CASE INFORMATION

Case ID: GEN-015
Case Name: Sarah Mitchell
Age: 34 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: X99 – Genital Disease NOS (Female)

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 thorough history to assess genital symptoms, risk factors, and red flags 2.2 Identifies when further investigations are warranted
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis for genital symptoms 3.2 Recognises red flags requiring urgent referral
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a structured and evidence-based management plan 4.2 Provides appropriate treatment options and patient education
5. Preventive and Population Health	5.1 Discusses sexual health screening, vaccination, and preventive strategies
6. Professionalism	6.1 Maintains patient confidentiality and demonstrates ethical practice
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation, follow-up, and referrals
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 when genital symptoms indicate a more serious underlying condition

CASE FEATURES

Female patient presenting with unexplained vulvar discomfort, irritation, and occasional pain.
Exploring differential diagnoses, including dermatological conditions (lichen sclerosus, dermatitis), infections (STIs, fungal, bacterial), and other gynaecological issues (vulvodynia, atrophic vaginitis, Bartholin’s cyst).
Addressing patient concerns, including fear of cancer, STI risk, and impact on sexual function.
Balancing reassurance with appropriate investigation and management.

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 Mitchell, a 34-year-old office worker, presents with persistent vulvar discomfort, irritation, and occasional sharp pain over the past two months. She describes an itchy and burning sensation, mainly around the vulva rather than inside the vagina.

She is concerned about whether this could be a sexually transmitted infection (STI) or something more serious, like cancer.

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Mitchell
Age: 34
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Combined oral contraceptive pill (COCP)

Past History

No history of STIs, diabetes, or immune conditions
Mild eczema as a child but no recent skin issues

Social History

Works as an office manager, sedentary lifestyle.

Family History

No family history of gynaecological cancers.

Smoking

Non-smoker

Alcohol

Drinks socially, 1-2 times per week

Vaccination and Preventative Activities

HPV vaccine completed
Last cervical screening test (CST) was 2 years ago, results normal

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 constant irritation and discomfort down there for two months now. I’m really worried—could this be an STI or something serious?”

General Information

Your name is Sarah Mitchell, and you are 34 years old.
You work as an office manager, and your job is mostly sedentary.
You are in a stable relationship for three years with a male partner and are sexually active.
You have had no recent new sexual partners.

Specific Information

(Reveal only when asked directly)

Background Information

You use the combined oral contraceptive pill (COCP) for contraception.
You had an STI test two years ago, which was negative.
Your last cervical screening test (CST) was two years ago and was normal.
The itching and irritation started two months ago and have been persistent.
You feel discomfort mainly around the vulva, rather than deep inside the vagina.
There is occasional sharp pain, but no constant pain.
You have no abnormal vaginal discharge, no strong odour, and no bleeding.
The irritation is worse after exercise, when wearing tight clothes, and after using certain soaps.
You sometimes feel drier than usual during sex, but no pain during urination or deep pelvic pain.

Vulvar Symptoms

The irritation is external, around the vulva, not deep inside.
No noticeable lumps, sores, ulcers, or visible skin changes.
No new rashes or scaling, but the area sometimes feels more sensitive.

Possible Triggers

You recently started using a new brand of soap and body wash.
You often wear synthetic underwear and tight leggings.
You sometimes shave the area, but not recently.
You have not had any recent infections or antibiotic use.

Sexual History

You have been with the same partner for three years.
Your partner has no symptoms (e.g., no itching, discharge, or visible sores).
You are monogamous and have no reason to suspect infidelity.
You had an STI check two years ago, which was negative.

Concerns and Expectations

You are worried this might be an STI, despite being in a monogamous relationship.
You are concerned about vulvar cancer because you read about it online.
You want to know what tests you need and whether this is treatable.
You are frustrated that the symptoms are not going away and want a clear diagnosis and solution.

Red Flag Symptoms (Reveal only when asked directly)

No persistent lumps, ulcers, or visible lesions.
No abnormal vaginal bleeding or pain during sex.
No unexplained weight loss or fatigue.
No swollen lymph nodes in the groin.

Emotional Cues & Body Language

You appear worried and a little frustrated.
If the doctor is vague or avoids answering directly, you will ask:
- “Are you sure this isn’t something serious like cancer?”
If the doctor suggests waiting before further testing, you may ask:
- “But I’ve had this for two months—shouldn’t we check it properly?”
If the doctor explains things well and provides a plan, you will feel reassured and ready to follow the advice.

Questions for the Candidate

(Ask these naturally throughout the consultation.)

“Could this be an STI? Do I need to tell my partner?”
“Why did this happen? Is it because of my soap or underwear?”
“Do I need any tests or a biopsy for cancer?”
“Is there anything I can do to stop the irritation?”
“Will this keep coming back?”
“Could my contraception be making this worse?”
“Would using a cream help, or do I need medication?”

Key Behaviours & Approach

You are worried about a serious condition and want reassurance.
If the doctor only prescribes medication without explaining the cause, you will ask:
- “But what’s actually causing this?”
If the doctor focuses too much on ruling out cancer and doesn’t suggest treatment, you may say:
- “That’s good to hear, but what can I do to stop this irritation?”
If the doctor mentions changing soap and underwear, you might ask:
- “How long should I wait before I know if that’s helping?”
If the doctor explains everything clearly and provides a step-by-step plan, you will feel reassured and willing to follow their advice.

