CASE INFORMATION

Case ID: SW001
Case Name: Sarah Thompson
Age: 45 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: A22 (Swelling)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Communicates appropriately to the person and the sociocultural context. 1.2 Engages the patient to gather information about symptoms, concerns, expectations, and impact on daily life. 1.4 Communicates effectively in routine and difficult situations.
2. Clinical Information Gathering and Interpretation	2.1 Gathers essential history relevant to the swelling. 2.2 Identifies red flags requiring urgent investigation.
3. Diagnosis, Decision-Making and Reasoning	3.1 Formulates appropriate differential diagnoses. 3.2 Uses clinical reasoning to prioritise key conditions and investigations.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a patient-centred management plan. 4.2 Initiates appropriate investigations and treatment.
5. Preventive and Population Health	5.1 Identifies and manages risk factors for chronic disease.
6. Professionalism	6.1 Provides patient-centred, non-judgmental care.
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and follow-up.
9. Managing Uncertainty	9.1 Balances risk and reassurance in an undifferentiated complaint.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises when to escalate care and refer appropriately.

CASE FEATURES

Concerned about deep vein thrombosis (DVT) after reading online.
Middle-aged female presenting with progressive swelling in her right leg over several weeks.
Mild pain and tightness but no trauma history.
No significant redness, warmth, or skin changes.
Past medical history includes hypertension and obesity.

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 Thompson, a 45-year-old office worker, presents to your clinic with a swollen right leg that she noticed over the past 3 weeks. She reports a gradual increase in size, with some tightness but no significant pain.She has mild ankle pitting oedema but no redness, warmth, or visible skin changes.

Her medical history includes hypertension and obesity (BMI 32), and she takes amlodipine 5mg daily. She is otherwise well, with no breathlessness, chest pain, or systemic symptoms.

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Thompson
Age: 45
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Amlodipine 5mg daily (for hypertension)

Past History

Hypertension (diagnosed 5 years ago)
No prior DVT, PE, or clotting disorders

Social History

Works full-time as an office manager (sedentary lifestyle)

Family History

Father had a stroke at 67
Mother has type 2 diabetes

Smoking & Alcohol

Non-smoker
Alcohol: Drinks socially (1-2 standard drinks per week)

Vaccination & Preventative Activities

Last pap smear and mammogram were normal
Up-to-date with routine immunisations

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 right leg has been swollen for a few weeks now. It’s getting worse, and I’m really worried it could be a blood clot.”

General Information

(Share freely if asked open-ended questions)

The swelling started gradually about three weeks ago.
No pain initially, but now feels a mild tightness around the ankle and calf.
No redness or warmth.
Notices the swelling more in the evening or after sitting for long periods at work.
Swelling doesn’t improve much overnight.

Specific Information

(Only revealed if asked directly)

Associated Symptoms

No shortness of breath or chest pain.
No fever, chills, or recent infections.
No numbness, tingling, or weakness in the leg.
No unexplained weight loss or systemic symptoms (e.g., night sweats).
No new rashes, bruising, or open sores on the leg.

Past Medical History & Risk Factors

Hypertension (diagnosed 5 years ago) – well-controlled on amlodipine 5mg daily.
Obesity (BMI 32) – has struggled with weight for years.
No diabetes, kidney disease, or heart problems.
No history of varicose veins or venous insufficiency.
No personal or family history of blood clots.

Medications & Lifestyle

Takes amlodipine 5mg daily for hypertension.
Does not take hormonal therapy or oral contraceptives.
Sits most of the day at work and doesn’t exercise regularly.
No recent long flights or car trips longer than 4 hours.
Drinks socially (1-2 drinks per week), non-smoker.

Patient’s Concerns & Expectations

“Could this be a DVT? Should I get a scan?”
“Will I need blood thinners?”
“Could it be something serious like heart or kidney failure?”
“Should I change my blood pressure medication?”
“Will this go away on its own, or do I need treatment?”

Emotional Cues & Body Language

Appears slightly anxious when discussing DVT risk.
Relaxes slightly if the doctor explains things well.
Becomes more concerned if the doctor dismisses concerns.
Pushes for a scan if the doctor downplays the swelling.
If the doctor focuses only on weight loss, becomes defensive.

Escalating Reactions Depending on the Doctor’s Approach

If the Doctor Provides a Clear Explanation & Plan

Feels reassured and agrees to the proposed tests and management.
Asks clarifying questions but trusts the doctor’s judgement.

If the Doctor Dismisses Concerns

Insists on a scan and questions why further testing isn’t being done.
May become frustrated and ask for a second opinion.

If the Doctor Focuses Only on Weight Loss

Feels judged and defensive.
Pushes back with:
- “I know I need to lose weight, but that doesn’t explain why my leg is swollen.”

