CASE INFORMATION

Case ID: OEDEMA-018
Case Name: Michael Thompson
Age: 67 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: K07 – Swollen ankles/oedema

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 causes of lower limb oedema 2.2 Identifies when further investigations are warranted
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis for bilateral lower limb oedema 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 lifestyle modifications and monitoring for chronic diseases
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 oedema is a sign of serious underlying disease

CASE FEATURES

Elderly male presenting with bilateral swollen ankles and mild shortness of breath.
Exploring differential diagnoses, including cardiac (heart failure), renal (nephrotic syndrome), hepatic, and venous insufficiency causes.
Addressing patient concerns, including worsening mobility, lifestyle implications, and the possibility of serious disease.
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

Michael Thompson, a 67-year-old retired accountant, presents with gradual swelling of both ankles over the past two months. He describes the swelling as worse in the evenings and notes some mild shortness of breath when walking uphill.

He is concerned this could be a sign of heart failure or kidney disease.

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Thompson
Age: 67
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Amlodipine 5mg daily (for hypertension)
Atorvastatin 20mg daily (for hypercholesterolaemia)

Past History

Hypertension (diagnosed 10 years ago)
Type 2 diabetes (diagnosed 5 years ago, managed with diet and metformin)
No history of heart disease, kidney disease, or liver disease

Social History

Retired, lives with wife, previously active but reduced activity due to swollen legs.

Family History

Father had heart failure in his 70s.
No family history of kidney or liver disease.

Smoking

Smoked 15 pack-years, quit 10 years ago.

Alcohol

Drinks socially, 1-2 times per week.

Vaccination and Preventative Activities

Up to date with vaccinations.
Last check-up 6 months ago, blood pressure well controlled.

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, my ankles have been swelling for the past couple of months, and I’ve started feeling a bit short of breath when walking. Could this be heart failure?”

General Information

Your name is Michael Thompson, and you are 67 years old.
You are a retired accountant, living with your wife.
You are generally healthy but have hypertension and type 2 diabetes.
You were fairly active but have reduced your walking in recent months due to swelling in your legs.

Specific Information

(Reveal only when asked directly)

Background Information

You do not have a history of heart disease or kidney disease but are concerned because your father had heart failure in his 70s.
You don’t take any new medications, and your blood pressure has been stable at recent check-ups.
Your ankles have been swelling gradually over the past two months.
The swelling is worse in the evenings and improves overnight but is not completely gone by morning.
The swelling is painless but makes your legs feel heavy and tight by the end of the day.
You have noticed your socks leave deep indentations by the evening.
In the past few weeks, you have experienced mild shortness of breath when walking uphill or climbing stairs, but you can still do most activities.
You haven’t had any sudden weight gain, but you feel slightly bloated.

Swelling Characteristics

Both ankles and lower legs are swollen, but your feet and upper legs are normal.
No pain, redness, or warmth in the swollen areas.
No varicose veins or history of leg ulcers.
No recent travel or long periods of immobility.
No known history of deep vein thrombosis (DVT).

Other Symptoms

No dizziness, palpitations, or fainting.
No chest pain or tightness.
No cough, wheezing, or waking up at night gasping for air.
No recent infections, fevers, or new rashes.
No urinary problems—passing urine normally.

Lifestyle Factors

You drink 1-2 glasses of wine per week, no heavy alcohol use.
You have been less active recently due to the swelling.
You have not changed your diet significantly, but your salt intake may be high due to processed foods.

Medications and Past Medical History

You take amlodipine for hypertension and atorvastatin for cholesterol.
You take metformin for diabetes, but your blood sugar has been well controlled.
You have no history of liver or kidney disease.
You have never had a heart attack.

Family History

Father had heart failure at age 75.
No family history of kidney or liver disease.

Concerns and Expectations

You are worried that this could be heart failure because of your father’s history.
You also wonder if this could be kidney disease related to diabetes.
You want to know what tests you need and whether you will need medication for this.
You are concerned about whether this will get worse over time.
You want to know if you need to change your diet or lifestyle.

Red Flag Symptoms (Reveal only when asked directly)

No severe breathlessness or needing to sleep upright.
No history of coughing up blood.
No jaundice or significant abdominal swelling.

Emotional Cues & Body Language

You appear worried but calm.
If the doctor hesitates or seems unsure, you will ask:
- “But how do we know for sure? Should I have a heart scan?”
If the doctor only mentions lifestyle changes without discussing tests, you may ask:
- “But what if this is something serious? Shouldn’t we check first?”
If the doctor mentions stopping or changing medications, you will say:
- “I’ve been on these medications for years. Could they really be causing this now?”
If the doctor explains things clearly and provides a structured 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 heart failure?”
“What tests do I need? Will I need an echocardiogram?”
“Is this related to my blood pressure medication?”
“Should I be doing anything differently in my lifestyle?”
“Will I need medication to treat this swelling?”
“Is this going to get worse over time?”
“Could this be kidney disease because of my diabetes?”
“Would compression stockings help, or should I avoid them?”

Key Behaviours & Approach

You are concerned but open to explanations and tests.
If the doctor only reassures you without suggesting investigations, you will say:
- “But how do we rule out something serious?”
If the doctor suggests stopping a medication (e.g., amlodipine), you may ask:
- “Isn’t this medication controlling my blood pressure? What should I take instead?”
If the doctor mentions a referral to a specialist, you will ask:
- “How long will that take? Do I need to do anything in the meantime?”
If the doctor explains things well and provides a clear plan, you will feel reassured and ready to proceed with the recommended investigations.

