CASE INFORMATION

Case ID: RESP-011
Case Name: Michael Harris
Age: 58 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: R99 – Respiratory disease, other

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 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 Interpretation	2.1 Takes a detailed history to assess respiratory symptoms, risk factors, and red flags 2.2 Selects appropriate investigations based on clinical presentation
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a broad differential diagnosis for persistent respiratory symptoms 3.2 Identifies red flags requiring urgent intervention
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a structured and evidence-based management plan 4.2 Provides advice on pharmacological and non-pharmacological management
5. Preventive and Population Health	5.1 Discusses smoking cessation, vaccination, and lung health screening
6. Professionalism	6.1 Maintains patient confidentiality and demonstrates ethical practice
7. General Practice Systems and Regulatory Requirements	7.1 Documents accurately and ensures 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 features suggestive of serious underlying disease requiring further assessment

CASE FEATURES

Middle-aged male presenting with a persistent, unexplained cough.
Exploring potential causes, including chronic respiratory disease, infections, occupational exposures, and malignancy.
Assessing risk factors, including smoking history, environmental exposure, and comorbidities.
Balancing reassurance and investigation, ensuring appropriate referrals and follow-up.
Providing preventive advice, including smoking cessation, vaccination, and lifestyle modifications.

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

Michael Harris, a 58-year-old retired construction worker, presents with a persistent cough for the past three months. He describes it as a dry, nagging cough, worse in the morning and evening but not producing much sputum. He also experiences mild breathlessness on exertion but no chest pain, fever, or weight loss.

Michael is concerned about whether this could be lung cancer or COPD, as he smoked for 30 years but quit five years ago.

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Harris
Age: 58
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

Smoked one pack per day for 30 years, quit 5 years ago
No history of asthma, COPD, or lung infections
Hypertension, managed with lifestyle changes

Social History

Worked in construction for 35 years, with exposure to dust and chemicals.

Family History

Father died of lung cancer at age 72.
No family history of asthma or autoimmune lung disease.

Smoking

Quit smoking five years ago, but previously smoked 30 pack-years.

Alcohol

Drinks 2-3 standard drinks per week.

Vaccination and Preventative Activities

Flu vaccine 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 had this annoying cough for months now, and I’m worried. My dad had lung cancer, and I used to smoke. Could this be something serious?”

General Information

Your name is Michael Harris, and you are 58 years old.
You are a retired construction worker, where you worked for over 35 years, often around dust and chemicals.
You quit smoking five years ago after 30 years of smoking one pack per day.
You are generally healthy, apart from mild hypertension managed with lifestyle changes.
You live with your wife, and you have two adult children.

Specific Information

(Reveal only when asked directly)

Background Information

You have had a persistent cough for about three months.
The cough is mostly dry, but sometimes feels a little tickly in the back of your throat.
The cough is worse in the mornings and at night but not constant throughout the day.
You feel slightly breathless on exertion, especially when walking uphill or carrying groceries, but not at rest.
You have not had any chest pain, fever, night sweats, or weight loss.
You haven’t noticed coughing up blood, but sometimes you have a little clear or white phlegm in the mornings.

Cough Characteristics

The cough comes and goes, but doesn’t seem to be improving.
It is worse when exposed to cold air or after talking for long periods.
You do not wheeze or wake up gasping for breath.
You sometimes feel a tight sensation in your throat but not in your chest.

Associated Symptoms

No chest pain, no sharp pains with breathing.
No fevers, chills, or night sweats.
No significant fatigue or unexplained weight loss.
No recent colds or infections before this started.
Occasionally feel a bit run-down, but generally okay.

Environmental and Occupational Exposure

You worked in construction for over 35 years, including handling cement, dust, and exposure to some asbestos in older buildings.
You wore masks sometimes, but not always, especially in the earlier years of your career.
Your cough seemed to get worse after retiring, possibly because you are spending more time indoors.

Concerns and Expectations

You are worried about lung cancer because your father was diagnosed with it at 72.
You wonder if this could be COPD, given your history of smoking.
You want to know if you need a scan or lung function tests.
You are open to lifestyle changes and treatment options if needed.
You don’t want to be put on unnecessary medication unless it’s really needed.

Red Flag Symptoms (Reveal only when asked directly)

No coughing up blood.
No sudden or severe shortness of breath.
No swollen legs, chest pain, or dizziness.

Emotional Cues & Body Language

You appear concerned but not panicked.
If the doctor is uncertain or dismissive, you may press further:
- “Are you sure this isn’t something serious?”
If the doctor mentions stress or mild airway irritation, you might respond:
- “But I’ve never had a cough like this before, and it’s not going away.”
If the doctor suggests waiting to see if it improves, you might ask:
- “What if this is something that needs to be caught early? Wouldn’t it be better to check now?”
If the doctor explains things well and offers a clear plan, you feel reassured but still want follow-up.

Questions for the Candidate

(Ask these naturally throughout the consultation.)

“Could this be lung cancer? Should I get a scan?”
“Do I have COPD? I smoked for a long time.”
“What can I do to stop this cough?”
“Do I need an inhaler or medication?”
“Will this get worse over time?”
“Should I be worried about my past exposure to dust and asbestos?”
“Would quitting smoking five years ago still help my lungs now?”
“Is there anything I can do to make my breathing better?”

Key Behaviours & Approach

You are worried about long-term lung health but are not in immediate distress.
If the doctor only prescribes cough syrup or a basic treatment, you may push for tests or a referral.
If the doctor doesn’t discuss lung health screening, you may ask about CT scans or spirometry.
If the doctor mentions lifestyle changes, you may ask for specific recommendations rather than general advice.
If the doctor suggests watchful waiting, you might ask:
- “How long should I wait before coming back if this doesn’t improve?”

