CCE-CE-148

CASE INFORMATION

Case ID: BPH-020
Case Name: John Patterson
Age: 67 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: Y85 – Benign Prostatic Hypertrophy

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 thorough history to assess lower urinary tract symptoms (LUTS)
2.2 Identifies when further investigations are warranted
3. Diagnosis, Decision-Making and Reasoning3.1 Develops a differential diagnosis for lower urinary symptoms
3.2 Recognises red flags requiring urgent referral
4. Clinical Management and Therapeutic Reasoning4.1 Develops an evidence-based management plan
4.2 Provides appropriate treatment options and patient education
5. Preventive and Population Health5.1 Discusses prostate cancer screening and lifestyle modifications
6. Professionalism6.1 Maintains patient confidentiality and demonstrates ethical practice
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate documentation, follow-up, and specialist referrals
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 when lower urinary symptoms require urgent intervention

CASE FEATURES

  • Elderly male presenting with lower urinary tract symptoms (LUTS), suggestive of benign prostatic hypertrophy (BPH).
  • Exploring differential diagnoses, including urinary tract infection (UTI), bladder pathology, and prostate cancer.
  • Addressing patient concerns, including impact on quality of life, risk of cancer, and treatment options.
  • 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:

  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

John Patterson, a 67-year-old retired school teacher, presents with gradual worsening of urinary symptoms over the past year. He describes increased urinary frequency, weak stream, hesitancy, and nocturia (2-3 times per night).

He is concerned about whether this could be prostate cancer and is frustrated with the frequent nighttime urination affecting his sleep.

PATIENT RECORD SUMMARY

Patient Details

Name: John Patterson
Age: 67
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • No known drug allergies

Medications

  • Perindopril 5mg daily (for hypertension)
  • Atorvastatin 20mg daily (for hypercholesterolaemia)

Past History

  • Hypertension (diagnosed 15 years ago)
  • Hypercholesterolaemia (diagnosed 10 years ago)
  • No history of urinary tract infections or kidney stones
  • No history of prostate cancer

Social History

  • Retired, lives with wife.
  • Drinks 1-2 glasses of wine per week.

Family History

  • Father had prostate cancer at 75.
  • No family history of bladder cancer or kidney disease.

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 having trouble with my urination for the past year. My stream is weaker, I have to go more often, and I keep waking up at night. Could this be prostate cancer?”

General Information

  • Your name is John Patterson, and you are 67 years old.
  • You are a retired school teacher, living with your wife.
  • You have always been independent and active, but your sleep is being disrupted by frequent nighttime urination.
  • You have never had prostate issues before and have never had a prostate examination or PSA test.

Specific Information

(Reveal only when asked directly)

Background Information

  • You take perindopril for hypertension and atorvastatin for high cholesterol.
  • You have a family history of prostate cancer (father diagnosed at 75), which makes you anxious about your own risk.
  • You have noticed gradual changes in your urination over the past year.
  • You experience:
    • Frequent urination during the day and night (nocturia 2-3 times per night).
    • Weak urinary stream, sometimes needing to strain to start urinating.
    • Hesitancy, meaning you have to wait a few seconds before urine starts flowing.
    • Incomplete emptying, where you still feel like there’s urine left after finishing.
  • You do not have any pain, burning, or blood in the urine.
  • You have never had complete urinary retention or required a catheter.
  • You feel frustrated by the nighttime urination because it is affecting your sleep and daily energy levels.

Urinary Symptoms

  • No sudden urgency leading to accidents (no incontinence).
  • No difficulty holding urine when you feel the need to go.
  • No burning or pain when urinating (ruling out infection).
  • No strong or foul-smelling urine.
  • No recent urinary tract infections (UTIs) or history of kidney stones.

Other Symptoms

  • No back pain, abdominal pain, or significant weight loss.
  • No erectile dysfunction or changes in sexual function.
  • No fever, chills, or general feeling of unwellness.

