CASE INFORMATION

Case ID: CCE-SUM-06
Case Name: Emily Carter
Age: 67
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: R81 – Pneumonia

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 symptom onset, risk factors, and red flags 2.2 Orders and interprets appropriate investigations (e.g., chest X-ray, blood tests)
3. Diagnosis, Decision-Making and Reasoning	3.1 Recognises clinical features of pneumonia and differentiates from other respiratory conditions 3.2 Identifies red flags requiring urgent referral (e.g., respiratory distress, sepsis)
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan, including antibiotics, supportive care, and follow-up 4.2 Identifies when hospital admission is required
5. Preventive and Population Health	5.1 Provides education on pneumonia prevention, vaccination, and smoking cessation (if applicable)
6. Professionalism	6.1 Demonstrates patient-centred care and acknowledges the impact of pneumonia on daily life
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and referral if hospitalisation is required
8. Procedural Skills	8.1 Performs or refers for relevant investigations, such as chest X-ray and sputum culture
9. Managing Uncertainty	9.1 Recognises when symptoms require further observation or specialist input
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies cases requiring urgent intervention, such as sepsis or respiratory failure

CASE FEATURES

Elderly woman presenting with cough, fever, and increasing shortness of breath.
History of recent upper respiratory tract infection (URTI) with worsening symptoms.
Risk factors: Age >65, history of asthma, mild chronic obstructive pulmonary disease (COPD).
Concerns about hospital admission and recovery time.
Needs assessment for severity and appropriate treatment plan.
Requires education on supportive care, vaccination, and red flag symptoms for deterioration.

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

Emily Carter, a 67-year-old retired teacher, presents with a cough, fever, and shortness of breath for the past five days. The symptoms started as a mild cold but have progressively worsened. She now has a productive cough with yellow-green sputum, fatigue, and difficulty breathing with exertion.

PATIENT RECORD SUMMARY

Patient Details

Name: Emily Carter
Age: 67
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Salbutamol inhaler (Ventolin) PRN
Budesonide/formoterol (Symbicort) inhaler daily

Past History

Asthma since childhood
Mild COPD (FEV1 70%)
No previous pneumonia or hospitalisation for respiratory illness

Social History

Retired, lives alone
Never smoked, minimal alcohol consumption

Family History

No family history of respiratory diseases

Vaccination and Preventative Activities

Flu vaccine last year but not up to date with pneumococcal vaccine

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 had this awful cough and fever for a few days, and it’s getting worse. I’m starting to feel really short of breath.”

General Information

You are Emily Carter, a 67-year-old retired teacher. You have been feeling unwell for five days, starting with a runny nose and a mild sore throat, which you thought was just a cold. However, over the last three days, your symptoms have worsened significantly.

Specific Information

(Reveal only when asked)

Background Information

Now, you have a persistent, productive cough with thick yellow-green mucus, along with a fever and chills. You feel worn out, weak, and more short of breath than usual. Even doing simple tasks like walking across the room makes you feel breathless and exhausted.

You have asthma and mild COPD, but this feels worse than your usual flare-ups. Your inhalers don’t seem to be helping much. You’re worried that this might be pneumonia, and you’re not sure if you need antibiotics or to go to the hospital.

Respiratory Symptoms

You feel short of breath when walking, but you can still speak in full sentences.
You have a productive cough with yellow-green phlegm, which has been thicker than usual.
You haven’t had chest pain or coughed up blood.
You feel like your chest is tight, and your breathing is laboured.
You have not had wheezing, but you feel like your airways are blocked.

Other Symptoms

You feel feverish, hot, and shivery at night.
You are tired all the time and don’t feel like eating.
You have no nausea, vomiting, or diarrhoea.
No recent travel or sick contacts.

Past Medical History and Medication Use

Asthma since childhood, managed with Salbutamol (Ventolin) PRN and Budesonide/formoterol (Symbicort) daily.
Mild COPD with no history of hospitalisation for lung infections.
You’ve had a few asthma flare-ups in the past, but this feels different.

Concerns and Expectations

You’re worried that this is pneumonia and unsure if antibiotics are needed.
You are afraid of being admitted to hospital and want to know if you can recover at home.
You want to know how long it will take to get better.
You wonder if there’s anything you can do to prevent this from happening again.

Emotional Cues & Body Language

You appear fatigued and slightly anxious, frequently pausing while speaking to catch your breath.
You touch your chest or lean forward slightly when describing your breathing difficulties.
You seem relieved if the doctor provides a clear plan.
If the doctor is vague or hesitant, you push for tests or a referral.

Questions for the Candidate (Ask Naturally During the Consultation)

“Do I have pneumonia? How serious is it?”
“Will I need to go to hospital, or can I recover at home?”
“What kind of treatment do I need? Do I need antibiotics?”
“How long will it take for me to feel better?”
“Do I need another vaccine to prevent this in the future?”
“How do I know if I’m getting worse and need to go to the hospital?”

