CASE INFORMATION

Case ID: CCE-2025-007
Case Name: Emily Johnson
Age: 27
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A98 (Microbiology/Immunology Test NOS)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages empathetically 1.2 Uses appropriate questioning techniques to explore symptoms and concerns 1.5 Provides clear explanations about test results and management
2. Clinical Information Gathering and Interpretation	2.1 Takes a comprehensive history relevant to immunological or infectious disease testing 2.2 Identifies red flags requiring further investigation
3. Diagnosis, Decision-Making and Reasoning	3.1 Interprets microbiology or immunology test results appropriately 3.3 Recognises the need for further investigations or specialist referral
4. Clinical Management and Therapeutic Reasoning	4.2 Develops a safe and patient-centred management plan 4.4 Balances watchful waiting, treatment, and follow-up strategies
5. Preventive and Population Health	5.3 Provides education on infection prevention and immune health
6. Professionalism	6.2 Manages patient anxiety and ensures appropriate follow-up of test results
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and communication of test results
9. Managing Uncertainty	9.2 Recognises when repeat testing or specialist referral is required
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises features of immunodeficiency or persistent infection requiring urgent management

CASE FEATURES

Young woman presenting for review of abnormal microbiology/immunology test results.
Recent history of recurrent infections and persistent fatigue.
Concerns about immune function and whether further testing is needed.
Discussion on possible underlying causes, including autoimmune conditions or primary immunodeficiency.
Need for appropriate investigations, lifestyle modifications, and specialist referral if indicated.

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 a physical 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 Johnson, a 27-year-old schoolteacher, has returned to discuss recent test results ordered due to recurrent infections and ongoing fatigue.

She has had three sinus infections and two episodes of bronchitis in the past year, requiring antibiotics. She also experiences fatigue, muscle aches, and occasional joint stiffness.

Her recent blood test results show:

Low immunoglobulin levels (IgG slightly below normal).
Negative HIV, hepatitis B/C serology.
Normal full blood count and inflammatory markers (CRP, ESR).

Her BP today is 118/75 mmHg, HR 72 bpm, and she appears well but anxious.

PATIENT RECORD SUMMARY

Patient Details

Name: Emily Johnson
Age: 27
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Oral contraceptive pill
Occasionally takes ibuprofen for headaches

Past History

No significant medical history

Family History

Mother has rheumatoid arthritis
No known history of primary immunodeficiency

Social History

Works as a schoolteacher, frequently exposed to children with infections.
No recent overseas travel.

Smoking & Alcohol

Non-smoker.
Drinks socially (1-2 glasses of wine per week).

Vaccination & Preventative Activities

Up to date on 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’m really worried about my immune system. Why do I keep getting sick?”

General Information

You are a 27-year-old schoolteacher who has been feeling run-down for about a year.
You’ve had several infections, including three sinus infections and two episodes of bronchitis, all requiring antibiotics.
You also experience fatigue, mild muscle aches, and occasional joint stiffness.

Specific Information

(Reveal Only When Asked)

Background Information

You are worried that your immune system is weak or that you might have an autoimmune disease.
You haven’t been tested for immune disorders before and aren’t sure what to expect.
You feel frustrated because your symptoms are affecting your daily life.

Symptoms & Infections

Timeline: Your symptoms have been ongoing for about a year.
Frequency: You have had at least five infections in the past 12 months.
Severity: Your infections require antibiotics, but you have never needed hospitalisation.
Other symptoms:
- No high fevers, night sweats, or unexplained weight loss.
- No persistent diarrhoea, mouth ulcers, or skin infections.
- No chronic cough or shortness of breath.
- No unusual rashes.

Family & Autoimmune History

Your mother has rheumatoid arthritis, which makes you concerned about an autoimmune disease.
You have never had joint swelling, prolonged morning stiffness, or Raynaud’s phenomenon.
No family history of lupus, multiple sclerosis, or primary immunodeficiency.

Lifestyle Factors & Stressors

Your job exposes you to sick children regularly.
You often feel stressed at work, which makes you feel more run-down.
You admit to not sleeping well lately due to work pressure.
Your diet is fairly balanced, but you don’t always eat enough fresh fruit and vegetables.
You drink 1–2 glasses of wine per week and don’t smoke.
No recent overseas travel or exposure to unusual infections.

Emotional Cues

Fear of Immune Deficiency

You ask: “Does this mean I have a weak immune system?”
If the doctor is vague, you press: “Should I see a specialist? I don’t want to keep getting sick.”

Worry About a Hidden Autoimmune Disease

You say: “My mum has rheumatoid arthritis. Could this be the start of something like that?”
If the doctor mentions further testing, you ask: “Are you thinking this could be serious?”

Frustration with Recurring Infections

You sigh and say: “It feels like I’m sick all the time. I just want to know why.”
If the doctor recommends lifestyle changes, you respond: “I already try to eat healthy, but it’s not helping.”

Uncertainty About Next Steps

If the doctor suggests monitoring, you ask: “How long should I wait before worrying?”
If a referral is mentioned, you ask: “What would a specialist do that we can’t do now?”

Key Questions for the Candidate

(Ask these naturally throughout the consultation, especially if the doctor hasn’t already addressed them.)

“What do my test results mean? Is this serious?”
“Why do I keep getting sick? Should I see a specialist?”
“Could this be an autoimmune disease? Should we do more tests?”
“What can I do to stop getting sick so often?”
“If my immune system is weak, will this be a lifelong problem?”

Possible Patient Reactions Based on the Candidate’s Response

If the Doctor Explains the Condition Clearly and Reassures You

You feel relieved and say: “So my immune system is working, but I just need to support it better?”
If lifestyle changes are suggested, you may ask: “Would taking vitamins help?”

