CCE-CE-087

CASE INFORMATION

Case ID: CCE-SUM-02
Case Name: Olivia Bennett
Age: 42
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A01 – Pain, General/Multiple Sites

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 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 Interpretation2.1 Takes a thorough history, including onset, severity, and impact of pain
2.2 Identifies red flags and differentiates between musculoskeletal, inflammatory, and neuropathic pain
3. Diagnosis, Decision-Making and Reasoning3.1 Identifies clinical features suggestive of fibromyalgia, chronic pain syndrome, or inflammatory conditions
3.2 Recognises red flags requiring urgent referral (e.g., malignancy, autoimmune disease)
4. Clinical Management and Therapeutic Reasoning4.1 Develops an evidence-based management plan, including pharmacological and non-pharmacological interventions
4.2 Ensures a multimodal approach to chronic pain management
5. Preventive and Population Health5.1 Provides education on lifestyle factors, mental health, and exercise in pain management
6. Professionalism6.1 Demonstrates patient-centred care and acknowledges the impact of chronic pain on quality of life
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate use of medications, avoiding opioid over-reliance
8. Procedural Skills8.1 Performs a relevant musculoskeletal examination if indicated
9. Managing Uncertainty9.1 Recognises when symptoms require further investigation or specialist input
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies cases requiring urgent intervention, such as malignancy, systemic inflammatory disease, or neurological conditions

CASE FEATURES

  • Middle-aged woman with generalised pain in multiple body areas for the past six months.
  • Reports fatigue, poor sleep, and mood changes, raising concerns about fibromyalgia or chronic pain syndrome.
  • Worried about an underlying medical condition (e.g., autoimmune disease, arthritis, or even cancer).
  • No red flag symptoms but experiencing significant impact on daily life.
  • Needs assessment for underlying causes, reassurance, and a structured pain management plan.
  • Requires education on lifestyle interventions, mental health, and non-opioid pain management strategies.

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:

  1. Take an appropriate history.
  2. Outline the differential diagnosis and key investigations required.
  3. Address the patient’s concerns.
  4. Develop a safe and patient-centred management plan.

SCENARIO

Olivia Bennett, a 42-year-old primary school teacher, presents with widespread body pain for the past six months. The pain is diffuse, affecting her neck, shoulders, lower back, and legs. She describes it as aching, persistent, and worse in the mornings.

She also feels constantly tired, struggles with poor sleep, and finds it difficult to concentrate at work. She has been feeling low in mood, wondering if the pain is due to stress or an undiagnosed condition.

PATIENT RECORD SUMMARY

Patient Details

Name: Olivia Bennett
Age: 42
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Occasional ibuprofen and paracetamol for pain relief

Past History

  • No history of autoimmune disease, arthritis, or malignancy
  • No previous chronic pain conditions

Social History

  • Works full-time as a primary school teacher, frequently on her feet

Family History

  • No known autoimmune disease, inflammatory arthritis, or malignancy

Smoking

  • Non-smoker

Alcohol

  • Drinks socially (1-2 glasses of wine per week)

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 in pain all over my body for months now. I wake up aching, and it doesn’t seem to go away. I’m worried there’s something really wrong with me.”

General Information

You are Olivia Bennett, a 42-year-old primary school teacher. For the past six months, you have had widespread body pain that seems to move around. It started with some discomfort in your shoulders and neck, but now your lower back, legs, and arms also feel sore.

The pain is worse in the mornings, and you often wake up feeling stiff and aching. Moving around helps a little, but the discomfort never fully goes away. By the afternoon, you feel exhausted and drained, even if you haven’t done anything physically demanding.

Specific Information

(Reveal only when asked)

Background Information

You have no history of major illnesses, injuries, or accidents. You haven’t changed your routine—you still go to work, look after your kids, and try to stay active, but lately, even simple tasks like standing for long periods or carrying groceries feel more difficult.

You feel constantly tired and never seem to get a good night’s sleep. You often wake up feeling unrefreshed, and even when you do sleep for 7–8 hours, you still feel fatigued the next day.

