CCE-CE-133

CASE INFORMATION

Case ID: URT-007
Case Name: Sarah Thompson
Age: 29 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: S98 – Urticaria​

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to understand concerns, ideas, and expectations
1.2 Provides clear explanations tailored to the patient’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, triggers, and risk factors
2.2 Selects appropriate investigations based on clinical presentation
3. Diagnosis, Decision-Making and Reasoning3.1 Develops a differential diagnosis for acute and chronic urticaria
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 avoidance of triggers and lifestyle modifications
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 anaphylaxis or underlying systemic disease requiring escalation

CASE FEATURES

  • Young adult presenting with recurrent itchy, raised skin welts.
  • Exploring potential triggers (foods, medications, stress, infections).
  • Differentiating between acute and chronic urticaria.
  • Assessing for signs of anaphylaxis or systemic illness.
  • Discussing antihistamines, trigger avoidance, and lifestyle measures.
  • Addressing patient anxiety about recurrence and long-term effects.

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

Sarah Thompson, a 29-year-old teacher, presents with itchy red welts (hives) appearing on her arms, legs, and torso for the past four days. The welts appear suddenly, last a few hours, then fade, but new ones keep appearing.

She has never had anything like this before and is worried about a serious allergy. She denies any breathing difficulties, throat swelling, or wheezing.

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Thompson
Age: 29
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • No known drug allergies

Medications

  • Started a new multivitamin last week
  • Occasionally takes ibuprofen for headaches

Past History

  • No known history of asthma, eczema, or autoimmune diseases

Social History

  • Works as a teacher, high stress due to workload

Family History

  • No family history of allergies or autoimmune diseases

Smoking

  • Non-smoker

Alcohol

  • Drinks socially, 1-2 times per week

Vaccination and Preventative Activities

  • Up to date with 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’ve been getting these really itchy welts all over my arms and legs for the past few days. They come and go, but it’s driving me crazy. What’s causing this?”

General Information

  • You are Sarah Thompson, a 29-year-old teacher.
  • You have never had skin issues before, and this rash is new and worrying.
  • The itchy red welts (hives) started four days ago and keep coming and going.

Specific Information

(Reveal only when asked directly)

Background Information

  • The welts appear suddenly, last for a few hours, and then fade away without leaving a mark, but new ones keep appearing elsewhere.
  • They mostly affect your arms, legs, and torso, and they feel hot and itchy but not painful.
  • You are feeling frustrated and uncomfortable due to the constant itching.

Rash Characteristics

  • The welts are raised, red, and irregular in shape, with some merging together into larger patches.
  • The rash is worse at night and after a hot shower.
  • You haven’t noticed any pus, scaling, or bruising.
  • Scratching the rash seems to make it worse, and sometimes new ones appear when you scratch nearby skin.

Associated Symptoms

  • You do not have fever, joint pain, or any flu-like symptoms.
  • You have not had any difficulty breathing, no swelling of the lips, throat, or tongue, no dizziness or fainting episodes.
  • Your appetite is normal, and you haven’t lost weight unintentionally.

Possible Triggers

  • You have not changed your soap, detergent, or skincare products recently.
  • You started a new multivitamin last week.
  • You had takeaway food the night before the symptoms started (fried chicken and chips).
  • You occasionally take ibuprofen for headaches, but not recently.
  • You have been under a lot of stress at work over the past month.

Concerns and Expectations

  • You are worried about this being a sign of a serious allergy.
  • You are concerned that it will keep happening or that it might become permanent.
  • You want to know if this could get worse and if you need an EpiPen.
  • You are wondering if you need an allergy test or if you should stop taking your multivitamin.
  • You are frustrated by the itching and discomfort and want a treatment that works quickly.

Red Flag Symptoms (Reveal only when asked directly)

  • No difficulty breathing or swallowing.
  • No swelling of the face, lips, tongue, or throat.
  • No dizziness, confusion, or loss of consciousness.
  • No blood or pus from the rash.

Emotional Cues & Body Language

  • You are mildly anxious but trying to remain calm and logical.
  • If the doctor seems uncertain or dismissive, you will become more worried and may ask:
    • “Are you sure this isn’t something serious?”
  • If the doctor explains things well, you relax but still want reassurance about recurrence.
  • If the doctor only prescribes medication without discussing lifestyle changes, you may ask:
    • “But what caused this? How do I stop it from happening again?”

Questions for the Candidate

(Ask these naturally throughout the consultation.)

  1. “Could this be a serious allergy? Should I get tested?”
  2. “Why does this keep coming back even though I haven’t eaten anything different?”
  3. “Do I need an EpiPen?”
  4. “Is there anything I can do to stop the itching?”
  5. “Will this go away on its own?”
  6. “Should I stop taking the multivitamin?”
  7. “Does stress really cause this?”
  8. “If this happens again, do I need to come back?”

