CCE-CE-052 - GP Exams

CASE INFORMATION

Case ID: CCE-MH-012
Case Name: Sarah Williams
Age: 32
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: P02 – Acute stress reaction

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 triggers, emotional and physical symptoms, and coping mechanisms 2.2 Identifies risk factors for prolonged distress or development of PTSD
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between an acute stress reaction, adjustment disorder, and other mental health conditions 3.2 Identifies when further mental health support or referral is required
4. Clinical Management and Therapeutic Reasoning	4.1 Provides evidence-based psychological first aid and coping strategies 4.2 Discusses follow-up and available mental health support services
5. Preventive and Population Health	5.1 Provides psychoeducation on stress reactions and early intervention strategies 5.2 Identifies at-risk individuals who may benefit from ongoing mental health support
6. Professionalism	6.1 Demonstrates empathy and a patient-centred approach to managing psychological distress
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate referrals to psychology, counselling, or crisis services as required
8. Procedural Skills	8.1 Conducts a brief mental health assessment, including risk assessment for self-harm
9. Managing Uncertainty	9.1 Recognises when distress may evolve into a more persistent mental health condition, such as PTSD
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and manages patients experiencing acute psychological distress effectively

CASE FEATURES

Need for psychological first aid, reassurance, and follow-up planning
Recent traumatic event leading to significant distress
Symptoms of anxiety, emotional numbness, and difficulty coping
Concerns about whether these feelings are normal or require treatment

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

Sarah Williams, a 32-year-old teacher, presents to your clinic experiencing severe stress, anxiety, and difficulty sleeping following a recent traumatic event.

Three days ago, Sarah was involved in a minor car accident, where her vehicle was hit from behind at a traffic light. While she was not physically injured, she felt terrified during the incident, and since then, she has been feeling on edge, emotionally numb, and unable to relax. She keeps replaying the event in her mind, and even though she knows she is safe, she feels overwhelmed and jumpy.

She wonders if she is developing PTSD and is worried she won’t be able to return to normal.

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Williams
Age: 32
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

None known

Medications

Nil regular medications

Past History

No prior history of anxiety, depression, or PTSD
No history of substance use or chronic illness

Social History

Works as a high school teacher, finds job moderately stressful.

Family History

No family history of mental illness or PTSD

Smoking

Non-smoker

Alcohol

Drinks 1–2 glasses of wine per week

Vaccination and Preventative Activities

Up to date with vaccinations

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, ever since the accident, I just don’t feel like myself. I can’t stop thinking about it, and I feel constantly on edge. Is this normal?”

General Information

Sarah Williams is a 32-year-old teacher who presents with severe stress, anxiety, and difficulty sleeping following a recent traumatic event.

Three days ago, she was involved in a minor car accident where her vehicle was hit from behind at a traffic light.
She was not physically injured, but she felt terrified at the time and froze for a few moments before being able to respond.
Since the accident, she has experienced persistent distress, hypervigilance, and emotional numbness.
She keeps replaying the event in her mind and feels anxious whenever she thinks about driving.

Specific Information

(To be revealed only when asked)

Background Information

Her main concerns are:

“Is this normal, or do I have PTSD?”
“Why do I feel like I’m still in danger even though I’m safe?”
“What can I do to stop these thoughts and feel normal again?”
“Do I need medication or counselling?”

Symptoms Since the Accident

Flashbacks and intrusive thoughts: Keeps replaying the accident in her mind, particularly at night.
Avoidance behaviours:
- Has avoided driving since the accident and took public transport to work instead.
- Tries to push away thoughts of the accident, but they keep coming back.
Hypervigilance and anxiety:
- Feels on edge and easily startled, especially by sudden noises (e.g., car horns).
- Feels her heart race when she sees cars braking suddenly.
Emotional numbing and detachment:
- Feels distant and disconnected from her normal routine.
- Finds it hard to concentrate at work.
Sleep disturbances:
- Wakes up in the middle of the night feeling anxious.
- Has nightmares about losing control of her car.

Psychosocial Factors

Has never experienced a similar reaction before.
Partner is supportive but unsure how to help, keeps telling her to “move on”.
No major financial or work stressors, but she is worried about her ability to keep teaching if she can’t concentrate.
Feels embarrassed about struggling with a “small accident”, especially since she was not physically hurt.

Coping Mechanisms and Attempts to Manage Stress

Tried deep breathing exercises, but they only help for a short time.
Has avoided talking about the accident, hoping it will go away.
Distracts herself with work, but the thoughts return when she is alone.
Has not spoken to a psychologist before and is unsure if therapy is necessary.

Emotional Cues

Sarah appears worried, slightly restless, and overwhelmed.

Frustrated with persistent thoughts: “Why can’t I just forget about it?”
Worried about losing control: “I don’t want to develop PTSD.”
Seeking reassurance: “Will this feeling go away, or is this my new normal?”
Feels guilty for struggling: “Other people have been through worse—why am I reacting like this?”

If the candidate provides a clear explanation and structured plan, Sarah will feel relieved and open to trying strategies.
If the candidate is vague or dismissive, Sarah may become more anxious or insist on medication.

Questions for the Candidate

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

“Is this PTSD?”
“How long will these feelings last?”
“Do I need medication for this?”
“What can I do to stop these thoughts?”
“Should I see a psychologist?”
“What if I can’t drive again?”
“Does this mean I’m weak?”

