CCE-CE-044 - GP Exams

CASE INFORMATION

Case ID: CCE-HT01
Case Name: Margaret Donnelly
Age: 62 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: T85 – Hypothyroidism/myxoedema

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages with the patient 1.2 Uses active listening and questioning techniques 1.5 Provides clear explanations regarding condition and management
2. Clinical Information Gathering and Interpretation	2.1 Gathers relevant history, including symptoms and risk factors 2.2 Selects and interprets appropriate investigations
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis 3.2 Recognises red flags for myxoedema crisis
4. Clinical Management and Therapeutic Reasoning	4.1 Formulates an evidence-based management plan 4.2 Prescribes appropriate medications and monitors treatment 4.3 Addresses potential complications of treatment
5. Preventive and Population Health	5.1 Counsels on lifestyle modifications and iodine intake 5.2 Screens for associated conditions (e.g., cardiovascular disease, osteoporosis)
6. Professionalism	6.2 Ensures patient-centred care and shared decision-making
7. General Practice Systems and Regulatory Requirements	7.2 Understands and follows prescribing regulations for thyroxine
8. Procedural Skills	8.1 Interprets pathology results, including TFTs
9. Managing Uncertainty	9.1 Manages symptoms that overlap with other conditions (e.g., depression, fatigue)
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and escalates care in cases of suspected myxoedema coma

CASE FEATURES

Preventive care (cardiovascular risk, osteoporosis risk, lifestyle modifications)
Fatigue, weight gain, cold intolerance, and cognitive symptoms in an elderly patient
Management of hypothyroidism with thyroxine replacement
Addressing medication adherence and ongoing monitoring
Recognition of complications, including myxoedema coma

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

SCENARIO

Margaret Donnelly, a 62-year-old woman, presents to your general practice clinic with complaints of fatigue, weight gain, and feeling cold all the time. She has also noticed some forgetfulness and dry skin over the last few months. Her daughter, who accompanied her today, is concerned that she seems slower in her thinking and movements. Margaret has a history of hypertension and hypercholesterolaemia but is otherwise well. She takes perindopril and atorvastatin.

On Examination:

Pulse: 55 bpm
Blood Pressure: 130/80 mmHg

PATIENT RECORD SUMMARY

Patient Details

Name: Margaret Donnelly
Age: 62 years
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Perindopril 5 mg daily
Atorvastatin 20 mg daily

Past History

Hypertension
Hypercholesterolaemia
No previous thyroid disorders

Social History

Retired teacher

Family History

Mother had osteoporosis
Father had cardiovascular disease
No known thyroid disease

Smoking

Never smoked

Alcohol

Occasional wine with dinner

Vaccination and Preventative Activities

Up to date with routine vaccinations, including influenza and pneumococcal vaccine

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 just feel exhausted all the time, doctor. I don’t know what’s wrong with me.”

General Information

Margaret Donnelly is a 62-year-old retired teacher who has been experiencing progressive fatigue over the last six months. She used to be quite active—she enjoyed gardening and taking walks with her husband—but now she finds herself too exhausted to do much of anything. She wakes up tired and never seems to feel refreshed, no matter how much she sleeps.

Specific Information

(Only reveal when asked)

Background Information

She has also gained about six kilograms over this period, despite eating the same way she always has. She tries to stay healthy, eating home-cooked meals with plenty of vegetables, but nothing seems to be helping.

Another problem is that she feels cold all the time. While her husband and daughter are comfortable, she often needs to wear extra layers, even in warm weather. She notices that her skin has become dry and rough, and her hair seems to be thinning, especially around her scalp.

Her memory hasn’t been as sharp as it used to be, and she feels like she’s in a mental fog. She’s been struggling with simple things, like remembering where she left her keys or what she was about to do next. Her daughter, who is in the room, mentions that Margaret sometimes takes longer to respond in conversations, as if she’s thinking more slowly.

She has no known history of thyroid disease and hasn’t had a check-up in over a year.

Symptoms

The fatigue is constant and doesn’t improve with rest. It is worse in the morning, and she has trouble getting started with her day.
She does not feel short of breath, nor does she have any chest pain or dizziness.
She has occasional constipation but hasn’t thought much of it.
Her face and hands feel puffy sometimes, especially in the mornings.
Her voice sounds hoarser than before, and her daughter agrees that it’s noticeably different.

Lifestyle

She eats three meals a day, mostly home-cooked, but doesn’t eat much seafood or iodised salt.
She used to walk daily but has stopped exercising due to lack of energy.
She sleeps 7-8 hours per night but wakes up feeling unrefreshed.
She has no changes in appetite, but her weight gain has been frustrating.

Concerns and Emotional Cues

She is worried this could be dementia because of her memory issues and slow thinking.
She is afraid of having to take medications for life if it turns out to be a thyroid problem.
She is frustrated that she keeps gaining weight despite eating the same.
Her daughter is concerned about her slowed speech and mental fog.
She is a bit sceptical about taking medication but wants to know what her options are.

Past Medical History

Hypertension (on perindopril)
High cholesterol (on atorvastatin)
No known history of thyroid disease
No previous major illnesses or surgeries

Family History

Mother had osteoporosis
Father had heart disease
No known thyroid issues in the family

Questions for the Candidate

“Is this just ageing, or could it be something serious?”
“Could this be dementia? My memory feels much worse.”
“Do I have to take medication for this forever?”
“Will I ever feel like myself again?”
“Is there anything I can do naturally to fix this?”

Emotional and Non-Verbal Cues

Margaret is mildly anxious but not panicked. She is more frustrated than worried, especially about her weight gain and fatigue.

