CASE INFORMATION

Case ID:
Case Name: Sarah Mitchell
Age: 52
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A85 – Adverse Effect of Medical Agent

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to gather relevant information about symptoms and concerns 1.2 Provides clear and empathetic explanations regarding the suspected adverse drug reaction and next steps
2. Clinical Information Gathering and Interpretation	2.1 Takes a comprehensive medication and allergy history to identify the causative agent 2.2 Interprets clinical signs and symptoms suggestive of an adverse drug reaction
3. Diagnosis, Decision-Making and Reasoning	3.1 Identifies clinical features of drug reactions and assesses severity 3.2 Recognises when to discontinue or modify medication and when referral is necessary
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based plan for managing the adverse drug reaction 4.2 Adjusts or replaces medications while considering patient safety and therapeutic needs
5. Preventive and Population Health	5.1 Provides education on medication safety and monitoring for future reactions
6. Professionalism	6.1 Demonstrates patient-centred care and reassures the patient about appropriate management
7. General Practice Systems and Regulatory Requirements	7.1 Ensures proper documentation and reporting of the adverse drug reaction
8. Procedural Skills	8.1 Performs necessary assessments such as blood tests if indicated
9. Managing Uncertainty	9.1 Recognises when symptoms require specialist referral for further evaluation
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies severe or life-threatening reactions requiring urgent care

CASE FEATURES

Middle-aged woman presenting with rash, itching, and facial swelling after starting a new medication.
History of hypertension and osteoarthritis, currently taking multiple medications.
Started NSAIDs (meloxicam) one week ago for knee pain.
Mild angioedema with no airway compromise, but patient is anxious about worsening symptoms.
Requires immediate assessment of severity and decision on stopping medication.
Needs education on medication safety, potential alternative treatments, and reporting of adverse reactions.

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 Mitchell, a 52-year-old administrative worker, presents with a rash, facial swelling, and itching that started three days ago. She had been experiencing knee pain due to osteoarthritis and was prescribed meloxicam (a nonsteroidal anti-inflammatory drug) one week ago.

She first noticed mild itchiness and redness on her arms two days after starting the medication. Over the past 24 hours, the rash has spread to her torso, and she now has mild swelling of her lips and around her eyes.

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Mitchell
Age: 52
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known medication allergies

Medications

Perindopril 5 mg daily (hypertension)
Meloxicam 7.5 mg daily (prescribed one week ago for knee pain)
Cetirizine 10 mg PRN (self-medicated for itching)

Past History

Hypertension
Osteoarthritis (knees, mild to moderate pain)

Social History

Works full-time in administration

Family History

No known history of drug allergies or autoimmune diseases

Smoking

Non-smoker

Alcohol

Drinks socially (1-2 glasses of wine on weekends)

Vaccination and Preventative Activities

Up to date with routine 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.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, I’ve developed this rash and swelling on my face, and I think it’s from the new medication I started for my knee pain.”

General Information

You are Sarah Mitchell, a 52-year-old administrative worker. You were prescribed meloxicam (a nonsteroidal anti-inflammatory drug – NSAID) one week ago to help with knee pain from osteoarthritis. Initially, you were happy with the medication because it seemed to reduce your knee pain, but after a few days, you started experiencing itching and a red rash on your arms.

Over the past 24 hours, the rash has spread to your torso, and your face has become puffy, with noticeable swelling around your lips and eyes. You feel itchy all over, but you don’t have trouble breathing, chest tightness, or difficulty swallowing.

Specific Information

(Reveal only when asked)

Background Information

You became worried about the swelling and took a cetirizine antihistamine, which provided mild relief but did not completely stop the swelling or rash. You’re concerned this could get worse and don’t know if you should stop taking meloxicam.

You have never had an allergic reaction before and don’t have any known medication allergies. You are worried this could be serious and are anxious about whether you need to go to hospital or take stronger medication like steroids.

You also want to know what you can take instead for your knee pain because paracetamol doesn’t seem to work well enough.

History of Symptoms

The itchiness started about three days ago, mainly on your arms.
Over the next two days, a red, blotchy rash developed, spreading to your chest and back.
In the last 24 hours, your face has started swelling, especially around your eyes and lips.
You took cetirizine (an antihistamine) last night, which helped a little but didn’t stop the swelling.
You haven’t had trouble breathing, wheezing, or swallowing, but you are worried it could happen.

Medication History

You were prescribed meloxicam (7.5 mg once daily) for knee pain one week ago.
Before this, you were only taking paracetamol, which wasn’t very effective.
You also take perindopril 5 mg daily for high blood pressure, which you’ve been on for years without issues.
You have never had an allergic reaction to medications before.

Medical History

Hypertension (well controlled with perindopril).
Osteoarthritis (affecting both knees, mild to moderate pain, worse after prolonged standing).

Lifestyle and Social History

You work full-time in an administrative role.
You live with your husband, and your children are grown and living independently.
You are active but struggle with knee pain, which is why you wanted something stronger than paracetamol.

Concerns and Expectations

You are worried that the swelling could get worse and wonder if you need to go to hospital.
You want to know if this is an allergic reaction and if it’s dangerous.
You are concerned about whether you should stop taking meloxicam.
You want to know what alternative pain relief options are available for your knee pain.
You are wondering if this reaction should be reported somewhere, so doctors know about it in the future.

