CCE-CE-056 - GP Exams

CASE INFORMATION

Case ID: CCE-RESP-016
Case Name: Michael Thompson
Age: 42
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: R05 – Cough

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 structured history of cough, including duration, nature (dry vs productive), triggers, and associated symptoms 2.2 Identifies red flags and risk factors for serious conditions (e.g., lung cancer, pneumonia, tuberculosis)
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis based on clinical findings 3.2 Identifies when further investigations or specialist referral is required
4. Clinical Management and Therapeutic Reasoning	4.1 Provides evidence-based management based on the suspected cause 4.2 Educates the patient on symptom relief, lifestyle modifications, and follow-up care
5. Preventive and Population Health	5.1 Identifies risk factors for chronic cough, including smoking, allergens, and occupational exposure 5.2 Encourages smoking cessation and vaccination where appropriate
6. Professionalism	6.1 Demonstrates empathy and a patient-centred approach
7. General Practice Systems and Regulatory Requirements	7.1 Identifies when referral for specialist assessment (e.g., respiratory physician) is required
8. Procedural Skills	8.1 Orders and interprets relevant investigations, such as chest X-ray, spirometry, and sputum culture if indicated
9. Managing Uncertainty	9.1 Recognises when symptoms require observation versus further intervention
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and appropriately manages conditions such as asthma, COPD, pneumonia, and malignancy

CASE FEATURES

Impact on sleep and daily activities
Persistent cough for six weeks, initially following a viral illness
Concerns about a serious underlying condition, including lung cancer
Need to differentiate between post-viral cough, asthma, reflux, and other causes

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

Michael Thompson, a 42-year-old warehouse manager, presents with a persistent dry cough for six weeks, which started after a cold. Initially, he thought it would go away on its own, but it has been disrupting his sleep and work.

He is worried because his father was a smoker and developed lung cancer. He has also noticed some occasional breathlessness but no chest pain, fever, or weight loss.

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Thompson
Age: 42
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known allergies

Medications

Nil regular medications

Past History

Occasional mild reflux symptoms, self-managed with over-the-counter antacids
No history of asthma or COPD

Social History

Works in a warehouse, occasional exposure to dust and fumes
Smoker – 10 cigarettes per day for 20 years
Alcohol intake – 2–3 beers on weekends
No recreational drug use

Family History

Father diagnosed with lung cancer in his late 60s
Mother has asthma

Smoking

10 pack-year smoking history

Alcohol

Social drinker, 2–3 beers per week

Vaccination and Preventative Activities

No recent 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, I’ve had this cough for weeks now, and I just can’t seem to shake it. I’m starting to worry it’s something serious.”

General Information

Michael Thompson is a 42-year-old warehouse manager who presents with a persistent dry cough lasting six weeks, which started after a cold. Initially, he thought it would go away on its own, but it has been disrupting his sleep and work.

Cough description: Dry, persistent, no phlegm, sometimes a tickling sensation in the throat.
Started six weeks ago after a viral illness, but hasn’t resolved.
Occasionally worse at night and after talking for long periods.

Specific Information

(To be revealed only when asked)

Background Information

No wheezing, fever, or chest pain.
No coughing up blood.
Occasionally feels breathless, especially after exertion.

His main concerns are:

“Why is my cough lasting so long?”
“Could this be something serious like lung cancer?”
“How can I get rid of it? It’s keeping me up at night.”

Triggers and Patterns

Cough is worse at night and early morning.
Sometimes triggered by talking, laughing, or cold air.
Not associated with exercise.
No clear seasonal pattern or known allergens.
Cough does not improve with cough syrups.

Medical and Family History

Smoker – 10 cigarettes per day for 20 years.
Occasional acid reflux, but never formally diagnosed or treated.
Father had lung cancer, diagnosed in his late 60s.
Mother has asthma, but Michael has never been diagnosed.
No previous history of pneumonia, tuberculosis, or chronic lung disease.

Work and Lifestyle Factors

Works in a warehouse, occasionally exposed to dust and fumes.
Smokes daily and drinks 2–3 beers on weekends.
Sleeps poorly due to coughing at night, making him feel tired at work.
Has not tried any regular medication to manage his symptoms.

Concerns About Serious Conditions

Worried about lung cancer due to family history and his smoking.
Wants to know if he needs an X-ray or scan.
Unsure if smoking is contributing to his symptoms.

Impact on Daily Life

Disturbing his sleep, causing daytime fatigue.
Embarrassed about coughing in meetings at work.
Avoids social situations because people keep asking if he’s sick.

Emotional Cues

Michael is concerned but open to discussion.

Anxious about lung cancer: “This cough won’t go away—what if it’s something serious?”
Frustrated with symptoms: “I feel fine otherwise, but this cough is ruining my sleep.”
Seeking reassurance: “Do I need an X-ray or other tests?”

If the candidate provides a structured explanation and management plan, Michael will be reassured and willing to make lifestyle changes.

If the candidate is vague or dismissive, he may insist on unnecessary tests or referrals.

Questions for the Candidate

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

“Why has my cough lasted so long?”
“Do I need an X-ray or scan?”
“Could this be lung cancer?”
“What treatments can help stop the cough?”
“Is smoking making this worse?”
“When should I come back if it doesn’t improve?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

Michael will feel reassured and motivated to consider smoking cessation.
He will accept that an X-ray is warranted based on risk factors.
He may say, “That makes sense. I’ll try the inhaler and see if things improve.”