Key Behaviours & Approach

  • You expect clear answers and reassurance.
  • If the doctor doesn’t discuss triggers, you will ask about what might have caused this.
  • If the doctor suggests chronic urticaria, you may ask:
    • “Does this mean I’ll have this forever?”
  • If the doctor focuses only on antihistamines without prevention strategies, you may ask:
    • “So what do I do if this happens again?”
  • If the doctor mentions stress as a factor, you may sound doubtful and say:
    • “I don’t see how stress could cause this—I’ve been stressed before, and this never happened.”

Additional Context for the Role-Player

  • You trust doctors but want practical advice rather than just being told to take medication.
  • You are open to lifestyle changes if they make sense.
  • You will follow medical advice if it is well explained.
  • If the doctor provides a clear explanation and plan, you will feel reassured and motivated to follow their recommendations.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, considering possible causes and risk factors for urticaria.

The competent candidate should:

  • Use open-ended questions to explore the onset, duration, and pattern of the rash.
  • Clarify rash characteristics: appearance, distribution, resolution, and recurrence.
  • Assess for triggers, including new medications, foods, infections, insect bites, and environmental exposures.
  • Ask about history of atopy (asthma, eczema, allergic rhinitis) and family history of allergies.
  • Explore lifestyle factors, including stress, recent illnesses, and physical exertion.
  • Assess for red flag symptoms: breathing difficulty, angioedema, dizziness, hypotension (suggestive of anaphylaxis).
  • Address the patient’s concerns about serious allergies and recurrence.

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

The competent candidate should:

  • Explain that acute urticaria is the most likely diagnosis, as it presents with transient, itchy wheals without systemic involvement.
  • Discuss other possible causes:
    • Chronic spontaneous urticaria (lasting >6 weeks, no clear trigger).
    • Allergic reaction (if linked to a specific exposure).
    • Physical urticaria (triggered by pressure, cold, or heat).
    • Viral exanthem (if recent infection).
    • Drug reaction (if linked to recent medication use).
  • Reassure the patient that most cases are self-limiting and that no clear trigger is found in many cases.

Task 3: Address the patient’s concerns, including recurrence, long-term management, and red flags for severe reactions.

The competent candidate should:

  • Acknowledge the patient’s concerns and explain that acute urticaria is often self-limiting.
  • Reassure that it is unlikely to be a serious allergy, as there are no signs of anaphylaxis.
  • Explain triggers and discuss when allergy testing is indicated (persistent or severe cases).
  • Discuss when to seek urgent care (breathing difficulty, swelling of face/throat, dizziness).
  • Provide guidance on symptom management and strategies to prevent future flares.

Task 4: Develop an initial management plan, including pharmacological and non-pharmacological treatment options, lifestyle modifications, and follow-up.

The competent candidate should:

  • Recommend non-sedating antihistamines (e.g., loratadine, cetirizine) for symptom control.
  • Advise avoiding suspected triggers, including stopping the new multivitamin.
  • Discuss lifestyle modifications, including stress management, avoiding hot showers, and wearing loose clothing.
  • Explain that chronic urticaria (>6 weeks) requires further workup but most cases resolve within days to weeks.
  • Arrange follow-up in 1-2 weeks to review symptoms.
  • Provide safety-netting advice, including when to seek emergency care for anaphylaxis symptoms.

SUMMARY OF A COMPETENT ANSWER

  • Takes a structured history, covering symptoms, triggers, and systemic involvement.
  • Provides a clear differential diagnosis, explaining why acute urticaria is most likely.
  • Addresses patient concerns empathetically, explaining why anaphylaxis is unlikely.
  • Offers an evidence-based management plan, including antihistamines, trigger avoidance, and follow-up.
  • Provides safety-netting, explaining when to seek emergency care.

PITFALLS

  • Failing to assess for anaphylaxis symptoms, such as breathing difficulty or angioedema.
  • Automatically ordering allergy tests, as they are not always indicated in acute urticaria.
  • Overlooking stress as a potential trigger, missing an opportunity for lifestyle advice.
  • Not addressing the patient’s anxiety, leading to unnecessary fear of serious allergies.
  • Providing vague treatment advice, rather than clear recommendations on antihistamines and avoidance strategies.
  • Failing to provide safety-netting, missing the chance to educate on red flags for severe reactions.

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 patient’s concerns and sociocultural context.
1.2 Engages the patient 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, including triggers, systemic symptoms, and atopy history.
2.2 Orders appropriate investigations only when indicated, avoiding unnecessary allergy tests.

3. Diagnosis, Decision-Making and Reasoning

3.1 Develops a structured differential diagnosis for acute urticaria.
3.2 Identifies red flags requiring urgent referral or further assessment.

4. Clinical Management and Therapeutic Reasoning

4.1 Formulates an evidence-based treatment plan, including antihistamines, lifestyle modifications, and avoidance strategies.
4.2 Provides pharmacological and non-pharmacological treatment options, ensuring a patient-centred approach.

5. Preventive and Population Health

5.1 Discusses lifestyle modifications, including trigger avoidance and stress management.

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, ensuring the patient understands when to seek urgent care.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises features suggestive of anaphylaxis or systemic illness requiring escalation.

Competency at Fellowship Level

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