Emotional Cues & Body Language

You look worried and slightly anxious, especially when discussing the swelling on your face.
You frown and touch your face lightly when talking about how puffy your lips and eyes feel.
You become more tense when asking if this could get worse or become dangerous.
You relax slightly if the doctor explains things clearly and reassures you that you are not in immediate danger.
If the doctor dismisses your concerns, you appear frustrated and push for more information.

Questions for the Candidate (Ask Naturally During the Consultation)

“Do you think this is an allergic reaction? Should I be worried?”
“Could this get worse? Do I need to go to hospital?”
“Do I need an adrenaline injection or steroids?”
“Should I stop taking meloxicam? What else can I take for my knee pain?”
“How do I know if this will happen again with other medications?”
“Should this be reported somewhere so it’s on my record?”

Response to Advice Given by the Candidate

If the candidate explains the reaction clearly, you feel reassured.
If they recommend stopping meloxicam, you ask what alternative pain relief options exist.
If they suggest monitoring symptoms, you ask what to watch for and when to seek urgent care.
If they recommend steroids or an EpiPen, you ask why this is necessary or if it’s just precautionary.
If they fail to mention reporting the reaction, you ask if this should be documented for future reference.

Final Thought

If the candidate explains the condition well, reassures you, and provides a structured treatment plan, you feel confident about managing the reaction. If they are vague, dismissive, or fail to address your concerns, you remain worried and dissatisfied with the consultation.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including symptom onset, medication use, and any past drug reactions.

The competent candidate should:

Elicit a clear timeline of symptom onset and progression, including:
- When the rash and swelling began.
- How quickly symptoms developed after starting meloxicam.
- Any previous similar reactions to medications.
Assess severity and associated symptoms, such as:
- Breathing difficulty, wheezing, or throat tightness (signs of anaphylaxis).
- Systemic symptoms (fever, joint pain, nausea).
- Effectiveness of antihistamines taken.
Take a thorough medication history, including:
- All current medications and recent changes.
- Over-the-counter drugs, herbal supplements.
- Previous drug allergies or intolerances.
Identify risk factors for adverse drug reactions, such as:
- NSAID sensitivity, history of asthma, chronic kidney disease.

Task 2: Identify features suggesting an adverse drug reaction and assess its severity.

The competent candidate should:

Recognise clinical features of an NSAID-induced allergic reaction, including:
- Urticarial rash and angioedema (lip and eye swelling).
- Onset within days of starting the medication.
Assess for severe or life-threatening symptoms:
- Airway involvement (stridor, swelling of the tongue or throat).
- Respiratory distress, hypotension, or shock.
- Progressive rash (e.g., Stevens-Johnson Syndrome, toxic epidermal necrolysis).
Classify severity:
- Mild to moderate reaction (rash and mild angioedema, no airway compromise).
- Severe reaction (anaphylaxis, systemic symptoms).
Decide on immediate vs. outpatient management based on severity.

Task 3: Explain the likely cause, management plan, and alternative treatment options.

The competent candidate should:

Explain in simple terms that this is a likely NSAID-induced allergic reaction.
Reassure the patient that there are no immediate signs of anaphylaxis but that medication should be stopped.
Provide a stepwise treatment approach:
- Stop meloxicam immediately.
- Continue antihistamines (e.g., cetirizine) for symptom relief.
- Consider oral corticosteroids (e.g., prednisolone) if swelling worsens.
- Monitor for any worsening symptoms (e.g., difficulty breathing).
Discuss alternative pain relief options:
- Paracetamol as a first-line option.
- Topical NSAIDs (if no reaction to them in the past).
- Referral for specialist pain management if needed.

Task 4: Ensure safe prescribing and appropriate follow-up, including documentation and reporting of the reaction.

The competent candidate should:

Document the adverse reaction in the patient’s medical record.
Provide an allergy label in prescribing software to prevent future exposure.
Educate the patient about NSAID cross-reactivity and alternatives.
Report the reaction to the Therapeutic Goods Administration (TGA) if appropriate.
Arrange follow-up:
- Review in a few days to ensure symptom resolution.
- Consider referral to an allergist for NSAID sensitivity testing.

SUMMARY OF A COMPETENT ANSWER

Takes a thorough history, including symptom timeline, medication use, and previous reactions.
Identifies clinical features of an NSAID-induced allergic reaction and assesses severity.
Explains the diagnosis clearly and reassures the patient about management.
Stops the offending drug and provides a structured treatment plan.
Discusses alternative pain management options.
Ensures proper documentation and reporting of the adverse reaction.

PITFALLS

Failing to assess severity adequately, particularly missing early signs of anaphylaxis.
Not discontinuing meloxicam, which could worsen the reaction.
Overprescribing oral corticosteroids unnecessarily in a mild case.
Not discussing alternative pain relief options, leaving the patient without a plan for osteoarthritis.
Failing to document or report the reaction, increasing the risk of future exposure.

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 sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive medication and allergy history to identify the causative agent.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies clinical features of drug reactions and assesses severity.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based plan for managing the adverse drug reaction.

5. Preventive and Population Health

5.1 Provides education on medication safety and monitoring for future reactions.

6. Professionalism

6.1 Demonstrates patient-centred care and reassures the patient about appropriate management.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures proper documentation and reporting of the adverse drug reaction.

8. Procedural Skills

8.1 Performs necessary assessments such as blood tests if indicated.

9. Managing Uncertainty

9.1 Recognises when symptoms require specialist referral for further evaluation.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies severe or life-threatening reactions requiring urgent care.

Competency at Fellowship Level

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