CCE-CE-115

CASE INFORMATION

Case ID: CCE-2025-009
Case Name: Olivia Bennett
Age: 29
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S06 (Rash)

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Establishes rapport and engages empathetically
1.2 Uses appropriate questioning techniques to explore symptoms and concerns
1.5 Provides clear explanations about diagnosis and management
2. Clinical Information Gathering and Interpretation2.1 Takes a detailed dermatological history
2.2 Identifies red flags requiring urgent intervention
3. Diagnosis, Decision-Making and Reasoning3.1 Differentiates between common and serious causes of rash
3.3 Recognises indications for further investigations or referral
4. Clinical Management and Therapeutic Reasoning4.2 Develops a safe and evidence-based management plan
4.4 Balances conservative and pharmacological treatment approaches
5. Preventive and Population Health5.3 Provides education on skin care, triggers, and when to seek further care
6. Professionalism6.2 Manages patient anxiety and ensures appropriate follow-up
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate documentation and communication of treatment plans
9. Managing Uncertainty9.2 Recognises when specialist referral is required (e.g., dermatologist for persistent or atypical rashes)
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies features of systemic illness requiring urgent management

CASE FEATURES

  • Young woman presenting with a new-onset rash.
  • History of recent antibiotic use, raising concern for drug reaction.
  • Concerns about whether the rash is serious or related to an allergy.
  • Requires differentiation between allergic, infectious, autoimmune, and other causes.
  • Needs education on symptom management, triggers, and red flag symptoms.

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:

  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 29-year-old office worker, presents with a widespread itchy rash that started two days ago.

She recently completed a course of amoxicillin for a sinus infection and is worried about an allergic reaction.

Her BP today is 118/72 mmHg, HR 78 bpm, and she appears well but anxious.

PATIENT RECORD SUMMARY

Patient Details

Name: Olivia Bennett
Age: 29
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Recently completed a 7-day course of amoxicillin for sinusitis

Past History

  • Mild asthma in childhood (no recent symptoms)
  • No history of eczema, psoriasis, or autoimmune diseases

Family History

  • Mother has hay fever and mild asthma
  • No family history of autoimmune or skin conditions

Social History

  • Works as an office administrator, no exposure to chemicals or irritants.

Smoking & Alcohol

  • Non-smoker.
  • Drinks 1-2 glasses of wine on weekends.

Vaccination & Preventative Activities

  • All routine vaccinations up to date.

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 itchy rash all over my body, and I’m really worried it’s an allergic reaction to my antibiotics.”

General Information

  • You are a 29-year-old office worker who developed a widespread, red, itchy rash that started two days ago.
  • The rash began on your torso and then spread to your arms and legs over the next 24 hours.
  • It feels warm and irritated, but not painful.

Specific Information

(Reveal Only When Asked)

  • You recently finished a 7-day course of amoxicillin for a sinus infection and are worried about an allergic reaction.
  • You have never had a reaction to antibiotics before.
  • You feel well otherwise, with no fever, no shortness of breath, and no swelling of your lips, face, or throat.
  • You are worried about whether this could happen again in the future and whether you should avoid antibiotics.

Rash Characteristics

  • The rash is red, blotchy, and itchy but not blistering, peeling, or painful.
  • It gets worse when you scratch and feels warm but not burning.
  • There are no raised wheals (hives), no pus, and no open sores.
  • You have no ulcers or sores in your mouth, eyes, or genitals.
  • No swelling of your lips, tongue, or face.

Recent Triggers & History

  • You recently finished amoxicillin for a sinus infection.
  • You have not changed soaps, detergents, or skincare products recently.
  • You have not eaten any new foods in the last few days.
  • You have a pet cat, but you’ve had it for years without problems.
  • No recent insect bites or exposure to new plants or chemicals.

Medical History & Family History

  • No history of eczema, psoriasis, or autoimmune diseases.
  • No asthma or hay fever, though your mother has mild asthma.
  • You had mild asthma as a child but have had no symptoms as an adult.
  • No family history of lupus, coeliac disease, or other autoimmune conditions.