If the Doctor is Too Dismissive or Vague

You become frustrated and say: “But what if we’re missing something serious?”
If the doctor avoids discussing your concerns about an autoimmune disease, you push back: “But my mum has arthritis. Couldn’t this be connected?”

If the Doctor Doesn’t Offer a Clear Plan

You ask: “So what do we do next? Just wait and see?”
If the doctor hesitates about further testing, you say: “I’d rather get tested now than worry for months.”

Role-Player’s Objective

Encourage the candidate to take a structured approach to discussing test results and exploring potential causes.
Assess whether the candidate can explain results clearly, avoiding unnecessary alarm while addressing concerns.
Determine if the candidate considers both primary and secondary causes of immune dysfunction.
Observe if the candidate provides a structured plan, including lifestyle measures, vaccination, and possible referral.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Explain the microbiology/immunology test results in an understandable way.

The competent candidate should:

Acknowledge the patient’s concerns and provide clear, empathetic communication about the test results.
Explain that the test results indicate slightly low immunoglobulin G (IgG) levels, but other markers, including HIV and hepatitis B/C serology, are negative.
Reassure the patient that a single low IgG result does not confirm an immune deficiency but warrants further assessment.
Explain that low IgG may be due to a variety of factors, including:
- Frequent infections or recent illness.
- Nutritional deficiencies.
- Chronic stress or lifestyle factors.
- Primary or secondary immunodeficiency (less likely but requires exclusion).
Outline the next steps, including additional testing, monitoring, and lifestyle modifications.

Task 2: Explore possible underlying causes, taking a relevant clinical history.

The competent candidate should:

Take a structured history, focusing on:
- Infection history: frequency, severity, need for hospitalisation, response to treatment.
- Autoimmune symptoms: joint pain, rashes, chronic diarrhoea, prolonged fevers.
- Family history of immune disorders or autoimmune diseases.
- Lifestyle factors: stress, diet, sleep quality, work exposure to infections.
- Vaccination history: response to childhood and adult vaccines (e.g., did past vaccines protect her?).
- Other medical conditions: history of allergies, asthma, or previous immune-related illnesses.
Identify any red flags that may indicate an underlying primary or secondary immune disorder, including:
- Recurrent deep-seated infections (e.g., pneumonia, sepsis).
- Chronic diarrhoea, weight loss, or malabsorption.
- Unusual or opportunistic infections.

Task 3: Outline an appropriate management plan, including further investigations and lifestyle advice.

The competent candidate should:

Plan further investigations based on findings, which may include:
- Repeat immunoglobulin levels (to assess persistence of low IgG).
- Vaccine response testing (e.g., pneumococcal and tetanus antibody levels).
- Lymphocyte subset analysis if significant immune dysfunction is suspected.
- Testing for coeliac disease or autoimmune conditions if symptoms suggest.
Discuss lifestyle modifications to optimise immune function:
- Adequate sleep and stress management.
- Balanced diet with sufficient vitamins (particularly vitamin D, zinc, iron).
- Regular physical activity and hydration.
- Smoking cessation if applicable.
Consider vaccinations, including pneumococcal and annual influenza vaccine, to enhance immune protection.
Arrange follow-up in 4–6 weeks to review any new infections, repeat blood tests, and assess the need for immunologist referral.

Task 4: Address the patient’s concerns, including the need for monitoring, treatment, and possible referral.

The competent candidate should:

Acknowledge the patient’s anxiety and provide balanced reassurance.
Explain that further monitoring is needed but that most mild IgG deficiencies do not lead to severe immune problems.
Discuss referral criteria, explaining that an immunologist may be involved if:
- Symptoms persist or worsen.
- Repeat tests confirm persistent IgG deficiency.
- The patient develops unusual or severe infections.
Empower the patient with education on infection prevention, lifestyle measures, and when to seek medical attention.
Offer written resources and encourage follow-up to reassess symptoms and test results.

SUMMARY OF A COMPETENT ANSWER

Explains test results clearly without unnecessary alarm.
Takes a structured history, including infections, autoimmune symptoms, and risk factors.
Identifies red flags that may indicate serious immune dysfunction.
Develops a structured management plan, including further tests, lifestyle changes, and monitoring.
Addresses patient concerns empathetically, explaining next steps and possible referrals.

PITFALLS

Failing to reassure the patient, leading to unnecessary anxiety.
Overlooking red flags such as unusual infections or weight loss.
Providing false reassurance without arranging appropriate follow-up.
Not considering autoimmune causes despite family history of rheumatoid arthritis.
Ignoring lifestyle factors that may be contributing to immune dysfunction.
Not explaining the need for repeat testing, leading to misunderstanding about diagnosis and management.

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

Competency Areas Assessed

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Uses appropriate questioning techniques to explore symptoms and concerns.
1.5 Provides clear explanations about test results and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history relevant to immunological or infectious disease testing.
2.2 Identifies red flags requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Interprets microbiology or immunology test results appropriately.
3.3 Recognises the need for further investigations or specialist referral.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops a safe and patient-centred management plan.
4.4 Balances watchful waiting, treatment, and follow-up strategies.

5. Preventive and Population Health

5.3 Provides education on infection prevention and immune health.

6. Professionalism

6.2 Manages patient anxiety and ensures appropriate follow-up of test results.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and communication of test results.

9. Managing Uncertainty

9.2 Recognises when repeat testing or specialist referral is required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises features of immunodeficiency or persistent infection requiring urgent management.

Competency at Fellowship Level

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