Expected Reactions Based on Candidate Performance

If the candidate provides reassurance and a structured plan:

Sarah will feel relieved and reassured.
She will accept recommendations for follow-up and psychological support.
She may say, “That makes sense. I’ll try the strategies you suggested.”

If the candidate is vague or dismissive:

Sarah may appear more anxious or push for unnecessary tests or medication.
She may say, “But what if this feeling never goes away?”

If the candidate does not provide a management plan:

Sarah may feel frustrated and hopeless, saying “So, what am I supposed to do now?”
She may seek a second opinion if she feels her concerns are not taken seriously.

Key Takeaways for the Candidate

Take a structured mental health history, assessing trauma, symptoms, and coping mechanisms.
Provide reassurance, explaining that acute stress reactions are normal and often resolve with time.
Offer evidence-based strategies, including:
- Grounding techniques (breathing exercises, mindfulness).
- Gradual exposure to driving to reduce avoidance.
- Encouraging supportive conversations with her partner.
Advise on when to seek further support, including referral to a psychologist if symptoms persist beyond 1 month.
Arrange follow-up in 1–2 weeks to assess symptom progression and emotional state.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including details of the triggering event, symptom severity, coping mechanisms, and impact on daily life.

The competent candidate should:

Elicit a detailed history of the traumatic event, including timing, nature, and emotional response.
Assess symptoms of acute stress reaction, including flashbacks, avoidance behaviours, hypervigilance, emotional numbness, and sleep disturbances.
Explore coping mechanisms, identifying helpful versus maladaptive strategies.
Determine the impact on daily life, including work performance, relationships, and social withdrawal.
Assess risk factors for prolonged distress, such as previous trauma, personal or family history of mental illness, and inadequate support systems.

Task 2: Assess for risk factors for prolonged distress, including previous trauma or mental health conditions.

The competent candidate should:

Identify pre-existing mental health conditions, such as anxiety, depression, or PTSD history.
Assess family history of mental illness, particularly PTSD, mood disorders, or substance use disorders.
Evaluate social and emotional support, identifying supportive relationships versus isolation.
Screen for maladaptive coping, such as substance use or avoidance behaviours.
Conduct a basic suicide risk assessment, ensuring no active suicidal ideation or self-harm risk.

Task 3: Provide psychological first aid, reassurance, and a structured management plan.

The competent candidate should:

Reassure the patient that acute stress reactions are normal and typically self-resolve within days to weeks.
Explain the difference between acute stress reaction and PTSD, ensuring realistic expectations about recovery.
Provide psychological first aid, including:
- Normalising reactions and validating distress.
- Encouraging self-care, including sleep hygiene, exercise, and relaxation techniques.
- Advising against avoidance, promoting gradual exposure to feared activities.
Discuss therapy options, particularly trauma-focused counselling if symptoms persist.
Avoid unnecessary medication but consider short-term use of melatonin or sedating antihistamines for sleep disturbances if needed.

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

The competent candidate should:

Arrange follow-up in 1–2 weeks to monitor symptom progression.
Refer for psychological support if:
- Symptoms persist beyond four weeks (consider PTSD risk).
- There is significant functional impairment or ongoing distress.
- The patient develops depression, severe anxiety, or panic attacks.
Ensure the patient has access to support services, such as:
- Lifeline (13 11 14) for immediate crisis support.
- Beyond Blue for general mental health resources.
- A psychologist under a Mental Health Care Plan if required.

SUMMARY OF A COMPETENT ANSWER

Takes a thorough trauma history, assessing emotional response and functional impact.
Identifies risk factors for prolonged distress, including previous trauma and mental health conditions.
Provides psychological first aid, including reassurance, self-care strategies, and gradual exposure.
Explains the difference between acute stress reaction and PTSD, setting realistic expectations.
Develops a structured follow-up plan, ensuring monitoring and early intervention if symptoms persist.

PITFALLS

Failing to explore the patient’s full trauma response, missing avoidance, hypervigilance, or emotional numbness.
Overlooking risk factors for prolonged distress, such as previous trauma or lack of support.
Minimising the patient’s distress, leading to feelings of invalidation.
Prescribing unnecessary medications, such as benzodiazepines, which may increase avoidance behaviours.
Not arranging follow-up, leading to missed early signs of PTSD.

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 triggers, emotional and physical symptoms, and coping mechanisms.
2.2 Identifies risk factors for prolonged distress or development of PTSD.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between an acute stress reaction, adjustment disorder, and other mental health conditions.
3.2 Identifies when further mental health support or referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides evidence-based psychological first aid and coping strategies.
4.2 Discusses follow-up and available mental health support services.

5. Preventive and Population Health

5.1 Provides psychoeducation on stress reactions and early intervention strategies.
5.2 Identifies at-risk individuals who may benefit from ongoing mental health support.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach to managing psychological distress.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate referrals to psychology, counselling, or crisis services as required.

8. Procedural Skills

8.1 Conducts a brief mental health assessment, including risk assessment for self-harm.

9. Managing Uncertainty

9.1 Recognises when distress may evolve into a more persistent mental health condition, such as PTSD.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and manages patients experiencing acute psychological distress effectively.

Competency at Fellowship Level

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