Additional Context for the Role-Player

You are willing to follow medical advice but want a clear explanation of why tests are or aren’t needed.
You are not against medical investigations, but you don’t want unnecessary procedures.
You are open to lifestyle changes, especially if they help you breathe better.
You want reassurance but also need a clear follow-up plan if symptoms persist.

Role-Player Summary

This case assesses the candidate’s ability to:

Take a structured history, identifying risk factors for chronic respiratory disease.
Provide a broad differential diagnosis, considering chronic bronchitis, COPD, post-viral cough, and malignancy.
Offer appropriate investigations, balancing clinical suspicion and patient anxiety.
Discuss preventive strategies, including smoking cessation, vaccination, and lung health monitoring.
Ensure safety-netting and follow-up, providing clear guidance on when to return if symptoms worsen.

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 respiratory symptoms.

The competent candidate should:

Elicit a detailed history, including onset, duration, severity, and triggers of the persistent cough.
Assess associated symptoms, including breathlessness, wheezing, sputum production, haemoptysis, fevers, night sweats, or weight loss.
Screen for red flag symptoms, such as persistent or worsening cough, haemoptysis, unexplained weight loss, or systemic symptoms.
Explore occupational and environmental exposures, particularly construction work, dust, chemicals, and asbestos.
Assess smoking history, calculating pack-years and discussing smoking cessation efforts.
Clarify past medical history, including chronic respiratory conditions, cardiovascular disease, and infections.
Explore impact on daily life, including work limitations, exercise tolerance, and sleep disruption.
Address patient concerns about lung cancer and COPD, ensuring a structured discussion about risks and next steps.

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

The competent candidate should:

Explain the most likely diagnoses, considering chronic bronchitis, post-viral cough, or early COPD, based on history.
Discuss other possible conditions, including:
- COPD – given smoking history and mild exertional breathlessness.
- Lung cancer – given family history and occupational exposure (though no red flags yet).
- Postnasal drip syndrome – if symptoms are worse at night or in cold air.
- GORD-related cough – if associated with reflux symptoms.
- Occupational lung disease – given exposure history.
Reassure the patient that cancer is unlikely, but investigations will help clarify the cause.
Provide a structured approach to further testing, balancing patient concerns and clinical necessity.

Task 3: Address the patient’s concerns, including fear of serious illness, investigations, and management options.

The competent candidate should:

Acknowledge the patient’s anxiety about lung cancer, and explain risk factors vs. current symptoms.
Discuss the need for further investigations, including:
- Spirometry to assess lung function and rule out COPD.
- Chest X-ray as an initial screen for lung pathology.
- Blood tests (FBC, CRP) to check for infection or inflammation.
Explain that imaging is recommended, but a CT scan would be considered only if X-ray findings are concerning.
Reassure the patient that quitting smoking has significantly reduced his lung cancer risk.
Explain lifestyle modifications, such as avoiding dust, improving indoor air quality, and optimising vaccination.

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

The competent candidate should:

Order initial investigations, including spirometry, chest X-ray, and targeted blood tests.
Encourage smoking cessation support, discussing NRT, medications (e.g., varenicline), and referral to quit services.
Trial symptomatic relief, such as saline nasal spray (if postnasal drip), proton pump inhibitors (if reflux), or bronchodilators (if airway obstruction is suspected).
Discuss preventive measures, including pneumococcal and annual influenza vaccination.
Provide safety-netting, advising the patient to return if symptoms worsen, new red flag symptoms develop, or test results are concerning.
Arrange follow-up in 2-4 weeks, depending on test results and symptom progression.

SUMMARY OF A COMPETENT ANSWER

Takes a comprehensive history, considering chronic bronchitis, COPD, occupational exposure, and malignancy risk.
Provides a structured differential diagnosis, explaining why COPD or chronic bronchitis is more likely than lung cancer.
Reassures the patient appropriately, balancing the need for investigations with clinical judgment.
Offers evidence-based management, including spirometry, chest X-ray, smoking cessation support, and symptom control.
Ensures appropriate safety-netting, advising when to return if symptoms persist or worsen.

PITFALLS

Failing to assess red flag symptoms, such as haemoptysis, unexplained weight loss, or systemic signs.
Over-reassuring the patient without appropriate investigations, missing potential pathology.
Over-investigating without strong clinical indications, causing unnecessary patient anxiety.
Ignoring occupational exposure, missing the risk of work-related lung disease.
Not addressing smoking cessation, missing an opportunity for preventive health intervention.
Failing to provide follow-up, leaving the patient uncertain about next steps.

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 smoking history, occupational exposure, and respiratory symptoms.
2.2 Orders appropriate investigations, balancing clinical suspicion and patient anxiety.

3. Diagnosis, Decision-Making and Reasoning

3.1 Develops a structured differential diagnosis, prioritising the most likely and serious conditions.
3.2 Identifies indications for further assessment or referral, ensuring red flags are addressed.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a patient-centred, evidence-based treatment plan, incorporating lifestyle changes, smoking cessation, and targeted therapy.
4.2 Ensures appropriate pharmacological and non-pharmacological management, promoting preventive health.

5. Preventive and Population Health

5.1 Discusses lung health maintenance, including smoking cessation, vaccination, and long-term monitoring.

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 further medical care.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises features suggestive of serious lung disease, ensuring timely referral if needed.

Competency at Fellowship Level

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