CASE INFORMATION

Case ID: CCE-NOS-01
Case Name: Michael Lawson
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: T99 – Endocrine/Metabolic/Nutritional Disease NOS

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 diagnosis and management plan
2. Clinical Information Gathering and Interpretation	2.1 Takes a comprehensive history, including risk factors for metabolic disease 2.2 Orders and interprets appropriate investigations for suspected endocrine/metabolic disorder
3. Diagnosis, Decision-Making and Reasoning	3.1 Identifies clinical features suggestive of an endocrine or metabolic disorder 3.2 Recognises when specialist referral is required for further investigation
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan, including pharmacological and non-pharmacological interventions 4.2 Ensures lifestyle modifications are incorporated into management
5. Preventive and Population Health	5.1 Provides education on dietary and lifestyle modifications to prevent disease progression
6. Professionalism	6.1 Demonstrates patient-centred care and acknowledges the impact of chronic disease on quality of life
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate monitoring and follow-up, including referrals where necessary
8. Procedural Skills	8.1 Performs appropriate physical examination and necessary bedside investigations (e.g., blood glucose testing)
9. Managing Uncertainty	9.1 Recognises when symptoms require further investigation or specialist input
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies cases requiring urgent intervention, such as diabetic ketoacidosis or adrenal crisis

CASE FEATURES

Needs education on lifestyle changes, medical management, and follow-up.
Middle-aged man presenting with unexplained fatigue, weight gain, and mild depression.
Complains of cold intolerance, constipation, and reduced energy levels.
Possible hypothyroidism, metabolic syndrome, or undiagnosed diabetes.
Requires assessment of thyroid function, blood glucose levels, and metabolic profile.

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 Lawson, a 45-year-old accountant, presents with fatigue, weight gain, and low mood over the past six months. He initially thought it was just work-related stress, but now he feels constantly tired, sluggish, and unmotivated. He has also noticed cold intolerance, mild constipation, and difficulty concentrating.

His weight has increased by 7 kg in the last six months, despite no major dietary changes. His wife has mentioned that he seems more irritable and withdrawn.

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Lawson
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular medications

Past History

No known history of diabetes, thyroid disease, or other endocrine conditions
No recent infections, surgeries, or major illnesses

Social History

Works in a sedentary job (accountant), minimal physical activity

Family History

Father had type 2 diabetes
No known family history of thyroid disorders or autoimmune diseases

Smoking

Non-smoker

Alcohol

Drinks 1–2 glasses of wine per week, no excessive intake

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 been feeling exhausted all the time, and I don’t know why. I’ve also put on weight even though I haven’t changed my diet.”

General Information

You are Michael Lawson, a 45-year-old accountant. Over the past six months, you’ve noticed that you are constantly tired, sluggish, and unmotivated. Initially, you thought it was just work-related stress, but now it feels like something more is going on.

You wake up feeling unrefreshed, even after 7–8 hours of sleep. You have low energy throughout the day, particularly in the afternoons, when you feel like you could fall asleep at your desk. You also feel more irritable than usual, and your wife has noticed you seem down and withdrawn.

Specific Information

(Reveal only when asked)

Background Information

In the last six months, you have gained 7 kg, despite no major changes in diet or lifestyle. You’ve always had an average diet, with some processed foods and high-carb meals, but you’ve never had trouble managing your weight before. You haven’t been exercising much because you feel too tired all the time.

You’ve also noticed feeling colder than usual, even when others around you seem comfortable. You sometimes wear an extra jumper indoors, which you never used to do. Your bowels have been sluggish, with mild constipation, but nothing severe. You sometimes feel like your thinking is slower, and you struggle to concentrate at work.

Your father had type 2 diabetes, and you’re worried you could be developing it too. You’re also wondering if this could be something hormonal, like a thyroid problem.

You’ve decided to come to the doctor because you want answers and a plan to feel better.

Symptoms

Fatigue started gradually six months ago and is getting worse.
No excessive thirst or frequent urination (not typical of diabetes).
No sweating, tremors, or palpitations (no signs of hyperthyroidism).
No recent illnesses, infections, or fevers.
No joint pain or muscle weakness.
No vision changes or headaches.
No significant hair loss, skin dryness, or brittle nails.

Diet and Lifestyle

Diet is average, but you do eat processed foods and high-carb meals sometimes.
Minimal physical activity due to work and lack of energy.
No significant alcohol intake (1–2 glasses of wine per week).
Non-smoker, no illicit drug use.

Concerns and Expectations

You are worried something is wrong with your metabolism.
You suspect a thyroid problem or pre-diabetes.
You want to know what tests you need to figure this out.
You want a plan to feel better, whether that means medication, lifestyle changes, or both.
You’re concerned about your long-term health, given your father had diabetes.

Emotional Cues & Body Language

You appear frustrated and confused about why this is happening.
You sigh and shake your head when discussing fatigue and weight gain.
You seem worried when discussing your father’s diabetes.
You lean forward when asking if this could be something serious.
You relax slightly if the doctor explains things clearly and gives a structured plan.
If the doctor is vague or dismissive, you become frustrated and push for more tests or referrals.

Questions for the Candidate (Ask Naturally During the Consultation)

“Do you think this could be my thyroid or something hormonal?”
“Could I have diabetes or a metabolism problem?”
“What tests do I need to figure this out?”
“Is there any medication that can help with my energy and weight?”
“What lifestyle changes should I make?”
“Will I need long-term treatment for this?”
“How long will it take before I start feeling better?”

