CASE INFORMATION

Case ID: CCE-FAT-010
Case Name: Laura Mitchell
Age: 41
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A04 – Weakness/Tiredness

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages the patient 1.2 Explores the patient’s concerns, ideas, and expectations 1.3 Provides clear and structured explanations about diagnosis, prognosis, and management
2. Clinical Information Gathering and Interpretation	2.1 Takes a focused history, including duration, severity, and associated symptoms 2.2 Identifies red flags and risk factors for underlying conditions (e.g., anaemia, hypothyroidism, depression)
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between common causes of fatigue (e.g., iron deficiency, thyroid disease, sleep disorders, mental health conditions) 3.2 Identifies when further investigations or specialist referral is required
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an individualised management plan based on the underlying cause 4.2 Provides lifestyle advice and medical interventions where necessary
5. Preventive and Population Health	5.1 Provides education on lifestyle factors affecting fatigue, including diet, exercise, and sleep hygiene 5.2 Encourages screening for chronic conditions (e.g., diabetes, cardiovascular disease)
6. Professionalism	6.1 Demonstrates empathy and a patient-centred approach to chronic fatigue management
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate follow-up and referrals to specialists where indicated
8. Procedural Skills	8.1 Orders and interprets relevant investigations, such as blood tests for iron, thyroid function, and glucose
9. Managing Uncertainty	9.1 Recognises when symptoms may be part of a functional disorder versus an organic condition
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and appropriately manages conditions such as chronic fatigue syndrome, anaemia, and hypothyroidism

CASE FEATURES

Potential psychosocial factors contributing to fatigue
Chronic fatigue impacting daily life and work performance
Concerns about possible underlying conditions (e.g., thyroid dysfunction, iron deficiency, depression, perimenopause)
Need for appropriate investigations and lifestyle recommendations

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

Laura Mitchell, a 41-year-old marketing manager, presents with persistent fatigue over the past six months. She describes waking up feeling unrefreshed, despite getting 7–8 hours of sleep per night. By midday, she struggles to concentrate at work and often needs multiple coffees to stay alert.

PATIENT RECORD SUMMARY

Patient Details

Name: Laura Mitchell
Age: 41
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

None known

Medications

Nil regular medications

Past History

No chronic illnesses
No history of depression or anxiety

Social History

Works full-time in marketing, reports high-stress levels
Limited exercise due to fatigue

Family History

Mother diagnosed with hypothyroidism in her 40s
No family history of diabetes or autoimmune diseases

Smoking

Non-smoker

Alcohol

Drinks 2–3 glasses of wine per week

Vaccination and Preventative Activities

Up to date with vaccinations and cervical screening

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.

SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, I’ve been feeling exhausted for months now, and I don’t know why. I get plenty of sleep, but I still wake up tired. Could it be something serious?”

General Information

Laura Mitchell is a 41-year-old marketing manager who presents with persistent fatigue over the past six months. She describes feeling constantly tired, even after a full night’s sleep. She used to be an energetic and active person, but now she struggles to get through the day without multiple coffees.

She wakes up feeling unrefreshed, and by midday, she experiences brain fog, difficulty concentrating, and low energy levels. This has started to affect her work performance, and she worries that her fatigue is becoming noticeable to colleagues.

Specific Information

(To be revealed only when asked)

Background Information

She has no major medical conditions but is concerned about possible causes, such as iron deficiency, thyroid problems, or early menopause. She is also wondering if stress is playing a role, as she juggles work, household responsibilities, and parenting two children.

She has no persistent low mood but feels frustrated and irritable due to her constant exhaustion.

Her main concerns are:

“Why am I so tired all the time? Could this be something serious?”
“Do I need blood tests to check for a medical condition?”
“Could this be early menopause?”
“What can I do to feel better?”

Fatigue and Sleep History

Fatigue is ongoing for six months, progressively worsening.
Sleeping 7–8 hours per night but wakes up feeling unrefreshed.
No difficulty falling asleep, but often wakes up once or twice at night.
No snoring, gasping, or partner-reported breathing issues.
Struggles to stay awake in the afternoons but doesn’t nap due to work.

