CASE INFORMATION

Case ID: PHT-001
Case Name: Sarah Thompson
Age: 45
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Code: K94 – Phlebitis/Thrombophlebitis

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their concerns and expectations. 1.2 Demonstrates active listening and empathy. 1.4 Explains diagnosis and management in a patient-centred manner.
2. Clinical Information Gathering and Interpretation	2.1 Takes a comprehensive history, including risk factors for venous thromboembolism. 2.2 Identifies red flags requiring further investigation.
3. Diagnosis, Decision-Making and Reasoning	3.1 Establishes a working diagnosis based on history and examination findings. 3.2 Differentiates between superficial thrombophlebitis and deep vein thrombosis.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan. 4.5 Provides pharmacological and non-pharmacological recommendations. 4.7 Uses shared decision-making to address concerns.
5. Preventive and Population Health	5.1 Identifies and manages modifiable risk factors for thrombophlebitis. 5.2 Provides patient education on prevention of recurrent episodes.
6. Professionalism	6.2 Provides reassurance and addresses patient concerns sensitively.
7. General Practice Systems and Regulatory Requirements	7.1 Documents history, investigations, and management plan appropriately.
9. Managing Uncertainty	9.3 Recognises when further imaging or specialist referral is required.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies when superficial thrombophlebitis may be associated with an underlying deep vein thrombosis (DVT).

CASE FEATURES

Middle-aged woman presenting with a red, tender, swollen area over a varicose vein.
Recent history of long-haul travel, increasing risk of venous thromboembolism (VTE).
Needs differentiation between superficial thrombophlebitis and deep vein thrombosis (DVT).
Patient concerned about possible complications, including pulmonary embolism (PE).
Requires discussion on risk reduction strategies and management options.

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

Sarah Thompson, a 45-year-old office worker, presents with a painful, red, and swollen area on her right lower leg over a varicose vein. The symptoms started three days ago and have gradually worsened. She describes the area as tender and warm but denies fever, chills, or generalised leg swelling.

Her observations today are:

BP: 122/80 mmHg
HR: 78 bpm, regular
Temp: 36.7°C
RR: 16 breaths/min
Oxygen saturation: 99% on room air

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Thompson
Age: 45
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Combined oral contraceptive pill (OCP) – for contraception and menstrual regulation

Past History

Varicose veins
No previous DVT, PE, or known clotting disorders

Social History

Occupation: Office worker – mostly sedentary
Smoking: Non-smoker
Alcohol: Occasional (1-2 drinks per week)
Exercise: Infrequent, mostly walking

Family History

Mother: Varicose veins
Father: Hypertension

Vaccination and Preventative Activities

Influenza vaccine – up to date
No recent cardiovascular risk screening

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 SCRIPTS

Opening Line

“Doctor, I’ve noticed this red, painful patch on my leg, and I’m worried it could be a clot.”

General Information

You are a 45-year-old office worker and generally in good health.
Three days ago, you noticed a red, tender area on your right lower leg, over a varicose vein that has been there for years.
The area has become progressively more painful and feels warm and slightly swollen.

Specific Information

(Only Provide If Asked)

Background Information

You returned from a 14-hour flight one week ago and were seated for most of the journey.
You have never had a blood clot before and don’t have any family history of clotting disorders.
You have been on the combined oral contraceptive pill (OCP) for 15 years, mainly for contraception and menstrual regulation.
You are concerned that this might be a serious clot and want to know if you need tests or treatment.

Symptoms and Red Flags

The pain is localised, and you don’t feel any generalised swelling in the whole leg.
The affected area is firm and warm, but the pain is only in one small section of your leg.
You have no fever, chills, or night sweats.
You have no chest pain or shortness of breath.
You have no sudden, severe swelling in the entire leg.

Lifestyle and Functional Impact

You work in an office job, sitting at a desk most of the day.
You do some walking, but you don’t have a regular exercise routine.
You don’t wear compression stockings, but you’ve heard about them.
You tend to cross your legs a lot while sitting.
You don’t drink much water during the day, especially when travelling.