Response to Advice Given by the Candidate

If the candidate explains the possible causes clearly, you feel reassured.
If they rule out serious concerns but take your symptoms seriously, you trust their judgement.
If they suggest lifestyle changes, you say you’re willing to try but need clear guidance.
If they suggest blood tests, you ask if you need to fast before them and how long results will take.
If they recommend medication, you ask about side effects and how long it takes to work.
If the doctor does not offer a structured plan, you push for more answers or a referral.

Final Thought

If the candidate explains possible causes, reassures you, and provides a structured management plan, you feel motivated and ready to follow their advice. If they are vague, dismissive, or don’t provide a clear next step, you leave feeling frustrated and worried about your health.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including symptoms, lifestyle factors, and medical history.

The competent candidate should:

Explore symptom onset and progression:
- Fatigue, weight gain, low mood, and cold intolerance over six months.
- Changes in bowel habits (mild constipation).
- Cognitive symptoms (poor concentration, mental fogginess).
Identify risk factors for metabolic or endocrine disease:
- Family history of diabetes (father with type 2 diabetes).
- Sedentary lifestyle, high-carb diet, minimal exercise.
Assess functional impact:
- Work performance, motivation, energy levels, and mental health impact.
Screen for associated conditions:
- No excessive thirst or polyuria (reducing likelihood of diabetes).
- No palpitations, tremors, or excessive sweating (reducing likelihood of hyperthyroidism).
Address patient concerns about metabolic or hormonal causes.

Task 2: Identify key clinical features and order appropriate investigations to determine the underlying cause.

The competent candidate should:

Recognise key clinical features suggestive of hypothyroidism:
- Fatigue, weight gain, cold intolerance, sluggish bowels, and low mood.
Differentiate from other metabolic conditions:
- Diabetes: No classic symptoms (polyuria, polydipsia).
- Depression: Low mood, but physical symptoms suggest metabolic cause.
- Sleep apnoea: Possible in an overweight patient, but fatigue pattern is different.
Order appropriate investigations:
- TSH and free T4 (assess for hypothyroidism).
- Fasting glucose and HbA1c (screen for diabetes).
- Lipid profile (assess for metabolic syndrome).
- Full blood count (FBC), iron studies (rule out anaemia as a cause of fatigue).
- Liver and kidney function tests (LFTs, UECs).
Explain to the patient the rationale for these tests.

Task 3: Explain the likely diagnosis, management options, and need for follow-up.

The competent candidate should:

Explain the most likely diagnosis:
- Primary hypothyroidism is suspected based on symptoms.
- Other possibilities include pre-diabetes or metabolic syndrome.
Discuss management strategies:
- If hypothyroidism is confirmed: Thyroxine replacement therapy (levothyroxine).
- If metabolic syndrome is present: Diet, exercise, and weight management.
Provide reassurance:
- Symptoms should improve with treatment.
- Regular monitoring of thyroid function is required.
Explain the need for follow-up in 4–6 weeks to assess response to treatment and repeat blood tests.

Task 4: Develop a safe, evidence-based management plan, including pharmacological and non-pharmacological strategies.

The competent candidate should:

Initiate appropriate treatment:
- Levothyroxine 50–100 mcg daily, titrated based on TSH levels.
- Dietary and exercise advice for metabolic health.
Provide education on hypothyroidism:
- Take levothyroxine on an empty stomach.
- Regular thyroid function monitoring is needed.
- Symptoms improve gradually over weeks to months.
Address metabolic risk factors:
- Encourage physical activity and balanced nutrition.
- Weight management to reduce risk of diabetes.
Plan follow-up:
- Review in 6 weeks with repeat TSH and symptom check.

SUMMARY OF A COMPETENT ANSWER

Takes a detailed history, identifying symptoms and metabolic risk factors.
Orders appropriate investigations, focusing on thyroid function and metabolic screening.
Explains the likely diagnosis clearly, reassuring the patient while outlining treatment.
Develops an individualised treatment plan, incorporating medications, lifestyle changes, and follow-up.
Ensures structured follow-up to monitor treatment response.

PITFALLS

Failing to consider hypothyroidism, leading to delayed diagnosis.
Not ordering thyroid function tests, missing a key cause of fatigue and weight gain.
Overlooking metabolic syndrome, failing to provide lifestyle advice.
Not addressing patient concerns about diabetes and metabolic health.
Lack of follow-up planning, missing treatment adjustments.

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 history, including risk factors for metabolic disease.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies clinical features suggestive of an endocrine or metabolic disorder.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan, including pharmacological and non-pharmacological interventions.

5. Preventive and Population Health

5.1 Provides education on dietary and lifestyle modifications to prevent disease progression.

6. Professionalism

6.1 Demonstrates patient-centred care and acknowledges the impact of chronic disease on quality of life.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate monitoring and follow-up, including referrals where necessary.

8. Procedural Skills

8.1 Performs appropriate physical examination and necessary bedside investigations (e.g., blood glucose testing).

9. Managing Uncertainty

9.1 Recognises when symptoms require further investigation or specialist input.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies cases requiring urgent intervention, such as diabetic ketoacidosis or adrenal crisis.

Competency at Fellowship Level

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