If the candidate is vague or dismissive:

Michael may push for unnecessary tests or second opinions.
He may say, “I need something stronger. Can you send me to a specialist?”

Key Takeaways for the Candidate

Take a structured cough history, identifying red flags.
Consider a broad differential diagnosis, including post-viral cough, reflux, asthma, and malignancy.
Provide a clear management plan, including smoking cessation advice.
Explain the role of investigations, ordering a chest X-ray if risk factors are present.
Ensure follow-up to monitor symptom resolution and review test results.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including duration, triggers, associated symptoms, and risk factors.

The competent candidate should:

Elicit a detailed cough history, including:
- Duration (acute, subacute, chronic) – Persistent for six weeks.
- Nature (dry vs productive) – Dry, tickling cough, worse at night.
- Triggers – Cold air, talking, and after meals.
- Associated symptoms – No fever, chest pain, or haemoptysis, occasional breathlessness.
Assess risk factors, such as:
- Smoking (10 pack-years, ongoing).
- Occupational exposures (warehouse dust, fumes).
- Family history of lung disease (father had lung cancer).
Identify red flags:
- Haemoptysis, significant weight loss, persistent breathlessness, or night sweats (not present in this case).
Consider common causes:
- Post-viral cough, GORD, asthma, smoking-related disease.

Task 2: Develop a differential diagnosis and identify any red flags requiring urgent investigation.

The competent candidate should:

Differentiate between common causes of chronic cough:
- Post-viral cough – Persistent after a viral illness, no fever or significant sputum.
- GORD-related cough – Worse after meals and at night, triggers present.
- Asthma/airway hyperreactivity – Cough triggered by cold air, talking, and exertion.
- Smoking-related disease (COPD, chronic bronchitis, malignancy) – Long-term smoking history.
Recognise when urgent investigations are required:
- Lung cancer suspicion (haemoptysis, unexplained weight loss, significant dyspnoea).
- Tuberculosis suspicion (chronic cough with night sweats, travel history, contact exposure).

Task 3: Provide a diagnosis and discuss an initial management plan.

The competent candidate should:

Explain the most likely diagnosis:
- Post-viral cough with possible reflux-related or smoking-related contribution.
- Explain why cancer is unlikely but why a chest X-ray is needed due to risk factors.
Management plan:
- Smoking cessation support (counselling, nicotine replacement therapy, Quitline referral).
- Trial of a proton pump inhibitor (PPI) if GORD is suspected.
- Trial of inhaled bronchodilator (salbutamol) to assess for airway hyperreactivity.
- Consider a short course of inhaled corticosteroids if symptoms persist.
- Encourage adequate hydration and avoidance of cough triggers.

Task 4: Educate the patient on symptom relief, lifestyle modifications, and when to seek further care.

The competent candidate should:

Advise on lifestyle modifications:
- Smoking cessation to improve lung health and reduce cough.
- Elevating the head while sleeping if reflux is suspected.
- Avoiding cough irritants like cold air, smoke, and strong odours.
Explain the need for a chest X-ray due to his smoking history.
Safety-netting advice:
- Return if cough persists beyond another four weeks, worsens, or red flag symptoms develop.
Arrange follow-up in two to four weeks to assess response to treatment and review test results.

SUMMARY OF A COMPETENT ANSWER

Takes a structured cough history, assessing triggers, associated symptoms, and risk factors.
Considers differential diagnoses, including post-viral cough, reflux, asthma, and smoking-related disease.
Recognises red flags requiring urgent investigation.
Provides an evidence-based management plan, including chest X-ray, smoking cessation, and targeted therapy.
Ensures follow-up to assess symptom resolution and review test results.

PITFALLS

Failing to recognise smoking as a significant risk factor, missing the need for a chest X-ray.
Overlooking GORD-related cough, leading to mismanagement with inappropriate treatments.
Not exploring occupational exposure, missing potential environmental triggers.
Reassuring the patient without adequate investigation, particularly given his family history of lung cancer.
Prescribing unnecessary antibiotics, as there is no evidence of bacterial infection.

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 structured history of cough, including duration, nature (dry vs productive), triggers, and associated symptoms.
2.2 Identifies red flags and risk factors for serious conditions (e.g., lung cancer, pneumonia, tuberculosis).

3. Diagnosis, Decision-Making and Reasoning

3.1 Develops a differential diagnosis based on clinical findings.
3.2 Identifies when further investigations or specialist referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides evidence-based management based on the suspected cause.
4.2 Educates the patient on symptom relief, lifestyle modifications, and follow-up care.

5. Preventive and Population Health

5.1 Identifies risk factors for chronic cough, including smoking, allergens, and occupational exposure.
5.2 Encourages smoking cessation and vaccination where appropriate.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.1 Identifies when referral for specialist assessment (e.g., respiratory physician) is required.

8. Procedural Skills

8.1 Orders and interprets relevant investigations, such as chest X-ray, spirometry, and sputum culture if indicated.

9. Managing Uncertainty

9.1 Recognises when symptoms require observation versus further intervention.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and appropriately manages conditions such as asthma, COPD, pneumonia, and malignancy.

Competency at Fellowship Level

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