Additional Context for the Role-Player

You trust medical advice but want a logical explanation of the diagnosis.
You are not anxious about unnecessary tests, but you want to make sure nothing serious is being missed.
You prefer practical advice rather than vague suggestions.
You want to be proactive in preventing this from happening again.

Role-Player Summary

This case assesses the candidate’s ability to:

Take a structured history, identifying risk factors for genital symptoms.
Provide a broad differential diagnosis, considering dermatological, infectious, and gynaecological conditions.
Offer appropriate treatment options, balancing pharmacological and lifestyle approaches.
Provide reassurance and education, addressing misconceptions about STIs and cancer.
Ensure safety-netting and follow-up, advising when to return if symptoms persist or worsen.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, considering potential causes of genital discomfort.

The competent candidate should:

Elicit key symptom details, including onset, duration, severity, and impact on daily life.
Assess discharge characteristics, including colour, consistency, and odour.
Identify associated symptoms, such as dyspareunia, dysuria, or abnormal bleeding.
Explore potential triggers, including hygiene products, synthetic clothing, shaving, or recent sexual activity.
Review the patient’s sexual health, including history of STIs, partner symptoms, and recent sexual contacts.
Assess medical history, including dermatological conditions (e.g., eczema, lichen sclerosus), diabetes, and immune disorders.
Address patient concerns, such as STIs, vulvar cancer, and recurrence.

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

The competent candidate should:

Explain the most likely diagnosis, considering the location (vulva vs. vagina), chronicity, and absence of discharge or systemic symptoms.
Discuss other possible conditions, including:
- Contact dermatitis – irritation from soaps, wipes, or synthetic underwear.
- Vulvodynia – chronic vulvar discomfort with no clear infectious cause.
- Lichen sclerosus – if there were whitening, atrophy, or scarring.
- Candidiasis – if there were thick white discharge and intense itching.
- Bacterial vaginosis (BV) – if discharge were thin, grey, and malodorous.
- STIs (e.g., herpes, chlamydia, gonorrhoea) – if there were lesions, pain, or partner symptoms.
Explain why cancer is unlikely, based on absence of persistent ulcers, bleeding, or lumps.
Discuss the need for further testing, if necessary, to clarify the diagnosis.

Task 3: Address the patient’s concerns, including potential causes, testing, and treatment options.

The competent candidate should:

Acknowledge the patient’s concerns and provide clear, non-alarming explanations.
Discuss STI risk, reassuring that monogamous relationships reduce risk but do not eliminate it completely.
Explain what tests may be needed, including:
- High vaginal swab for candida/BV.
- STI screening if history suggests risk.
- Skin biopsy if dermatoses are suspected.
Provide a clear treatment plan, tailored to the likely cause.
Discuss symptom relief, including avoiding irritants, using emollients, and wearing breathable cotton underwear.
Provide realistic expectations for symptom resolution and follow-up.

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

The competent candidate should:

Order appropriate investigations, such as:
- Vaginal pH testing to differentiate BV from candida.
- Swabs for STIs and microbiological testing if indicated.
- Dermatological assessment if chronic vulvar irritation is present.
Provide symptomatic relief, such as:
- Topical emollients to soothe irritation.
- Avoiding scented soaps and harsh products.
- Using a barrier cream if friction is contributing to irritation.
Offer pharmacological treatment, including:
- Topical antifungal (if candida is suspected).
- Topical steroids (if inflammatory conditions like lichen sclerosus are suspected).
Discuss lifestyle changes, such as:
- Switching to cotton underwear and loose clothing.
- Avoiding daily use of panty liners.
- Using a pH-balanced wash if needed.
Schedule follow-up in 2-4 weeks, or sooner if symptoms persist or worsen.

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, covering symptom characteristics, sexual health, lifestyle factors, and dermatological history.
Provides a broad differential diagnosis, prioritising contact dermatitis, vulvodynia, candidiasis, and STIs.
Explains the condition clearly, addressing concerns about STIs and cancer.
Develops an evidence-based management plan, including investigations, symptom relief, and lifestyle modifications.
Ensures appropriate safety-netting, advising when to return for review.

PITFALLS

Failing to differentiate from other causes, such as STIs, dermatoses, and irritant/contact dermatitis.
Overlooking red flags, such as unexplained bleeding, persistent ulcers, or suspicious lesions.
Not considering lifestyle and environmental factors, leading to recurrent symptoms.
Providing unclear follow-up instructions, leaving the patient uncertain about next steps.
Not addressing the patient’s concerns about cancer and STIs, which may lead to ongoing anxiety.

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 dermatological, sexual, and lifestyle factors.
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 structured, evidence-based treatment plan, incorporating investigations and symptom relief.
4.2 Ensures appropriate pharmacological and non-pharmacological management, promoting preventive health.

5. Preventive and Population Health

5.1 Discusses sexual health screening and prevention strategies, including safe hygiene practices and STI education.

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 gynaecological conditions requiring escalation.

Competency at Fellowship Level

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