Medical History and Risk Factors

You have varicose veins, but they have never been painful or problematic before.
You don’t have a history of DVT or pulmonary embolism.
You have been taking the OCP long-term, but you are not sure if it increases your risk of clots.
You have no known clotting disorders.
You are a non-smoker and drink 1-2 alcoholic drinks per week.

Emotional and Psychological State

You are worried that this could be serious, especially after your long flight.
You are concerned about whether this could spread or lead to a pulmonary embolism (PE).
You feel anxious because you don’t know whether this needs urgent medical attention.
You are worried about long-term risks, including recurrence or needing blood thinners.

Concerns & Expectations

You want to know if this could be a deep vein thrombosis (DVT).
You want to know if you need an ultrasound or blood test to confirm the diagnosis.
You are unsure about the difference between superficial thrombophlebitis and a DVT.
You are wondering if you need to stop taking the pill to reduce your risk.
You want to know what you can do to prevent this from happening again.
You have heard about compression stockings but don’t know if they are helpful.

Possible Questions for the Candidate

“Do I need an ultrasound or blood test?”
“Could this spread and cause a more serious clot?”
“What’s the difference between this and a DVT?”
“Should I stop taking the pill?”
“How can I prevent this from happening again?”
“Do I need to wear compression stockings?”
“Could this be dangerous if left untreated?”
“Would blood thinners help with this?”

How to Respond to the Candidate’s Explanations

If the Candidate Explains That This Is Likely Superficial Thrombophlebitis:

“So does that mean it’s not serious?”
“How do you know it’s not a DVT?”

If the Candidate Recommends Conservative Treatment (e.g., NSAIDs, Compression Stockings):

“Will just taking ibuprofen really be enough?”
“Do I need to rest, or should I keep walking?”

If the Candidate Suggests Further Investigations:

“What kind of tests would show if this is serious?”
“Would an ultrasound definitely rule out a clot?”

If the Candidate Mentions the Role of the OCP in Clot Risk:

“Should I stop taking the pill now?”
“Are there safer options for contraception?”

If the Candidate Discusses Prevention Strategies:

“What can I do on flights to prevent this?”
“Would wearing compression stockings every day help?”

Role-Playing Tips for the Candidate Assessment

You are anxious but not panicked. You are seeking clear, factual information.
You want reassurance but also a thorough assessment. You are not dismissive of the risks.
If the candidate dismisses your concerns too quickly, push back. Ask, “But how do we know this isn’t more serious?”
If the candidate recommends lifestyle changes, express some doubt. Ask, “Will walking more actually make a difference?”
If the candidate doesn’t explain the condition well, ask for clarification. “Can you explain exactly what’s happening in my vein?”

Final Line (If the Candidate Handles the Case Well)

“Thanks, Doctor. I feel more reassured now. I’ll try the anti-inflammatories and compression stockings, and I’ll come back if it gets worse. I’ll also think about whether I should change my contraception.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including risk factors for thrombophlebitis and venous thromboembolism.

The competent candidate should:

Establish rapport and ensure a patient-centred discussion to explore concerns and expectations.
Take a detailed symptom history, including:
- Onset, duration, and progression of redness, pain, swelling.
- Associated symptoms, such as fever, generalised leg swelling, or systemic symptoms.
- Recent travel, immobility, or trauma to the leg.
Assess risk factors for venous thromboembolism (VTE):
- Personal or family history of DVT or pulmonary embolism (PE).
- Use of the combined oral contraceptive pill (OCP).
- Varicose veins, obesity, or malignancy.
- Recent long-haul travel or prolonged immobility.
Screen for red flags suggesting deep vein thrombosis (DVT) or pulmonary embolism (PE):
- Calf swelling >3 cm compared to the other leg.
- Sudden onset breathlessness, pleuritic chest pain, or haemoptysis.
- New onset unilateral leg pain with tenderness over the deep veins.
Address the patient’s concerns about potential complications, including DVT, PE, or long-term risks.

Task 2: Discuss your differential diagnosis and outline an initial management plan.