Response to Advice Given by the Candidate

If the candidate explains pneumonia clearly, you feel reassured but still ask about treatment.
If they recommend home management with antibiotics, you ask how long symptoms will last.
If they mention hospitalisation as an option, you ask what signs mean you should go to the hospital.
If they discuss vaccination, you ask if that will prevent this from happening again.
If the doctor is uncertain or doesn’t provide clear guidance, you push for more tests or a second opinion.

Final Thought

If the candidate explains pneumonia well, reassures you, and provides a structured management plan, you feel comfortable following their advice. If they are vague, dismissive, or fail to address your concerns about hospitalisation and recovery, you remain anxious and push for further tests or referral.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including symptom onset, risk factors, and red flag symptoms.

The competent candidate should:

Clarify key symptom details:
- Onset: Started as a mild cold five days ago, worsening over the past three days.
- Cough: Productive, yellow-green sputum, persistent, worsening.
- Shortness of breath: Worse on exertion, not yet at rest.
- Fever and chills: Feels hot, shivery at night.
- Fatigue and appetite loss: More tired than usual, reduced appetite.
Assess risk factors and red flags:
- Age ≥65 (higher risk for complications).
- History of asthma and mild COPD (increased susceptibility).
- No recent hospitalisation or antibiotic use.
- No recent travel or sick contacts.
Identify patient concerns:
- Worried about hospitalisation and recovery time.
- Unsure if antibiotics are needed.
- Wants to know how to prevent future infections.

Task 2: Identify key clinical features and order appropriate investigations to confirm the diagnosis.

The competent candidate should:

Recognise features of pneumonia:
- Productive cough, fever, worsening shortness of breath.
- History of asthma and COPD increasing susceptibility.
Differentiate from other conditions:
- COPD exacerbation: Less likely due to fever and sputum colour.
- Heart failure: Less likely as no leg swelling, PND, or orthopnoea.
- Pulmonary embolism: No pleuritic chest pain, no risk factors.
Order relevant investigations:
- Chest X-ray: Confirm consolidation, rule out other causes.
- Full blood count (FBC), CRP: Assess infection and inflammation.
- Sputum culture if severe symptoms.
- Oxygen saturation (SpO₂) to assess severity.

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

The competent candidate should:

Explain the diagnosis in simple terms:
- Likely pneumonia, a lung infection causing inflammation and mucus buildup.
- Not just a COPD flare-up, as fever and infection signs are present.
Discuss treatment options:
- If mild (able to manage at home): Oral antibiotics, fluids, rest.
- If moderate/severe (oxygen low, difficulty breathing at rest): Hospital admission.
Provide clear follow-up advice:
- Review in 48 hours if worsening.
- Return immediately for severe breathlessness, confusion, chest pain, worsening fever.
- Follow-up in 2-4 weeks after recovery.

Task 4: Develop a safe, evidence-based management plan, including antibiotic selection, supportive care, and hospital referral if necessary.

The competent candidate should:

For mild-moderate community-acquired pneumonia (CAP) (CURB-65 score 0-1):
- Amoxicillin 1g TDS for 5-7 days, OR Doxycycline 100mg BD if penicillin-allergic.
- Paracetamol for fever and pain relief.
- Increase fluid intake, rest, monitor symptoms.
For moderate-severe pneumonia (CURB-65 ≥2 or hypoxia):
- Consider hospital admission for IV antibiotics and oxygen support.
- Blood cultures if hospitalisation is required.
Preventive care:
- Pneumococcal and annual influenza vaccination.
- Optimise COPD/asthma management (ensure proper inhaler use).
- Encourage good hand hygiene and avoiding sick contacts.

SUMMARY OF A COMPETENT ANSWER

Takes a thorough history, identifying risk factors and red flags.
Orders appropriate investigations, including chest X-ray and blood tests.
Explains pneumonia clearly, reassuring the patient and outlining treatment.
Develops a structured management plan, including antibiotics, supportive care, and hospital referral if needed.
Provides clear follow-up instructions and preventive advice.

PITFALLS

Failing to differentiate pneumonia from COPD exacerbation, delaying treatment.
Not considering hospital admission for moderate/severe pneumonia.
Prescribing inappropriate antibiotics or incorrect duration.
Not providing clear safety net advice about when to seek urgent care.
Overlooking vaccination and preventive measures.

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 symptom onset, risk factors, and red flags.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises clinical features of pneumonia and differentiates from other respiratory conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan, including antibiotics, supportive care, and hospital referral if needed.

5. Preventive and Population Health

5.1 Provides education on pneumonia prevention, vaccination, and smoking cessation (if applicable).

6. Professionalism

6.1 Demonstrates patient-centred care and acknowledges the impact of pneumonia on daily life.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and referral if hospitalisation is required.

8. Procedural Skills

8.1 Performs or refers for relevant investigations, such as chest X-ray and sputum culture.

9. Managing Uncertainty

9.1 Recognises when symptoms require further observation or specialist input.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies cases requiring urgent intervention, such as sepsis or respiratory failure.

Competency at Fellowship Level

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