CCE-CE-129

CASE INFORMATION

Case ID: IMP-003
Case Name: Liam O’Connor
Age: 6 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S84 – Impetigo​

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the parent to understand concerns, ideas, and expectations
1.2 Provides clear explanations tailored to the parent’s level of health literacy
1.4 Uses effective consultation techniques, including active listening and empathy
2. Clinical Information Gathering and Interpretation2.1 Takes a focused history to explore symptom onset, progression, and risk factors
2.2 Selects appropriate investigations based on clinical presentation
3. Diagnosis, Decision-Making and Reasoning3.1 Develops a differential diagnosis for skin lesions
3.2 Identifies potential red flags indicating serious underlying conditions
4. Clinical Management and Therapeutic Reasoning4.1 Develops a safe and effective management plan
4.2 Provides advice on pharmacological and non-pharmacological management
5. Preventive and Population Health5.1 Discusses hygiene, prevention of spread, and school exclusion criteria
6. Professionalism6.1 Maintains patient confidentiality and demonstrates ethical practice
7. General Practice Systems and Regulatory Requirements7.1 Documents accurately and ensures appropriate follow-up
9. Managing Uncertainty9.1 Provides reassurance and safety-netting when the diagnosis is unclear
10. Identifying and Managing the Patient with Significant Illness10.1 Recognises features suggestive of complications requiring escalation of care

CASE FEATURES

  • Paediatric case involving a common but highly contagious skin infection
  • Parent’s concern about the child’s rash, possible school exclusion, and treatment
  • Addressing differential diagnoses, including eczema, herpes simplex, and scabies
  • Focus on communication, particularly parent education about hygiene and treatment adherence
  • Management based on Australian guidelines, including topical vs oral antibiotics

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

Liam O’Connor, a 6-year-old boy, is brought in by his mother due to a rash around his mouth and nose. The rash started four days ago as small red spots, which have now formed honey-coloured crusts. His mother is concerned because the rash is spreading and some of the spots are oozing.

PATIENT RECORD SUMMARY

Patient Details

Name: Liam O’Connor
Age: 6 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • No known drug allergies

Medications

  • Nil regular medications

Past History

  • No history of eczema or skin conditions
  • No previous episodes of impetigo

Social History

  • Lives with both parents and a 3-year-old sister

Family History

  • No family history of significant dermatological conditions
  • Sibling has had occasional mild eczema

Smoking

  • Non-exposure (parents are non-smokers)

Vaccination and Preventative Activities

  • Up to date with childhood vaccinations, including MMR and varicella

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 this rash on Liam’s face. It started a few days ago, and now it’s getting worse. Do you think it’s serious?”

General Information

  • Liam is a 6-year-old boy who has developed a rash around his nose and mouth over the past four days.
  • The rash started as small red spots, which then formed blisters and crusts.
  • The crusts are honey-coloured, and the rash has been spreading, now appearing on his chin and one cheek.
  • The rash doesn’t seem painful, but Liam scratches it occasionally.

Specific Information

(Reveal only when asked directly)

Background Information

  • He is otherwise well, with no fever, lethargy, or loss of appetite.
  • The mother hasn’t noticed any similar rashes on other family members, but she’s seen a few children at Liam’s school with similar skin issues recently.
  • No history of eczema or other skin conditions.
  • The family has a cat and a dog, but neither has any visible skin issues.

Rash Characteristics

  • The rash started near the nose before spreading to the mouth, chin, and cheek.
  • The lesions began as red spots, turned into blisters, and then crusted over with a yellow, flaky layer.
  • Some of the crusted areas appear moist, with occasional oozing.
  • Liam scratches at the rash, but says it doesn’t hurt much.
  • No swelling, bleeding, or pus-like discharge beyond the expected crusting.

Risk Factors

  • Liam has been attending school as usual, and his mother thinks he may have caught this from classmates.
  • He often touches his face and doesn’t always wash his hands properly after playing.
  • The family has a 3-year-old sibling at home, and the mother is concerned about her catching it.
  • No recent travel, no new skincare products or soaps.