Lifestyle Factors

  • You drink 2-3 cups of coffee daily, including one in the evening.
  • You drink 1-2 glasses of wine per week, often in the evening.
  • You limit fluids before bed, but still wake up needing to urinate.
  • You walk daily for exercise but avoid long trips due to frequent urination.

Family History

  • Father had prostate cancer at age 75, but you are unsure if it was aggressive.
  • No family history of bladder cancer or kidney disease.

Concerns and Expectations

  • You are worried this could be prostate cancer.
  • You want to know if you need a PSA test or a prostate exam.
  • You want treatment to improve your sleep and quality of life.
  • You are concerned this might get worse over time and affect your independence.

Red Flag Symptoms (Reveal only when asked directly)

  • No blood in urine (haematuria).
  • No significant weight loss or night sweats.
  • No history of urinary retention requiring emergency care.
  • No numbness or weakness in the legs (no signs of spinal compression).

Emotional Cues & Body Language

  • You appear worried but calm, seeking reassurance about prostate cancer risk.
  • If the doctor avoids addressing cancer directly, you will ask:
    • “But how do we know for sure that this isn’t cancer?”
  • If the doctor focuses only on lifestyle changes, you will ask:
    • “Aren’t there medications that could help?”
  • If the doctor mentions a prostate exam, you will be slightly hesitant but open to discussion:
    • “I’ve never had one before. Is it really necessary?”
  • If the doctor provides a clear diagnosis and management plan, you will feel reassured and willing to follow recommendations.

Questions for the Candidate

(Ask these naturally throughout the consultation.)

  1. “Do I need a PSA test?”
  2. “Could this be cancer?”
  3. “Are there any treatments to help me sleep better?”
  4. “Will this get worse over time?”
  5. “Would reducing coffee and alcohol help?”
  6. “Will I need surgery?”
  7. “If this isn’t cancer, why is my prostate growing?”
  8. “Is there anything I should be doing to prevent further problems?”

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 mentions lifestyle modifications, you will ask:
    • “Will that really make a difference, or do I need medication?”
  • If the doctor suggests medication, you may ask:
    • “Are there any side effects I should be worried about?”
  • If the doctor mentions a prostate exam or PSA testing, you may ask:
    • “How reliable is the PSA test? What happens if it’s high?”

Additional Context for the Role-Player

  • You trust medical advice but want a clear explanation of the diagnosis.
  • You are open to testing but need reassurance about the purpose and necessity of each test.
  • You want to improve your symptoms without unnecessary interventions.
  • You prefer practical advice and want to understand how to prevent worsening symptoms.

Role-Player Summary

This case assesses the candidate’s ability to:

  • Take a structured history, identifying features of BPH while ruling out prostate cancer and other urinary conditions.
  • Provide a differential diagnosis, considering BPH, UTI, bladder pathology, and prostate cancer.
  • Explain the need for investigations, including urinalysis, PSA testing, and possibly imaging.
  • Offer initial management strategies, including lifestyle changes, medication options, and referral if needed.
  • Address patient concerns empathetically, particularly about prostate cancer, treatment options, and prognosis.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, considering potential causes of lower urinary tract symptoms (LUTS).

The competent candidate should:

  • Clarify symptom onset, duration, and progression, noting severity and impact on daily life.
  • Assess specific urinary symptoms, including:
    • Storage symptoms – frequency, urgency, nocturia.
    • Voiding symptoms – weak stream, hesitancy, straining, incomplete emptying.
    • Post-micturition symptoms – dribbling, sensation of incomplete voiding.
  • Rule out red flag symptoms, such as:
    • Haematuria, weight loss, significant pain, or recurrent urinary retention.
  • Explore lifestyle and fluid intake habits, including caffeine and alcohol consumption.
  • Review medication history, particularly anticholinergics, diuretics, and antihypertensives, which may exacerbate symptoms.
  • Assess past medical and family history, focusing on prostate cancer, urinary tract infections (UTIs), and kidney disease.
  • Address the patient’s concerns, particularly about cancer risk and treatment options.