You have also noticed difficulty concentrating and feel foggy-headed at times, which is making your job as a teacher more challenging. You feel like your mood has been lower than usual, but you’re not sure if that’s because of the pain or something else.

You have tried paracetamol and ibuprofen, but they don’t seem to make a big difference. You’re worried this could be something serious, like an autoimmune disease, arthritis, or even cancer.

Pain Symptoms

  • The pain is aching, sometimes burning, and varies in intensity.
  • It is not sharp, stabbing, or localised to one joint.
  • It doesn’t follow a specific pattern and moves around the body.
  • No recent injuries, falls, or infections.
  • No redness, swelling, or warmth in the joints.

Systemic Symptoms

  • No fever, night sweats, or unintentional weight loss.
  • No numbness, tingling, or weakness in limbs.
  • No changes in bowel habits, skin rashes, or hair loss.

Medical and Family History

  • No personal history of arthritis, lupus, or thyroid disease.
  • No family history of autoimmune diseases or malignancy.

Lifestyle Factors

  • You work full-time as a primary school teacher, which involves standing and moving around a lot.
  • You are married with two children, and your household is busy but supportive.
  • You experience moderate work-related stress, but nothing extreme.
  • You eat relatively well and don’t drink excessively.
  • You do not smoke and rarely drink alcohol.

Concerns and Expectations

  • You are worried that this could be a serious medical condition.
  • You want to know if you need blood tests or scans to check for diseases like arthritis, lupus, or even cancer.
  • You feel frustrated because the painkillers you’ve tried haven’t helped much.
  • You want a clear explanation and plan to help manage the pain.
  • You wonder if you need to see a specialist for further evaluation.

Emotional Cues & Body Language

  • You appear tired and emotionally drained.
  • You rub your arms or back occasionally, showing discomfort.
  • You seem anxious when discussing the possibility of a serious illness.
  • You lean forward when asking about tests and investigations, showing concern.
  • You relax slightly if the doctor explains the condition well and reassures you.

Questions for the Candidate (Ask Naturally During the Consultation)

  1. “What do you think is causing this pain? Could it be something serious?”
  2. “Do I need any tests or scans to find out what’s wrong?”
  3. “What treatments actually work? Painkillers don’t seem to help much.”
  4. “Is this something I’ll have forever, or can it go away?”
  5. “Do I need to see a specialist for this?”
  6. “Could this be something like arthritis or an autoimmune disease?”
  7. “Is my stress or lack of sleep making this worse?”

Response to Advice Given by the Candidate

  • If the candidate explains fibromyalgia or chronic pain syndrome clearly, you feel relieved but still ask if any tests are needed.
  • If they recommend lifestyle changes (exercise, stress reduction, sleep hygiene), you ask how long it will take to notice improvement.
  • If they suggest physiotherapy or psychological support, you ask if it’s really necessary or if medication is a better option.
  • If they mention medications like antidepressants (amitriptyline, duloxetine), you ask if that means they think this is all in your head.
  • If the doctor dismisses your concerns or doesn’t provide a clear plan, you feel frustrated and push for tests or a specialist referral.

Final Thought

If the candidate explains the likely diagnosis well, reassures you, and provides a structured management plan, you feel more in control and ready to follow their advice. If they are vague, dismissive, or fail to address your concerns about serious illness, you remain worried and push for more investigations or specialist referrals.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including symptom onset, severity, and associated symptoms such as fatigue and mood changes.

The competent candidate should:

  • Clarify the pain characteristics:
    • Onset (gradual over six months).
    • Location (generalised, affecting multiple sites including neck, shoulders, back, and legs).
    • Nature (aching, sometimes burning, non-localised).
    • Aggravating and relieving factors (worse in the morning, improves slightly with movement).
  • Identify associated symptoms:
    • Fatigue, poor sleep, difficulty concentrating (“brain fog”).
    • Low mood, anxiety about possible serious illness.
  • Screen for red flags suggesting systemic disease:
    • Weight loss, night sweats, fevers, neurological symptoms, joint swelling.
  • Assess functional impact:
    • Effect on daily life and work performance.
  • Explore patient’s concerns:
    • Fear of an underlying autoimmune disease, arthritis, or malignancy.