Lifestyle and Diet

Eats mostly processed or quick meals due to a busy schedule.
Rarely eats red meat, prefers chicken and vegetarian options.
Drinks 3–4 cups of coffee daily to stay alert.
Drinks 2–3 glasses of wine per week.
Rarely exercises, used to do yoga once a week, but now feels too exhausted.

Psychosocial Factors

High-stress job, often brings work home.
Married with two children (aged 8 and 10).
Feels overwhelmed managing work, family, and home responsibilities.
No major financial or relationship stress, but constantly feels “on edge”.
Denies persistent low mood or anhedonia but acknowledges feeling irritable and frustrated.

Medical Symptoms and Red Flags

No recent weight loss or gain.
No palpitations, tremors, or excessive sweating.
No joint pain, swelling, or prolonged muscle aches.
No heavy periods, but cycles are slightly irregular.
Occasional headaches and muscle soreness, but no focal neurological symptoms.
No recent infections or prolonged recovery from illness.

Emotional Cues

Laura is frustrated but open to discussion.

Concerned about her symptoms: “I don’t feel like myself anymore.”
Worried about underlying conditions: “Could this be something serious?”
Worried about hormones: “Am I starting menopause early?”
Looking for solutions: “What can I do to feel better?”

If the candidate is reassuring and informative, she will engage positively. If the candidate is vague or dismissive, she may become frustrated or push for unnecessary tests.

Questions for the Candidate

Laura will ask some of the following questions, especially if the doctor does not address them directly:

“Do I need blood tests? What should I check for?”
“Could this be low iron or a thyroid problem?”
“Is this normal for my age?”
“What lifestyle changes can help?”
“Should I take vitamins or supplements?”
“Could this be chronic fatigue syndrome?”
“Do I need hormone tests for early menopause?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

Laura will be reassured and engaged in her management plan.
She will accept recommendations for investigations and treatment options.
She may say, “That makes sense. I’ll try making those changes and come back if things don’t improve.”

If the candidate is vague or dismissive:

Laura may appear frustrated or push for unnecessary tests.
She might say, “But why has this suddenly changed? Are you sure it’s nothing serious?”

If the candidate does not address her concerns about menopause:

Laura may say, “So, could this be perimenopause? Should I be on hormone therapy?”
She might seem uncertain or distressed about next steps.

Key Takeaways for the Candidate

Take a structured fatigue history, covering onset, severity, lifestyle, and medical causes.
Consider differential diagnoses, including:
- Iron deficiency or anaemia (low energy, dietary risk factors).
- Hypothyroidism (family history, fatigue, brain fog).
- Perimenopause (irregular periods, sleep disturbances).
- Chronic stress or burnout (work and home pressures).
- Depression or anxiety (fatigue with psychosocial stressors).
- Chronic fatigue syndrome or sleep disorders.
Order appropriate investigations, including:
- Full blood count and iron studies.
- Thyroid function tests.
- Fasting glucose or HbA1c (if metabolic concerns).
- Vitamin B12 and folate levels.
Provide evidence-based lifestyle advice, including:
- Optimising diet (more whole foods, iron-rich foods).
- Reducing caffeine intake.
- Encouraging regular low-impact exercise.
- Improving sleep hygiene.
Discuss follow-up, ensuring symptom monitoring and further assessment if needed.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including symptom duration, impact, associated symptoms, and lifestyle factors.

The competent candidate should:

Elicit a detailed fatigue history, including onset, duration, severity, and progression.
Assess associated symptoms, including sleep quality, weight changes, mood symptoms, palpitations, and muscle weakness.
Explore lifestyle factors, such as diet, caffeine intake, alcohol, exercise, and work-life balance.
Screen for red flags, such as unexplained weight loss, night sweats, fevers, or neurological symptoms.
Assess psychosocial factors, including stress, anxiety, depression, or burnout.
Clarify past medical and family history, particularly thyroid disease, anaemia, diabetes, and autoimmune conditions.

Task 2: Identify potential underlying causes and recommend appropriate investigations.