Concerns and Expectations

  • The mother is worried about the rash spreading further or leaving scars on Liam’s face.
  • She wants to know if Liam needs antibiotics or if it will go away on its own.
  • She is concerned about how long Liam will need to stay home from school.
  • She wants to prevent her younger child from catching it and is asking for hygiene advice.
  • She’s unsure if the rash needs any special cleaning or treatment at home.

Red Flag Symptoms (Reveal only when asked directly)

  • No swelling around the eyes or lips.
  • No high fever, chills, or feeling unwell.
  • No painful sores inside the mouth.
  • No history of previous similar rashes.
  • No recent insect bites or injuries to the area before the rash appeared.

Emotional Cues & Body Language

  • The mother is concerned but not panicked.
  • She leans forward slightly, watching the doctor closely, expecting a clear diagnosis.
  • If the doctor gives vague answers, she might press further: “But if this is bacterial, shouldn’t he take antibiotics?”
  • If the doctor explains things well, she relaxes a little but still seeks confirmation about school exclusion and hygiene measures.
  • If the doctor suggests a wait-and-see approach, she might look doubtful and say, “But I don’t want this to get worse—are you sure it won’t spread more?”
  • If the doctor does not address prevention, she will ask, “What if my 3-year-old catches this? How do I stop that?”

Questions for the Candidate

(Ask these naturally throughout the consultation.)

  1. “Is this contagious? Should I keep him away from his sister?”
  2. “How long does he need to stay home from school?”
  3. “Will this leave scars on his face?”
  4. “Does he need antibiotics, or can it go away on its own?”
  5. “How can I stop it from spreading?”
  6. “Should I clean the sores with anything?”
  7. “Is there anything we should change at home, like washing his clothes separately?”
  8. “If my daughter gets a rash, should I bring her in straight away?”

Key Behaviours & Approach

  • The parent expects a clear diagnosis and management plan.
  • If the doctor fails to address prevention, she will ask questions about hygiene and household measures.
  • If the doctor minimises her concerns, she may say, “But it’s spreading! How do I know it won’t get worse?”
  • If the doctor explains things well, she will be reassured and willing to follow the treatment plan.
  • If the doctor recommends antibiotics, she may ask, “Are there any side effects? Will this make him resistant to antibiotics in the future?”
  • If the doctor recommends just topical treatment, she might ask, “Are you sure a cream is enough? How long before I see an improvement?”

Additional Context for the Role-Player

  • You trust doctors, but you want thorough explanations.
  • You are a proactive parent and want to ensure your child gets the best care possible.
  • You are willing to follow medical advice, but you expect clear guidance on treatment and prevention.
  • If the doctor suggests natural remedies or non-antibiotic options, you may ask, “Is that really enough? What if it doesn’t clear up?”
  • You don’t want to overuse antibiotics, but you also don’t want to risk complications.
  • You have no medical background, so you prefer simple, straightforward explanations without too much jargon.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the parent, considering possible causes of the rash.

The competent candidate should:

  • Use open-ended questions to allow the parent to describe the rash’s onset, progression, and associated symptoms.
  • Establish key characteristics of the rash: initial appearance, presence of blisters or crusting, colour, spread, and any associated discomfort or itchiness.
  • Assess for systemic symptoms (fever, malaise, lymphadenopathy) that may suggest complications or an alternative diagnosis.
  • Obtain a contact history, particularly exposure to other children with similar symptoms.
  • Investigate risk factors, such as poor hygiene, minor skin injuries, insect bites, or underlying conditions like eczema.
  • Ask about treatments tried at home, including creams, antiseptics, or antibiotics.
  • Explore parental concerns, including worries about scarring, school exclusion, or spread within the household.

Task 2: Formulate a differential diagnosis and explain it to the parent.

