CASE INFORMATION

Case ID: BRE-017
Case Name: Olivia Matthews
Age: 42 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: X20 – Breast lump/mass (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 breast lump characteristics, 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 a breast lump 3.2 Recognises red flags requiring urgent referral
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan 4.2 Provides appropriate treatment options and patient education
5. Preventive and Population Health	5.1 Discusses breast cancer screening and self-examination education
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 specialist 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 a breast lump is suspicious and requires urgent investigation

CASE FEATURES

Middle-aged woman presenting with a recently discovered breast lump.
Exploring differential diagnoses, including benign and malignant causes.
Addressing patient concerns, including fear of breast cancer and implications for her family.
Balancing reassurance with appropriate investigation and timely referral.

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

Olivia Matthews, a 42-year-old project manager, presents with a breast lump she noticed a few weeks ago while showering. She describes it as painless and firm, located in the upper outer quadrant of her left breast.

She is worried about breast cancer as her maternal aunt had breast cancer at 50.

PATIENT RECORD SUMMARY

Patient Details

Name: Olivia Matthews
Age: 42
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 previous breast disease or lumps
No history of autoimmune conditions or significant chronic illnesses

Social History

Works as a project manager, describes work as high-stress.

Family History

Maternal aunt diagnosed with breast cancer at 50.
No known BRCA mutations in the family.

Smoking

Non-smoker

Alcohol

Drinks socially, 2-3 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 found a lump in my left breast a few weeks ago, and I’m really scared. Could this be cancer?”

General Information

Your name is Olivia Matthews, and you are 42 years old.
You work as a project manager in a high-pressure job.
You live alone and have no children.
You are generally healthy, with no major medical conditions.

Specific Information

(Reveal only when asked directly)

Background Information

You have never had any previous breast issues or lumps.
You have been on the combined oral contraceptive pill (COCP) for over 10 years for contraception.
You first noticed the lump about 3 weeks ago while showering.
The lump is painless but firm, and you can still feel it.
It is located in the upper outer quadrant of your left breast.
You are worried because it hasn’t gone away, and you haven’t noticed a lump there before.
You are scared that this could be breast cancer.

Lump Characteristics

The lump feels firm, round, and does not move easily under the skin.
You estimate it to be about 2 cm in size.
It hasn’t grown significantly over the last 3 weeks.
It does not seem to change with your menstrual cycle.

Other Breast Symptoms

You have not noticed any pain, redness, or swelling.
There is no nipple discharge, inversion, or crusting.
There are no visible skin changes or dimpling.
You have not felt any lumps in your right breast.

Menstrual and Hormonal History

Your periods are regular, every 28 days, with no significant premenstrual breast tenderness.
You have been taking the COCP continuously for contraception.
You have never used hormone replacement therapy (HRT).
You have never had fertility treatments.

Family History

Your maternal aunt was diagnosed with breast cancer at 50.
You do not know if there are BRCA gene mutations in your family.
There is no history of ovarian or other cancers in your family.

Lifestyle Factors

You do not smoke.
You drink 2-3 glasses of wine per week.
You exercise occasionally but lead a fairly sedentary lifestyle.

Concerns and Expectations

You are terrified that this could be cancer and want reassurance and clear answers.
You want to know what tests you will need.
You are worried about your family history and whether that increases your risk.
You are anxious about whether this will require surgery, chemotherapy, or long-term treatment.
You do not know much about breast lumps and are unsure if benign lumps can persist.

Red Flag Symptoms (Reveal only when asked directly)

You have not had any unexplained weight loss, fatigue, or night sweats.
You have not felt any lumps in your armpit.
You have not noticed any changes in the shape or size of your breast.

Emotional Cues & Body Language

You appear worried and slightly on edge.
If the doctor is vague or avoids answering directly, you will ask:
- “But could this be cancer?”
If the doctor suggests waiting before further testing, you may ask:
- “I’m really anxious—shouldn’t we do tests now instead of waiting?”
If the doctor mentions that many lumps are benign, you might ask:
- “How do we know for sure? Do I need a biopsy?”
If the doctor provides clear explanations and a plan, you will feel reassured and ready to follow their advice.

Questions for the Candidate

(Ask these naturally throughout the consultation.)

“Do you think this could be cancer?”
“What tests do I need? Will I need a biopsy?”
“Should I be worried about my family history?”
“What happens if this lump is benign? Will it go away?”
“What are my treatment options if this turns out to be serious?”
“Should I be checking my breasts more often? How do I do that properly?”
“Would it help if I changed my diet or lifestyle?”
“If this is cancer, does it mean I’ll need chemotherapy?”

