CASE INFORMATION

Case ID: CCE-2025-UI01
Case Name: Margaret Johnson
Age: 67
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: U04 (Urinary Incontinence)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Communicates appropriately for the sociocultural context. 1.2 Engages patient to explore symptoms, concerns, and expectations. 1.4 Effectively communicates in difficult situations.
2. Clinical Information Gathering and Interpretation	2.1 Uses a structured approach to history-taking. 2.2 Identifies relevant clinical signs and symptoms.
3. Diagnosis, Decision-Making and Reasoning	3.1 Forms an appropriate differential diagnosis. 3.2 Uses clinical reasoning and guidelines.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a patient-centred management plan. 4.2 Implements non-pharmacological and pharmacological management.
5. Preventive and Population Health	5.1 Provides education on modifiable risk factors and prevention strategies.
6. Professionalism	6.1 Maintains a respectful and empathetic approach.
7. General Practice Systems and Regulatory Requirements	7.1 Provides referrals appropriately.
9. Managing Uncertainty	9.1 Considers possible causes and adjusts management as needed.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies red flag symptoms and organises appropriate follow-up.

CASE FEATURES

Needs education, lifestyle changes, and possible referral.
Elderly female with urinary incontinence affecting quality of life.
History of urgency, frequency, and occasional leakage for the past 6 months.
Concerned about social embarrassment and isolation.
Possible contributing factors: vaginal atrophy, pelvic floor weakness, medications, chronic cough.

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.

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

Margaret Johnson, a 67-year-old retired teacher, presents with bothersome urinary incontinence that has worsened over the past 6 months. She describes occasional urgency and leakage when she coughs or laughs. She is embarrassed and avoiding social activities due to the fear of accidents.

She has a history of vaginal atrophy, chronic cough due to mild COPD, and is on a diuretic (hydrochlorothiazide) for hypertension. She is concerned this could be something serious and wants to know if it is “just a normal part of ageing”.

PATIENT RECORD SUMMARY

Patient Details

Name: Margaret Johnson
Age: 67
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Hydrochlorothiazide 12.5mg daily (Hypertension)
Salbutamol inhaler PRN (Mild COPD)
Vaginal oestrogen cream PRN

Past History

Hypertension
Mild COPD
Vaginal atrophy
No prior urogynaecological surgeries

Social History

Lives alone, independent in ADLs
Recently stopped attending social events due to incontinence concerns

Family History

Mother had Type 2 Diabetes and hypertension
No family history of incontinence or neurological disorders

Smoking

Ex-smoker (quit 10 years ago)

Alcohol

Occasional wine on weekends

Vaccination and Preventative Activities

Last cervical screening test 3 years ago – normal
Up to date with influenza and pneumococcal vaccines

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’m getting embarrassed to leave the house because I keep having little accidents. I don’t know what to do.”

General Information

(Share Freely If Asked Open-Ended Questions)

Symptoms started about 6 months ago and have gradually gotten worse.
Experiences sudden urges to urinate and sometimes doesn’t make it to the toilet in time.
Leaks a little when she coughs, sneezes, or laughs.
Has been wearing a pad daily, changing it two to three times a day.
Drinks about 1.5L of fluids daily, including two cups of tea in the morning.
Worried this could be a sign of something serious, like cancer.

Specific Information

(Only Provide If Directly Asked)

Voiding History:

No issues with initiating urination.
No nocturia (not waking up to urinate at night).
No dysuria (pain while urinating).
No UTI symptoms like burning or urgency associated with pain.

Medical History and Risk Factors:

Has COPD with a chronic cough that worsens in cold weather.
Takes hydrochlorothiazide for hypertension, doesn’t know if it affects her bladder.
Has postmenopausal vaginal dryness and uses oestrogen cream occasionally.
Stopped exercising because she is worried about leaking urine while walking.
No history of diabetes, kidney disease, or neurological conditions.

Impact on Quality of Life:

Avoids long outings because she doesn’t know when she will need the toilet.
Feels embarrassed in social settings, has stopped using public transport.
Worried about the smell of urine, even though no one has mentioned it.
Feels isolated because she is withdrawing from activities she once enjoyed.
Prefers to explore natural options before considering medications.
Doesn’t want surgery and hopes this can be managed conservatively.

Emotional Cues & Body Language:

Looks anxious when talking about symptoms, wrings hands.
Hesitates when discussing social withdrawal, as if ashamed.
Relieved if given reassurance that this can be managed without surgery.
Visibly uncomfortable when talking about potential odour concerns.