Lifestyle & Work Factors

  • You work full-time in an office and have not been exposed to any chemicals or allergens.
  • You exercise regularly and eat a balanced diet.
  • You drink 1-2 glasses of wine on weekends but haven’t had alcohol since your antibiotics.
  • You don’t smoke.
  • No recent overseas travel.

Emotional Cues

Fear of a Severe Allergic Reaction

  • You ask: “Could this be a serious allergy? Will it get worse?”
  • If the doctor reassures you too quickly, you say: “But what if it happens again? Do I need an EpiPen?”

Concern About Recurrence & Work Impact

  • You sigh and say: “I just don’t want this to happen every time I take antibiotics.”
  • If the doctor suggests antihistamines, you ask: “Will I still be able to go to work?”

Worry About Long-Term Risks

  • You ask: “Should I avoid all antibiotics now, or just penicillin?”
  • If the doctor suggests waiting for the rash to clear, you respond: “But how will I know if it’s safe to take antibiotics in the future?”

Frustration About Symptoms

  • You rub your arm and say: “The itching is driving me crazy—I haven’t slept well the past two nights.”
  • If the doctor suggests avoiding scratching, you say: “I’ve tried, but it’s so hard not to scratch.”

Key Questions for the Candidate

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

  1. “What’s causing this rash? Is it from the antibiotics?”
  2. “Could this be something serious like Stevens-Johnson syndrome?”
  3. “Do I need to avoid all antibiotics now?”
  4. “How long will it take to go away, and what can I do to stop the itching?”
  5. “Could this happen again in the future?”

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, this is just a mild reaction, and I don’t need to panic?”
  • If the doctor suggests antihistamines, you say: “That makes sense. How long should I take them?”

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 specialist referral, you push back: “I don’t want to take any risks—should I see an allergy specialist?”

If the Doctor Doesn’t Offer a Clear Plan

  • You ask: “So what do I actually need to do to get better?”
  • If the doctor hesitates about medications, you say: “I just need something that will help with the itching.”

Role-Player’s Objective

  • Encourage the candidate to take a structured dermatological history, exploring onset, progression, and triggers.
  • Assess whether the candidate recognises red flags, such as blistering, mucosal involvement, or systemic symptoms.
  • Observe if the candidate provides a clear explanation about drug reactions and when to be concerned.
  • Determine if the candidate gives practical management advice, including itch relief, follow-up, and antibiotic precautions.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a structured dermatological history, including onset, progression, associated symptoms, and triggers.

The competent candidate should:

  • Establish rapport and acknowledge the patient’s concern about an allergic reaction.
  • Take a structured dermatological history, including:
    • Onset and progression: When did the rash start? Has it spread or changed?
    • Associated symptoms: Itching, pain, swelling, fever, shortness of breath, mucosal involvement.
    • Triggers: Recent medications (amoxicillin), infections, food, skincare products, chemicals.
    • Past medical history: History of eczema, psoriasis, allergies, asthma, autoimmune disease.
    • Family history: Presence of allergic conditions, autoimmune diseases, or recurrent rashes.
    • Systemic symptoms: Fatigue, weight loss, joint pain, oral ulcers (concern for systemic illness).
    • Social & occupational factors: Recent travel, work-related exposures, pet contact.
  • Identify red flags:
    • Blistering, skin peeling, mucosal involvement → urgent review for Stevens-Johnson syndrome (SJS).
    • Facial/lip swelling, wheezing, or difficulty breathing → anaphylaxis risk, immediate emergency care.

Task 2: Explain the likely diagnosis and need for further investigations if required.