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

The competent candidate should:

  • Explain that benign prostatic hypertrophy (BPH) is the most likely cause, given the gradual onset of urinary symptoms, absence of pain, and age-related prostate enlargement.
  • Discuss other possible conditions, including:
    • Prostate cancer – if symptoms include haematuria, significant weight loss, or a hard, irregular prostate on examination.
    • Bladder outlet obstruction (e.g., urethral stricture) – if history of instrumentation, trauma, or recurrent UTIs.
    • Chronic urinary tract infection (UTI) – if symptoms include dysuria, urgency, and recurrent infections.
    • Overactive bladder syndrome – if urgency and frequency are predominant without voiding difficulties.
  • Reassure the patient that BPH is a common, manageable condition, but further tests are needed to confirm the diagnosis and rule out serious 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 concerns about prostate cancer, explaining that BPH does not increase cancer risk but symptoms overlap.
  • Explain the need for investigations, including:
    • Urinalysis – to rule out infection or haematuria.
    • Serum prostate-specific antigen (PSA) – to assess prostate cancer risk.
    • International Prostate Symptom Score (IPSS) – to quantify symptom severity.
    • Renal function tests (UECs) – to assess for post-renal obstruction.
    • Bladder ultrasound (if needed) – to check for post-void residual volume and bladder stones.
  • Discuss lifestyle modifications, including:
    • Reducing caffeine, alcohol, and evening fluid intake.
    • Double voiding techniques to empty the bladder fully.
    • Pelvic floor exercises to improve urinary control.
  • Reassure the patient that medical treatments are available, including medications to relax the prostate and improve flow.

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

The competent candidate should:

  • Order initial investigations, including:
    • Urinalysis, PSA, renal function tests (UECs), and IPSS scoring.
    • Bladder ultrasound if symptoms are moderate to severe.
  • Initiate medical therapy if appropriate, such as:
    • Alpha-blockers (e.g., tamsulosin) for symptom relief.
    • 5-alpha reductase inhibitors (e.g., finasteride) if significant prostate enlargement.
  • Provide non-pharmacological advice, including:
    • Fluid management (reducing caffeine/alcohol, avoiding excessive evening fluids).
    • Bladder training techniques and timed voiding strategies.
  • Discuss surgical options if symptoms are severe or refractory, such as:
    • Transurethral resection of the prostate (TURP) in cases of significant obstruction or failure of medical therapy.
  • Arrange follow-up in 4-6 weeks to review symptoms, investigation results, and treatment response.

SUMMARY OF A COMPETENT ANSWER

  • Takes a detailed history, covering urinary symptoms, risk factors, and red flags.
  • Provides a structured differential diagnosis, considering BPH, prostate cancer, UTI, and bladder dysfunction.
  • Explains the need for investigations, including PSA testing, urinalysis, and bladder ultrasound.
  • Develops an evidence-based management plan, incorporating medications, lifestyle modifications, and potential surgical referral.
  • Ensures appropriate follow-up, monitoring for symptom progression or complications.

PITFALLS

  • Failing to assess for red flag symptoms, such as haematuria, weight loss, or urinary retention.
  • Not considering prostate cancer as a differential, leading to missed or delayed diagnosis.
  • Over-reassuring the patient without offering investigations, particularly PSA testing and urinalysis.
  • Not providing clear management strategies, such as lifestyle changes and medication options.
  • Delaying follow-up, missing opportunities for symptom monitoring and early intervention if symptoms worsen.

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 LUTS, red flags, and lifestyle 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 BPH while excluding 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 lifestyle modifications and medical therapy.
4.2 Ensures appropriate pharmacological and non-pharmacological management, promoting preventive health.

5. Preventive and Population Health

5.1 Discusses prostate cancer screening and lifestyle modifications.

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 prostate cancer or urinary retention requiring urgent intervention.

Competency at Fellowship Level

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