Task 2: Identify key clinical features and assess for serious underlying conditions, such as inflammatory arthritis or malignancy.

The competent candidate should:

  • Recognise key clinical features suggesting fibromyalgia or chronic pain syndrome:
    • Widespread pain in the absence of inflammation.
    • Associated fatigue, cognitive issues, and mood disturbances.
  • Differentiate from other conditions:
    • Inflammatory arthritis (morning stiffness >1 hour, joint swelling).
    • Polymyalgia rheumatica (older age, high inflammatory markers).
    • Neuropathic pain syndromes (burning pain, tingling, localised to dermatomes).
    • Autoimmune conditions (e.g., lupus, rheumatoid arthritis).
  • Consider further investigations if red flags are present:
    • FBC, ESR/CRP (for systemic inflammation or malignancy).
    • Thyroid function tests.
    • Vitamin D and iron studies (fatigue assessment).

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

The competent candidate should:

  • Explain the likely diagnosis:
    • Fibromyalgia or chronic widespread pain syndrome, given widespread pain, fatigue, poor sleep, and normal inflammatory markers.
  • Provide reassurance:
    • This is a recognised medical condition and not life-threatening.
    • No evidence of serious illness (arthritis, cancer, autoimmune disease).
  • Outline management principles:
    • Non-pharmacological approaches (exercise, physiotherapy, cognitive therapy).
    • Medications if required (low-dose amitriptyline or duloxetine for pain modulation).
  • Discuss follow-up plan:
    • Review in 4-6 weeks to assess symptom management and treatment adherence.

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

The competent candidate should:

  • Prioritise non-pharmacological treatments:
    • Gradual increase in low-impact exercise (e.g., swimming, yoga, walking).
    • Cognitive-behavioural therapy (CBT) for pain coping strategies.
    • Improved sleep hygiene (consistent routine, limiting stimulants before bed).
  • Introduce pharmacological options if necessary:
    • Amitriptyline (low dose) or duloxetine if pain is significantly impacting quality of life.
    • Avoid opioids and NSAIDs, as they are not effective for fibromyalgia.
  • Provide education on lifestyle modifications:
    • Stress management techniques.
    • Dietary adjustments (ensuring adequate vitamin D and magnesium intake).
  • Plan follow-up:
    • Reassess in 4-6 weeks to monitor symptom progression and treatment response.

SUMMARY OF A COMPETENT ANSWER

  • Takes a detailed history, assessing symptom onset, pattern, associated symptoms, and impact on function.
  • Excludes serious underlying conditions, ensuring no red flag symptoms.
  • Explains fibromyalgia or chronic pain syndrome clearly, reassuring the patient.
  • Develops a multimodal management plan, including exercise, physiotherapy, psychological support, and appropriate medication.
  • Emphasises non-pharmacological approaches and avoids opioid over-reliance.
  • Ensures structured follow-up to monitor progress and adjust treatment.

PITFALLS

  • Failing to assess for red flag symptoms, missing potential serious conditions.
  • Over-investigating without clinical indications, leading to unnecessary tests and patient anxiety.
  • Over-reliance on medication, particularly opioids or NSAIDs, which are ineffective in fibromyalgia.
  • Dismissing the patient’s symptoms as purely psychological, rather than addressing the condition holistically.
  • Not providing a structured pain management plan, leaving the patient uncertain about the next steps.

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 thorough history, including symptom onset, severity, and red flag symptoms.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies clinical features suggestive of fibromyalgia or chronic pain syndrome.

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 lifestyle factors, mental health, and exercise in pain management.

6. Professionalism

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

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate use of medications, avoiding opioid over-reliance.

8. Procedural Skills

8.1 Performs a relevant musculoskeletal examination if indicated.

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 malignancy, systemic inflammatory disease, or neurological conditions.

Competency at Fellowship Level

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