Suggested Dialogue Responses

If the Doctor Explains a DVT is Unlikely:

“I’m glad it’s not a clot, but what else could be causing the swelling? Will it go away on its own?”

If the Doctor Recommends Conservative Management:

“How long should I wait before coming back if it doesn’t get better?”

If the Doctor Suggests Amlodipine Might Be Causing the Swelling:

“Could I try a different blood pressure medication? I don’t want my leg to stay swollen.”

If the Doctor Recommends Compression Stockings or Elevation:

“Will that actually help? I don’t want to just cover up the problem.”

Closing Thoughts & Expectations

Wants a logical explanation for the swelling.
Will follow recommendations if they seem reasonable.
Expects at least some form of testing (D-dimer or Doppler ultrasound) to rule out DVT.
If reassured properly, feels comfortable with monitoring before further tests.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient regarding their leg swelling.

The competent candidate should:

Use open-ended questions to explore the onset, duration, progression, and nature of the swelling.
Ask about associated symptoms (pain, redness, warmth, systemic symptoms).
Assess for red flag symptoms (shortness of breath, chest pain, unilateral swelling).
Obtain relevant past medical history (hypertension, heart failure, kidney disease, venous insufficiency, DVT history).
Review medications, particularly those that may contribute to oedema (amlodipine, NSAIDs, corticosteroids).
Explore lifestyle factors, including mobility, recent travel, and occupation-related prolonged sitting.
Address patient concerns and expectations (DVT fear, diagnostic tests, treatment options).

Task 2: Outline your differential diagnosis and rationale.

The competent candidate should:

Consider serious causes first:
- Deep vein thrombosis (DVT) – if unilateral, with associated pain, warmth, or risk factors.
- Heart failure – if bilateral swelling with exertional dyspnoea, orthopnoea.
- Renal disease – if associated with proteinuria, frothy urine.
- Liver disease – if history of cirrhosis, alcohol use, jaundice.
Consider non-life-threatening causes:
- Medication-induced oedema – especially calcium channel blockers like amlodipine.
- Chronic venous insufficiency – if worsens with standing, improves with leg elevation.
- Lymphoedema – if chronic, non-pitting, history of trauma or cancer treatment.

Task 3: Explain your management plan, including investigations and patient education.

The competent candidate should:

Low suspicion for DVT:
- Use Well’s score to stratify risk.
- If low-risk: D-dimer test, avoid unnecessary Doppler ultrasound.
High suspicion for DVT:
- Urgent Doppler ultrasound, start anticoagulation if confirmed.
If medication-induced oedema suspected:
- Consider changing antihypertensive (e.g., ACE inhibitor instead of amlodipine).
If heart/renal/liver disease suspected:
- Order BNP, renal function tests, liver function tests, ECG.
Conservative measures:
- Leg elevation, compression stockings, avoiding prolonged sitting.
- Encourage mobility and weight management if relevant.
Safety netting:
- Educate about red flag symptoms (sudden worsening, breathlessness).
- Arrange follow-up for review of symptoms and test results.

SUMMARY OF A COMPETENT ANSWER

Takes a thorough history including risk factors, associated symptoms, and medications.
Forms a differential diagnosis prioritising serious causes (DVT, heart failure, renal/liver disease).
Uses evidence-based investigation strategies (Well’s score, D-dimer, Doppler ultrasound if needed).
Provides patient-centred management (medication review, lifestyle advice, compression therapy).
Communicates clearly with appropriate safety netting and follow-up.

PITFALLS

Failing to assess for DVT risk factors (recent travel, surgery, immobilisation).
Ordering unnecessary tests (e.g., Doppler ultrasound for low-risk cases without using Well’s score).
Overlooking medication-induced oedema (especially calcium channel blockers).
Not considering systemic causes like heart failure or kidney disease.
Not addressing patient concerns about serious causes like DVT.

REFERENCES

MARKING

Each competency area is 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 person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations, and the full impact of their illness.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Applies a structured approach to history-taking.
2.2 Identifies and prioritises key information relevant to the case.

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulates a logical and evidence-based differential diagnosis.
3.2 Uses clinical decision rules appropriately (e.g., Well’s score).

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a patient-centred management plan.
4.2 Selects and justifies appropriate investigations.
4.3 Implements safe and effective treatment strategies.

5. Preventive and Population Health

5.1 Provides preventive advice regarding cardiovascular risk factors.

6. Professionalism

6.1 Maintains a respectful and patient-centred approach.

9. Managing Uncertainty

9.1 Uses clinical reasoning to balance risks and benefits of testing.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and escalates care for potentially serious conditions.

Competency at Fellowship Level

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