Key Behaviours & Approach

You are worried but logical and want a structured plan.
If the doctor only reassures you without recommending further testing, you will say:
- “But how can we be sure without checking properly?”
If the doctor explains things well and gives a clear management plan, you will feel reassured and ready to proceed with testing.
If the doctor mentions waiting to see if the lump changes, you will say:
- “But I’ve already had this lump for three weeks—shouldn’t we act now?”
If the doctor suggests a referral to a breast specialist, you may ask:
- “How soon can I get an appointment? Should I be worried?”

Additional Context for the Role-Player

You trust medical advice but want a logical explanation of what is happening.
You are not opposed to tests or referrals, but you want to know what each test is for.
You do not want to be dismissed or told it’s “probably nothing” without proper investigation.
You want to be proactive about your health and understand how to monitor for changes.

Role-Player Summary

This case assesses the candidate’s ability to:

Take a structured history, identifying risk factors and red flags for malignancy.
Provide a broad differential diagnosis, considering fibroadenoma, cyst, and malignancy.
Explain the need for imaging (mammogram and ultrasound) and possible biopsy.
Offer initial management strategies, including safety-netting and follow-up.
Address patient concerns empathetically, particularly about cancer, testing, and family history.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, considering potential causes of a breast lump.

The competent candidate should:

Elicit key symptom details, including onset, duration, size, and changes over time.
Assess lump characteristics, including pain, mobility, texture, and tenderness.
Identify associated symptoms, such as nipple discharge, skin changes, breast pain, or axillary lumps.
Review menstrual and hormonal history, noting hormonal contraception, HRT use, and menstrual cycle influence.
Assess risk factors, including family history of breast cancer, genetic predisposition (e.g., BRCA mutations), and lifestyle factors.
Address patient concerns, particularly regarding cancer fears, diagnostic steps, and treatment implications.

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

The competent candidate should:

Explain the most likely diagnoses, considering:
- Fibroadenoma – common in younger women, firm, mobile, and painless.
- Breast cyst – fluid-filled, may fluctuate with the menstrual cycle.
- Mastitis or abscess – associated with pain, redness, and infection signs.
- Fat necrosis – following trauma, presenting as a firm, irregular lump.
- Breast cancer – less common but important to exclude, particularly with painless, fixed lumps, nipple changes, or skin dimpling.
Reassure the patient that many breast lumps are benign, but investigations are necessary for confirmation.
Explain the next steps for diagnosis, including imaging and potential biopsy.

Task 3: Address the patient’s concerns, including the need for investigations, potential outcomes, and follow-up.

The competent candidate should:

Acknowledge the patient’s anxiety about breast cancer, and provide clear, non-alarming explanations.
Explain why imaging is required, including:
- Mammogram (first-line for patients over 40).
- Breast ultrasound (better for younger women or dense breasts).
- Fine-needle aspiration (FNA) or core biopsy, if imaging findings are suspicious.
Discuss family history implications, explaining that having a relative with breast cancer slightly increases risk, but genetic testing is not needed unless multiple family members are affected.
Outline possible outcomes, including the likelihood of benign vs. malignant findings.
Ensure safety-netting, advising when to return for reassessment or urgent review.

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

The competent candidate should:

Order appropriate investigations, such as:
- Bilateral mammogram and breast ultrasound.
- FNA or core biopsy if imaging suggests malignancy.
- BRCA genetic testing if strong family history is present.
Provide reassurance and practical advice, including:
- Breast self-examination techniques for ongoing monitoring.
- Lifestyle modifications, such as reducing alcohol intake and maintaining a healthy weight.
Discuss possible referral to a breast specialist, particularly if the lump is suspicious or requires biopsy.
Arrange follow-up in 1-2 weeks, ensuring the patient understands next steps based on investigation results.

SUMMARY OF A COMPETENT ANSWER

Takes a detailed history, assessing lump characteristics, risk factors, and red flags.
Provides a structured differential diagnosis, explaining why benign conditions are more likely but requiring confirmation.
Addresses patient concerns empathetically, particularly about cancer fears and diagnostic uncertainty.
Develops an evidence-based management plan, including appropriate imaging and potential biopsy.
Ensures clear follow-up and safety-netting, advising the patient on what to expect next.

PITFALLS

Failing to assess red flag symptoms, such as nipple discharge, skin changes, or axillary lymphadenopathy.
Not considering all differentials, assuming all lumps are either benign or cancerous without proper assessment.
Over-reassuring the patient without ordering investigations, leading to missed diagnoses.
Not addressing the patient’s concerns, particularly regarding family history and long-term risk.
Delaying follow-up or referral, causing patient distress and potential disease progression.

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 lump characteristics, risk factors, and red flags.
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 benign and malignant causes.
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 possible referrals.
4.2 Ensures appropriate pharmacological and non-pharmacological management, promoting preventive health.

5. Preventive and Population Health

5.1 Discusses breast screening recommendations, including mammograms and self-examination.

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 malignancy requiring urgent investigation.

Competency at Fellowship Level

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