The competent candidate should:

  • Explain the most likely diagnosis in simple terms:
    • This rash is consistent with a delayed (non-IgE-mediated) hypersensitivity reaction to amoxicillin.
    • It is not an immediate anaphylactic reaction but still indicates amoxicillin should be avoided in the future.
  • Differentiate between possible causes:
    • Drug reaction (most likely): Delayed onset, non-blistering, itchy, widespread.
    • Viral exanthem: Can mimic a drug rash but often occurs with systemic viral symptoms.
    • Autoimmune rash: Less likely given no history of lupus, psoriasis, or connective tissue disease.
  • Explain when further investigations are needed:
    • If blistering, peeling, mucosal involvement → urgent referral to hospital/dermatology.
    • If systemic symptoms (joint pain, fever, weight loss) → consider autoimmune or haematological causes.
    • If uncertain cause or recurrent reactions → referral for allergy testing.

Task 3: Outline your management plan, including symptomatic relief and follow-up.

The competent candidate should:

  • Provide immediate symptom relief:
    • Oral antihistamines (e.g., loratadine, cetirizine) to reduce itching.
    • Topical corticosteroids (e.g., hydrocortisone, betamethasone for more severe cases) for local inflammation.
    • Paracetamol for general discomfort (avoid NSAIDs if uncertain about the cause).
  • Advise on skin care:
    • Avoid scratching to prevent secondary infection.
    • Use gentle, fragrance-free moisturisers (e.g., sorbolene, QV cream).
    • Cool compresses and oatmeal baths for relief.
  • Discuss medication precautions:
    • Avoid all penicillin-based antibiotics (consider referral for allergy testing if future antibiotic use is a concern).
    • If future antibiotics are needed, recommend clarifying allergies with a doctor first.
  • Plan follow-up:
    • Review in 48–72 hours if symptoms persist or worsen.
    • If rash resolves but the patient remains concerned about allergies, consider referral for formal allergy testing.

Task 4: Address the patient’s concerns, particularly about allergies, recurrence, and work implications.

The competent candidate should:

  • Acknowledge the patient’s anxiety about future antibiotic reactions.
  • Explain that this reaction is not life-threatening but amoxicillin should be avoided in the future.
  • Reassure that most drug rashes resolve within 1–2 weeks without complications.
  • Discuss the likelihood of recurrence:
    • This reaction suggests penicillin sensitivity but does not mean all antibiotics are unsafe.
    • Consider allergy testing before future antibiotic prescriptions if the patient is very concerned.
  • Address work concerns:
    • The rash itself is not contagious, and she can continue working.
    • If itching is severe, discuss taking an antihistamine at night to avoid daytime drowsiness.
  • Discuss red flags for urgent care:
    • If rash worsens, blisters, peels, or involves the mouth/eyes, seek immediate medical review.

SUMMARY OF A COMPETENT ANSWER

  • Takes a comprehensive dermatological history, focusing on onset, progression, triggers, and red flags.
  • Explains the likely cause clearly, differentiating between drug reaction, viral rash, and autoimmune causes.
  • Recognises red flags requiring urgent care, including blistering, mucosal involvement, or systemic symptoms.
  • Develops a structured management plan, including antihistamines, skin care, and follow-up.
  • Addresses the patient’s concerns about antibiotic allergies, work, and future recurrence.

PITFALLS

  • Failing to assess for red flags, such as mucosal involvement (SJS) or anaphylaxis risk.
  • Overprescribing medications, such as antibiotics or NSAIDs, without clear indication.
  • Not providing education on penicillin avoidance, leading to future risk of severe reactions.
  • Neglecting patient concerns, particularly work impact, recurrence, and long-term implications.
  • Providing false reassurance without follow-up, missing worsening reactions requiring urgent care.

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 diagnosis and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a detailed dermatological history.
2.2 Identifies red flags requiring urgent intervention.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common and serious causes of rash.
3.3 Recognises indications for further investigations or referral.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops a safe and evidence-based management plan.
4.4 Balances conservative and pharmacological treatment approaches.

5. Preventive and Population Health

5.3 Provides education on skin care, triggers, and when to seek further care.

6. Professionalism

6.2 Manages patient anxiety and ensures appropriate follow-up.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and communication of treatment plans.

9. Managing Uncertainty

9.2 Recognises when specialist referral is required (e.g., dermatologist for persistent or atypical rashes).

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies features of systemic illness requiring urgent management.

Competency at Fellowship Level

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