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 understand why they are necessary.
You do not want to be dismissed or told it’s “just ageing” without a thorough assessment.
You want to be proactive about your health and understand how to manage or prevent worsening symptoms.

Role-Player Summary

This case assesses the candidate’s ability to:

Take a structured history, identifying potential causes of bilateral lower limb oedema.
Provide a broad differential diagnosis, considering heart failure, medication effects, venous insufficiency, and renal/hepatic causes.
Explain the need for investigations (blood tests, echocardiogram, urinalysis, Doppler ultrasound if needed).
Offer initial management strategies, including lifestyle modifications, medication review, and follow-up.
Address patient concerns empathetically, particularly about heart failure, prognosis, and treatment options.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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

The competent candidate should:

Elicit key symptom details, including onset, duration, progression, and variability of swelling.
Assess systemic symptoms, such as dyspnoea, orthopnoea, fatigue, weight changes, and abdominal swelling.
Explore potential causes, including cardiac (heart failure), renal (nephrotic syndrome), hepatic (cirrhosis), and venous insufficiency.
Review medication history, particularly calcium channel blockers (amlodipine), NSAIDs, steroids, and hormone therapy.
Identify red flags, including sudden unilateral swelling (DVT risk), signs of pulmonary oedema, or significant weight gain.
Address patient concerns, particularly regarding heart failure, kidney disease, and prognosis.

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

The competent candidate should:

Discuss common causes of bilateral oedema, including:
- Cardiac failure – if associated with breathlessness, orthopnoea, and nocturnal dyspnoea.
- Medication-induced oedema – commonly linked to amlodipine or NSAIDs.
- Chronic venous insufficiency – often worsened by prolonged standing and relieved by leg elevation.
- Renal disease (e.g., nephrotic syndrome) – if proteinuria, frothy urine, or facial swelling is present.
- Liver disease (cirrhosis, portal hypertension) – if associated with ascites, jaundice, or alcohol history.
Explain why immediate hospital referral is not needed, but further tests are essential to determine the cause.
Provide reassurance that oedema is a common condition with multiple treatable causes.

Task 3: Address the patient’s concerns, including the need for investigations, potential outcomes, and lifestyle modifications.

The competent candidate should:

Acknowledge the patient’s anxiety about possible heart failure or kidney disease.
Explain the rationale for investigations, including:
- Blood tests – FBC, UECs, LFTs, BNP (if heart failure suspected), TFTs.
- Urinalysis – to assess for proteinuria (renal cause).
- ECG and echocardiogram – if cardiac involvement is suspected.
- Doppler ultrasound – if venous insufficiency or DVT is a concern.
Provide initial lifestyle advice, including salt reduction, leg elevation, and regular exercise.
Explain medication review, discussing possible adjustments to amlodipine or diuretic initiation if indicated.
Ensure safety-netting, advising the patient to seek urgent care if worsening breathlessness, chest pain, or sudden weight gain occurs.

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

The competent candidate should:

Order initial investigations, such as:
- FBC, UECs, LFTs, BNP, TFTs, urinalysis.
- ECG and echocardiogram, if cardiac failure is suspected.
- Doppler ultrasound, if venous insufficiency or DVT needs exclusion.
Modify medications, including:
- Reviewing amlodipine use, considering an alternative antihypertensive if needed.
- Considering diuretics (e.g., furosemide) cautiously, if appropriate.
Provide lifestyle advice, including:
- Leg elevation and compression stockings (if appropriate).
- Regular exercise and avoiding prolonged sitting or standing.
- Salt and fluid management, particularly in suspected heart failure.
Arrange follow-up in 1-2 weeks, ensuring test results are reviewed and further management is adjusted accordingly.

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, covering oedema characteristics, systemic symptoms, and red flags.
Provides a clear differential diagnosis, considering cardiac, renal, hepatic, and venous causes.
Explains the need for investigations, balancing reassurance with the importance of diagnostic workup.
Develops an evidence-based management plan, incorporating investigations, lifestyle changes, and medication review.
Ensures safety-netting and follow-up, advising the patient on red flags requiring urgent review.

PITFALLS

Failing to assess for red flags, such as sudden unilateral swelling (DVT) or worsening breathlessness (heart failure).
Not considering medication-related oedema, particularly amlodipine, NSAIDs, or steroids.
Overlooking renal or hepatic causes, missing an opportunity for early intervention.
Not providing clear follow-up instructions, leaving the patient unsure of next steps.
Prescribing diuretics without identifying the underlying cause, leading to potential electrolyte imbalances.

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 medication review and risk factors.
2.2 Orders appropriate investigations, balancing clinical suspicion and patient safety.

3. Diagnosis, Decision-Making and Reasoning

3.1 Develops a structured differential diagnosis, prioritising cardiac, renal, hepatic, and venous 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 potential medication review.
4.2 Ensures appropriate pharmacological and non-pharmacological management, promoting preventive health.

5. Preventive and Population Health

5.1 Discusses lifestyle modifications, including diet, fluid balance, and exercise.

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 disease requiring escalation.

Competency at Fellowship Level

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