parental concerns about school absence, contagiousness, and recurrence.

Task 4: Address the parent’s concerns, including school absence and infection prevention.

The competent candidate should:

Empathise with the parent’s concerns and acknowledge their worry.
Explain that Jacob should stay home until he has been fever-free for 24 hours and that GAS is no longer contagious after 24 hours of antibiotics (if prescribed).
Discuss infection prevention, including hand hygiene, cough etiquette, and avoiding close contact.
Educate on when tonsillectomy might be considered.
- Current guidelines suggest tonsillectomy if recurrent tonsillitis as defined by:
  - ≥7 episodes in 1 year,
  - ≥5/year for 2 years, or
  - ≥3/year for 3 years
Provide reassurance about long-term outcomes and the low risk of serious complications.

SUMMARY OF A COMPETENT ANSWER

Structured history-taking covering key symptoms, duration, and red flags.
Differentiation of viral vs bacterial causes using evidence-based tools.
Clear, patient-centred communication with explanations appropriate for a parent.
Antibiotic stewardship principles are applied in line with Australian guidelines.
Preventive health advice, including infection control and school attendance.
Safety-netting advice to ensure appropriate follow-up if symptoms worsen.

PITFALLS

Failing to explore key symptoms, such as swallowing difficulty, hydration status, and systemic involvement.
Overprescribing antibiotics without clear bacterial features or risk factors.
Inadequate parental reassurance leading to frustration or unnecessary anxiety.
Not addressing school absence and infection prevention, which are key parental concerns.
Failure to provide safety-netting or discuss red flags requiring urgent review.

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, including symptom onset, duration, severity, and associated symptoms.
2.2 Interprets clinical features to differentiate viral vs bacterial tonsillitis.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms a differential diagnosis considering common and serious causes of sore throat.
3.2 Uses clinical scoring tools (e.g., Centor/McIsaac) to guide antibiotic use.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a management plan appropriate for viral vs bacterial tonsillitis.
4.2 Provides appropriate antibiotic stewardship and symptomatic relief advice.

5. Preventive and Population Health

5.1 Provides education on infection prevention (e.g., hand hygiene, school exclusion guidelines).

6. Professionalism

6.1 Maintains a professional and empathetic approach when addressing parental concerns.

7. General Practice Systems and Regulatory Requirements

7.1 Provides appropriate guidance on medical certificates/school absence requirements.

9. Managing Uncertainty

9.1 Recognises when further assessment or referral is needed (e.g., recurrent tonsillitis, airway obstruction risk).

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises red flag symptoms that may indicate complications (e.g., peritonsillar abscess, airway obstruction).

Competency at Fellowship Level

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