She pauses before speaking, reflecting her slowed cognitive function. She sometimes rubs her arms, indicating her discomfort with the cold.

Her daughter looks at the candidate for reassurance, wanting to make sure her concerns are being addressed.

If the candidate is reassuring and patient, Margaret will relax slightly but still remain cautious about medications. If the candidate is dismissive or rushes through the consultation, she may become more withdrawn and less likely to engage in discussions about management.

THE COMPETENT CANDIDATE

Task 1: Take an appropriate history from the patient, considering symptoms, risk factors, and impacts on daily life.

The competent candidate should:

Use open-ended questions to gather a comprehensive history of symptoms including fatigue, weight gain, cold intolerance, constipation, cognitive changes, and hoarseness.
Explore progression and duration of symptoms to differentiate from other causes of fatigue (e.g., depression, anaemia, chronic disease).
Ask about lifestyle factors such as diet (iodine intake), activity levels, and adherence to existing medications.
Assess functional impact, including changes in daily activities, social interactions, and mood.
Identify red flags for myxoedema coma, including extreme fatigue, confusion, bradycardia, and hypothermia.
Explore family history of thyroid disease, autoimmune conditions, and metabolic disorders.
Address the patient’s concerns, including fear of dementia and reluctance to take lifelong medication.

Task 2: Explain your differential diagnosis and outline any relevant investigations.

The competent candidate should:

Outline a structured differential diagnosis, prioritising hypothyroidism but also considering:
- Depression or cognitive impairment (similar fatigue, cognitive issues).
- Chronic fatigue syndrome.
- Anaemia (iron/B12/folate deficiency).
- Obstructive sleep apnoea (fatigue, weight gain).
- Medication side effects (e.g., beta-blockers).
Explain the rationale for ordering investigations, including:
- Thyroid function tests (TFTs) – TSH (elevated in primary hypothyroidism), free T4 (low in overt hypothyroidism).
- Full blood count (FBC) – anaemia differential.
- Electrolytes and renal function – to check for secondary causes or complications.
- Lipid profile – common in hypothyroidism.
- Iron studies, B12, folate – if anaemia is suspected.
Discuss interpretation of results, focusing on how abnormal findings correlate with clinical symptoms.

Task 3: Discuss the diagnosis of hypothyroidism with the patient and provide an appropriate management plan.

The competent candidate should:

Explain the diagnosis of hypothyroidism in simple terms, linking symptoms to hormone deficiency.
Provide reassurance that it is common and treatable with medication.
Discuss levothyroxine replacement therapy, including:
- Starting dose (e.g., 25-50 mcg/day, titrated based on TSH levels).
- Monitoring (TSH every 6 weeks until stable, then every 6-12 months).
- Possible side effects (palpitations, hyperthyroidism if overdosed).
- Importance of medication adherence (taking it on an empty stomach, avoiding interactions with calcium/iron supplements).
Address patient concerns, including long-term medication use and fears about dementia.
Provide lifestyle advice on iodine intake, healthy diet, and weight management.
Safety-net by discussing signs of myxoedema coma and when to seek urgent care.

Task 4: Address any patient concerns regarding treatment and potential complications.

The competent candidate should:

Acknowledge Margaret’s concerns and provide empathy while addressing misconceptions.
Explain that hypothyroidism is a lifelong condition, but well-managed treatment restores normal function.
Reassure that memory and cognitive issues often improve with treatment.
Discuss medication safety, particularly avoiding under- or overtreatment.
Outline potential complications, such as cardiovascular risks, and how monitoring prevents issues.
Offer written patient information and discuss follow-up plan.

SUMMARY OF A COMPETENT ANSWER

Takes a thorough history, covering symptom onset, progression, and impact on daily life.
Forms a structured differential diagnosis, considering alternative causes.
Explains investigations clearly, linking rationale to clinical reasoning.
Communicates the diagnosis effectively, addressing patient concerns.
Provides a clear, evidence-based management plan, including levothyroxine and lifestyle advice.
Demonstrates patient-centred care, ensuring shared decision-making.

PITFALLS

Failing to consider alternative diagnoses (e.g., depression, anaemia, sleep apnoea).
Overcomplicating explanations, leading to confusion or fear.
Not addressing patient concerns, particularly about medication.
Neglecting red flags for myxoedema coma.
Not discussing lifestyle modifications (iodine intake, weight management).
Failing to explain monitoring requirements (TSH follow-up).

REFERENCES

MARKING

Each competency area is assessed on the following scale:

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

Competency Areas Assessed in This Case:

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 symptoms, concerns, and expectations.
1.5 Provides clear explanations regarding diagnosis and management.

2. Clinical Information Gathering and Interpretation

2.1 Gathers a thorough history, considering symptoms, risk factors, and lifestyle.
2.2 Selects and interprets appropriate investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms a structured differential diagnosis.
3.2 Recognises red flags for myxoedema crisis.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.2 Prescribes levothyroxine and monitors treatment.

5. Preventive and Population Health

5.1 Counsels on lifestyle modifications (diet, iodine intake).
5.2 Screens for associated risks (cardiovascular disease, osteoporosis).

6. Professionalism

6.2 Ensures patient-centred care and shared decision-making.

7. General Practice Systems and Regulatory Requirements

7.2 Follows prescribing guidelines for thyroxine therapy.

8. Procedural Skills

8.1 Interprets thyroid function test results.

9. Managing Uncertainty

9.1 Manages symptoms that overlap with other conditions.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and escalates care in cases of suspected myxoedema coma.

Competency at Fellowship Level

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