The competent candidate should:

Consider differential diagnoses, including:
- Iron deficiency or anaemia (fatigue, pallor, dietary risk factors).
- Hypothyroidism (family history, fatigue, brain fog, weight gain).
- Perimenopause (irregular cycles, sleep disturbances, mood swings).
- Chronic stress or burnout (work and home pressures, poor sleep).
- Depression or anxiety (fatigue, psychosocial stressors, low motivation).
- Chronic fatigue syndrome or sleep disorders.
Order relevant investigations, including:
- Full blood count and iron studies (assess for anaemia or iron deficiency).
- Thyroid function tests (rule out hypothyroidism).
- Fasting glucose or HbA1c (screen for diabetes).
- Vitamin B12 and folate levels (assess for deficiencies).
- Electrolytes, liver function, and renal function tests (to exclude systemic disease).

Task 3: Provide an initial management plan, including symptom relief, lifestyle modifications, and medical treatments where necessary.

The competent candidate should:

Provide general fatigue management strategies, including:
- Improving sleep hygiene (consistent bedtime, limiting screen time, reducing caffeine).
- Encouraging physical activity, even in small increments.
- Addressing diet and hydration, ensuring adequate protein, iron, and complex carbohydrates.
If a specific cause is identified, provide appropriate management, such as:
- Iron supplements if iron deficiency is present.
- Thyroid hormone replacement for hypothyroidism.
- Menopause-related management (e.g., hormone therapy if needed).
- Stress management strategies, including relaxation techniques or referral for psychological support.
Provide patient education, explaining that fatigue often has multiple contributing factors and requires a holistic approach.

Task 4: Discuss follow-up and when further assessment or specialist referral may be required.

The competent candidate should:

Arrange follow-up in 4–6 weeks to review test results and symptom progression.
Refer to a specialist if:
- Unexplained weight loss, night sweats, or systemic symptoms persist.
- Severe fatigue continues despite normal investigations (consider sleep study, endocrinology referral).
- Psychosocial factors suggest burnout, depression, or anxiety requiring further intervention.
Ensure patient has realistic expectations, as fatigue management often involves gradual improvements rather than instant resolution.

SUMMARY OF A COMPETENT ANSWER

Elicits a thorough fatigue history, assessing symptoms, lifestyle, and psychosocial contributors.
Considers and explains differential diagnoses, including iron deficiency, hypothyroidism, perimenopause, and chronic stress.
Orders relevant investigations, including blood tests and targeted screening for underlying conditions.
Provides an evidence-based management plan, including medical, lifestyle, and psychological interventions.
Discusses the importance of follow-up, ensuring ongoing monitoring and escalation if needed.

PITFALLS

Failing to explore full fatigue history, missing key factors such as sleep disturbances, psychosocial stressors, or nutritional deficits.
Overlooking red flags, such as unexplained weight loss, neurological symptoms, or persistent night sweats.
Delaying investigations, leading to missed diagnoses of hypothyroidism, anaemia, or diabetes.
Not addressing lifestyle contributors, including diet, caffeine intake, alcohol use, and exercise habits.
Providing a generic management plan without tailoring recommendations to the patient’s specific lifestyle and concerns.
Failing to arrange follow-up, leading to poor monitoring of symptoms and treatment effectiveness.

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 Provides clear and structured explanations about diagnosis, prognosis, and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a focused history, including duration, severity, and associated symptoms.
2.2 Identifies red flags and risk factors for underlying conditions (e.g., anaemia, hypothyroidism, depression).

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common causes of fatigue (e.g., iron deficiency, thyroid disease, sleep disorders, mental health conditions).
3.2 Identifies when further investigations or specialist referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an individualised management plan based on the underlying cause.
4.2 Provides lifestyle advice and medical interventions where necessary.

5. Preventive and Population Health

5.1 Provides education on lifestyle factors affecting fatigue, including diet, exercise, and sleep hygiene.
5.2 Encourages screening for chronic conditions (e.g., diabetes, cardiovascular disease).

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach to chronic fatigue management.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate follow-up and referrals to specialists where indicated.

8. Procedural Skills

8.1 Orders and interprets relevant investigations, such as blood tests for iron, thyroid function, and glucose.

9. Managing Uncertainty

9.1 Recognises when symptoms may be part of a functional disorder versus an organic condition.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and appropriately manages conditions such as chronic fatigue syndrome, anaemia, and hypothyroidism.

Competency at Fellowship Level

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