The competent candidate should:

Explain that the most likely diagnosis is superficial thrombophlebitis (STP), given:
- Localised redness, warmth, and tenderness over a varicose vein.
- No significant leg swelling, systemic symptoms, or severe pain.
Differentiate between:
- Superficial thrombophlebitis (STP) – self-limiting, localised inflammation, low risk of embolism.
- Deep vein thrombosis (DVT) – significant swelling, tenderness along deep veins, risk of PE.
- Cellulitis – spreading erythema, systemic symptoms.
Explain the initial management plan, including:
- Pain relief – NSAIDs (e.g., ibuprofen) to reduce inflammation.
- Compression therapy – stockings to improve venous circulation.
- Encouraging mobility – avoiding prolonged immobility.
- Monitoring for worsening symptoms – new swelling, increasing pain, systemic symptoms.
Discuss when investigations are warranted:
- DVT unlikely if localised symptoms and no high-risk factors.
- Consider venous ultrasound if symptoms are extensive or there is concern about a concurrent DVT.

Task 3: Address the patient’s concerns about potential complications and long-term management.

The competent candidate should:

Reassure the patient that superficial thrombophlebitis (STP) is generally a mild condition and does not usually lead to serious complications.
Explain that the risk of progression to DVT is low but must be monitored.
Address concerns about long-term recurrence by discussing:
- Risk reduction strategies, including weight management and regular movement.
- The role of compression stockings in preventing recurrence.
- Consideration of OCP alternatives if ongoing risk factors are present.
Provide clear safety-netting advice:
- Seek urgent care if: increasing leg swelling, worsening pain, breathlessness, or chest pain.
- Follow up if symptoms persist beyond 2-4 weeks.

Task 4: Develop a comprehensive management plan, including investigations, pharmacological and non-pharmacological interventions, and prevention strategies.

The competent candidate should:

Non-pharmacological management:
- Encourage mobility to prevent venous stasis.
- Apply warm compresses to relieve pain.
- Wear compression stockings to improve circulation.
Pharmacological treatment:
- NSAIDs (ibuprofen, diclofenac) for pain and inflammation.
- Consider low-molecular-weight heparin (LMWH) if extensive involvement or high risk of DVT.
Consider further investigations if:
- Symptoms extend beyond the superficial veins.
- The patient has high-risk features for DVT (e.g., prior history, strong family history).
- There is clinical uncertainty.
Preventive strategies:
- Regular movement and leg exercises, especially during long flights.
- Compression stockings in high-risk individuals.
- OCP review – consider alternatives if thrombosis risk is a concern.
Arrange follow-up in 1-2 weeks to reassess symptoms and ensure no progression to DVT.

SUMMARY OF A COMPETENT ANSWER

Takes a thorough history, covering risk factors, symptoms, and red flags.
Differentiates between superficial thrombophlebitis and DVT, ensuring appropriate management.
Provides a structured management plan, including pain relief, compression therapy, and preventive strategies.
Addresses patient concerns, including potential complications and long-term prevention.
Uses shared decision-making, particularly regarding contraception and lifestyle modifications.
Provides clear safety-netting and follow-up recommendations.

PITFALLS

Failing to assess red flags (e.g., severe swelling, breathlessness, signs of PE).
Over-investigating – ordering venous ultrasound unnecessarily in a low-risk patient.
Underestimating the patient’s concerns – dismissing the risk of recurrence or progression.
Not addressing modifiable risk factors, such as OCP use and prolonged immobility.
Neglecting to explain the difference between STP and DVT, leaving the patient uncertain.
Failing to provide clear safety-netting advice, potentially missing serious complications.

REFERENCES

MARKING

Each competency area is rated 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 Engages the patient to understand their concerns and expectations.
1.2 Demonstrates active listening and empathy.
1.4 Explains diagnosis and management in a patient-centred manner.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history, including risk factors for venous thromboembolism.
2.2 Identifies red flags requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Establishes a working diagnosis based on history and examination findings.
3.2 Differentiates between superficial thrombophlebitis and deep vein thrombosis.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.5 Provides pharmacological and non-pharmacological recommendations.
4.7 Uses shared decision-making to address concerns.

Competency at Fellowship Level

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