Questions for the Candidate:

“Is this a normal part of ageing?” (Looks concerned)
“Do I have to take medication for this?” (Slightly hesitant, seems reluctant)
“What can I do to prevent accidents?” (Leans forward, eager to hear options)
“Should I see a specialist for this?” (Appears unsure, looking for guidance)

Potential Responses to Candidate’s Management Plan:

If lifestyle modifications are suggested (e.g., reducing tea, bladder training, pelvic floor exercises):

“I didn’t know there were exercises for this! How do I do them?” (Looks interested)
“I suppose I could cut back on tea, but I love my morning cup.” (Reluctant but considering)

If medication is suggested:

“I don’t really want to take more pills. What are the side effects?” (Hesitant)
“If it’s just to help with urgency, maybe I’ll think about it.” (Not fully convinced but open)

If referral to a specialist (e.g., urogynaecologist or pelvic floor physiotherapist) is suggested:

“I’d rather not have any surgery. Can a physio really help?” (Skeptical but interested)

If reassurance is provided:

“So this isn’t something dangerous, like cancer?” (Visibly relieved)

Summary of Role-Player Behaviour:

Engages in discussion but is embarrassed at times.
Prefers conservative management options over medication or surgery.
Wants reassurance that this isn’t a serious condition.
Needs clear, practical strategies she can use in daily life.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient regarding urinary incontinence.

The competent candidate should:

Use open-ended questions to allow the patient to describe symptoms.
Explore onset, duration, frequency, severity, and triggers of incontinence.
Ask about associated symptoms (e.g., urgency, dysuria, nocturia, haematuria).
Assess fluid intake, caffeine/alcohol consumption, and bowel habits.
Inquire about medical history (e.g., COPD, diabetes, neurological conditions).
Ask about medications that may contribute to incontinence (e.g., diuretics).
Explore psychosocial impact (e.g., embarrassment, social withdrawal).
Screen for red flags (e.g., haematuria, pelvic pain, significant prolapse).

Task 2: Outline the likely diagnosis and differential diagnoses.

The competent candidate should:

Diagnose mixed urinary incontinence (urge + stress components).
Discuss other differentials:
- Stress incontinence (due to weak pelvic floor).
- Urge incontinence (overactive bladder, neurological causes).
- Overflow incontinence (urinary retention, detrusor underactivity).
- Functional incontinence (mobility issues, cognitive impairment).
Address risk factors, including age, menopause, smoking (COPD), chronic cough, and obesity.
Exclude serious pathology (e.g., malignancy, UTI, neurological disease).

Task 3: Explain the management plan, ensuring it is patient-centred.

The competent candidate should:

Provide reassurance that this is common and treatable.
Recommend lifestyle modifications:
- Reduce caffeine/alcohol intake.
- Weight loss if overweight.
- Quit smoking to reduce chronic cough.
Advise bladder training (timed voiding, urge suppression techniques).
Pelvic floor exercises (refer to women’s health physiotherapist).
Review medications (consider alternatives to diuretics).
Discuss topical vaginal oestrogen for postmenopausal atrophy.
Consider medications (anticholinergics, mirabegron) for urge incontinence.
Address psychosocial impact and encourage continued social activities.
Discuss referral options if conservative measures fail (e.g., urogynaecologist).

SUMMARY OF A COMPETENT ANSWER

Comprehensive history covering symptoms, triggers, and psychosocial impact.
Appropriate differential diagnoses with relevant exclusions.
Patient-centred management incorporating lifestyle, conservative treatments, and medication.
Clear and empathetic communication, ensuring patient concerns are addressed.

PITFALLS

Failing to screen for red flags (e.g., haematuria, neurological symptoms).
Overlooking medication review, particularly diuretics.
Not exploring psychosocial impact, leading to inadequate patient engagement.
Jumping to medications or surgery without first considering conservative options.
Providing generic advice without tailoring it to the patient’s lifestyle.

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 symptoms, ideas, concerns, expectations of healthcare, and the full impact of their illness experience.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers information through history-taking that is relevant, comprehensive, and systematic.

3. Diagnosis, Decision-Making and Reasoning

3.1 Synthesises clinical information to make appropriate and timely decisions.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides evidence-based, patient-centred management plans.

5. Preventive and Population Health

5.1 Identifies risk factors and provides preventive healthcare strategies.

6. Professionalism

6.1 Demonstrates empathy, respect, and professionalism in patient interactions.

7. General Practice Systems and Regulatory Requirements

7.1 Understands referral pathways and multidisciplinary management.

9. Managing Uncertainty

9.1 Identifies and addresses uncertainties in diagnosis and management.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages conditions that significantly impact quality of life.

Competency at Fellowship Level

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