The competent candidate should:

  • Provide a structured differential diagnosis, including:
    • Impetigo (most likely): Superficial bacterial infection with characteristic honey-coloured crusting.
    • Herpes simplex virus (HSV): Painful vesicles with clear fluid, often recurrent.
    • Hand, foot, and mouth disease: Vesicular rash in the mouth, hands, and feet, often with systemic symptoms.
    • Eczema with secondary infection: Background dry, scaly skin with superimposed bacterial infection.
    • Scabies or insect bites: Itchy lesions with possible secondary infection.
  • Clearly communicate that impetigo is the most likely diagnosis based on the clinical presentation.
  • Explain why other conditions are less likely and which features to monitor for alternative diagnoses.

Task 3: Address the parent’s concerns empathetically and discuss school exclusion.

The competent candidate should:

  • Acknowledge and validate the parent’s concerns about the rash worsening or leaving scars.
  • Explain that impetigo is highly contagious but treatable, with most cases resolving without scarring if treated promptly.
  • Outline school exclusion recommendations:
    • Children should remain home until 24 hours after starting appropriate antibiotic treatment.
    • Reinforce the importance of hygiene measures to reduce further spread.
  • Provide safety-netting advice, including signs of worsening infection (e.g., fever, swelling, pus, or spreading redness).

Task 4: Develop an initial management plan, including treatment, prevention, and follow-up.

The competent candidate should:

  • Recommend first-line treatment based on Australian guidelines:
    • Topical antibiotics (mupirocin 2% ointment) for localised mild cases.
    • Oral antibiotics (flucloxacillin or cephalexin) for extensive or recurrent impetigo.
  • Provide hygiene advice:
    • Keep nails short to prevent scratching.
    • Clean affected areas with warm water and mild soap.
    • Avoid sharing towels, pillows, or clothing.
  • Discuss school return, ensuring the child is treated for at least 24 hours before resuming attendance.
  • Arrange follow-up in one week if symptoms persist or worsen.
  • Advise the parent when to seek urgent medical attention, such as spreading redness, fever, or signs of cellulitis.

SUMMARY OF A COMPETENT ANSWER

  • Thorough history-taking covering rash progression, systemic symptoms, contact history, and risk factors.
  • Clear, structured differential diagnosis with impetigo as the leading cause, and discussion of alternative possibilities.
  • Empathetic communication addressing concerns about spread, scarring, and school exclusion.
  • Evidence-based management plan including antibiotics, hygiene measures, and prevention strategies.
  • Appropriate safety-netting and follow-up to ensure resolution and prevent complications.

PITFALLS

  • Failing to consider differential diagnoses, such as herpes simplex or eczema.
  • Not addressing school exclusion, leaving parents unclear about when the child can return.
  • Overprescribing oral antibiotics when topical treatment alone would be sufficient.
  • Not providing hygiene and prevention advice, increasing the risk of household transmission.
  • Neglecting safety-netting, missing potential complications like cellulitis or systemic infection.

REFERENCES

MARKING

Each competency area is assessed 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 parent’s concerns and sociocultural context.
1.2 Engages the parent to gather information about symptoms, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Elicits a comprehensive history focused on skin infection and risk factors.
2.2 Orders appropriate investigations only if necessary, considering clinical diagnosis.

3. Diagnosis, Decision-Making and Reasoning

3.1 Develops a structured differential diagnosis for skin rashes in children.
3.2 Identifies red flags requiring further assessment.

4. Clinical Management and Therapeutic Reasoning

4.1 Formulates an evidence-based treatment plan, using topical or oral antibiotics appropriately.
4.2 Provides pharmacological and non-pharmacological treatment options.

5. Preventive and Population Health

5.1 Discusses hygiene measures and strategies to reduce transmission.

6. Professionalism

6.1 Maintains confidentiality and ethical decision-making.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures accurate documentation and appropriate follow-up.

9. Managing Uncertainty

9.1 Provides reassurance and safety-netting when the diagnosis is unclear.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises potential complications requiring escalation.

Competency at Fellowship Level

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