CASE INFORMATION

Case ID: 0034
Case Name: Michael Johnson
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: F99 – Eye/adnexa disease, other

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Uses patient-centred communication 1.2 Gathers relevant clinical and psychosocial information 1.4 Explains diagnosis and management effectively
2. Clinical Information Gathering and Interpretation	2.1 Conducts a focused history and examination
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a reasonable differential diagnosis 3.2 Justifies investigations and treatment options
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a safe, evidence-based management plan
5. Preventive and Population Health	5.1 Provides education on eye health and preventive strategies
6. Professionalism	6.3 Maintains patient-centred care and respect
7. General Practice Systems and Regulatory Requirements	7.2 Documents and follows appropriate referral pathways
9. Managing Uncertainty	9.1 Recognises red flags and indications for specialist referral
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and manages potentially serious eye conditions

CASE FEATURES

Concerned about worsening vision and risk of long-term damage.
A 45-year-old male presents with persistent eye discomfort, redness, and foreign body sensation.
The symptoms have gradually worsened over two weeks, affecting daily activities.
No history of eye trauma, but mild dry eye symptoms in the past.
Works outdoors as a construction worker, with high sun and dust exposure.
No significant past medical history, no contact lens use, and no history of autoimmune disease.

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 Johnson, a 45-year-old construction worker, presents with persistent eye irritation and redness that has gradually worsened over two weeks. He describes a gritty, foreign body sensation and occasional blurred vision but denies severe pain, photophobia, or discharge.

He has a history of mild dry eye symptoms, particularly after long days working outdoors in windy and dusty environments. He has no history of autoimmune disease, recent eye infections, or contact lens use.

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Johnson
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular medications

Past History

Mild dry eye symptoms in the past (never formally diagnosed)

Social History

Works as a construction worker
Non-smoker, drinks alcohol socially

Family History

No family history of glaucoma or autoimmune disease

Smoking and Alcohol

Non-smoker
Alcohol: 2-3 drinks per week

Vaccination and Preventive Activities

Up to date with routine 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

“Hi Doctor, I’ve been having this really annoying eye irritation for the past couple of weeks, and it’s getting worse. It feels like something is stuck in my eye.”

General Information

Your name is Michael Johnson, you’re 45 years old, and you work as a construction worker.
You first noticed eye irritation about two weeks ago, but at first, you thought it would go away on its own.
The irritation is mostly in the right eye but sometimes affects both.
It feels gritty and dry, like there’s a foreign body in the eye, especially after long days outdoors.

Specific Information

(Only Reveal If Asked)

Background Information

The redness has worsened, and there’s been some occasional blurry vision, but no major pain, swelling, or discharge.
You haven’t had this problem before, except for mild dry eye symptoms when working in windy conditions.
You’ve never seen an eye specialist before and don’t wear glasses or contact lenses.
You don’t have any allergies that you’re aware of and haven’t had any eye infections or injuries in the past.

Symptoms and Progression

The redness started mildly but has gotten worse over the past week.
It’s worse in the evenings, especially after a full day outside.
Over-the-counter lubricating drops haven’t helped much, and you’ve tried rinsing your eyes with water.
You haven’t noticed any discharge or crusting in the morning.
No light sensitivity or severe pain, just an irritating, gritty feeling.

Lifestyle and Work Exposure

You work in construction, often exposed to dust, wind, and strong sunlight.
You don’t regularly wear sunglasses or protective eyewear at work, except when using machinery.
Your eyes sometimes feel dry at work, but you never thought much of it before.
You spend a lot of time outdoors, often squinting in the sun.

Medical History

No past eye conditions diagnosed.
No family history of eye disease, glaucoma, or autoimmune diseases.
No history of diabetes or high blood pressure.
You are otherwise healthy and don’t take any regular medications.

Concerns and Expectations

You’re worried about your vision because the blurriness has started happening more often.
You’re concerned that this might be something serious, like an eye infection or long-term damage.
You want to know if your job is making this worse and if you need to change anything at work.
You’re hoping for something stronger than just lubricating drops, since they haven’t helped much.
You don’t want this to affect your work, so you want a clear treatment plan.
You’re wondering if you need to see a specialist or if this can be treated in general practice.

Emotional Cues and Body Language

Mildly frustrated: You expected this to improve, but it’s been two weeks and hasn’t gone away.
Anxious about vision: You worry that this could be something serious.
Engaged but cautious: You want to understand what’s happening and prefer a direct, clear explanation.
Slightly restless: You may rub your eyes occasionally but are careful not to make it worse.

Questions for the Doctor

“Do you think this could be something serious?”
“Could my work be making this worse?”
“Will I need medication, or is this just something that will go away on its own?”
“Do I need to see an eye specialist, or can you manage this?”
“Could this affect my vision in the long run?”

If the Doctor Asks About Your Preferences for Treatment

You would prefer a quick solution, like medication or eye drops that actually work.
You are open to making small changes at work, but you don’t want to stop working outdoors.
If told to wear sunglasses or protective eyewear, you’ll say:
- “I don’t really like wearing glasses, but if it will help, I’ll give it a shot.”

If the Doctor Reassures You That This Isn’t Serious

You will feel relieved but still ask:
- “So what do I do to stop it from coming back?”

Key Takeaways for the Role-Player

Your main concern is worsening vision and whether this could be something serious.
You’re open to treatment, but you want something that works quickly.
You don’t want this to interfere with your work, so you’re looking for practical solutions.
You’re engaged in the consultation and will ask follow-up questions if needed.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient

The competent candidate should:

Use open-ended questions to explore the nature and duration of the patient’s eye symptoms, including redness, irritation, foreign body sensation, and blurriness.
Elicit associated symptoms such as pain, discharge, photophobia, itching, and visual disturbances.
Take a comprehensive occupational and environmental history, including dust, wind, UV exposure, and use of protective eyewear.
Assess previous eye conditions or injuries, past ophthalmology visits, and use of corrective lenses.
Explore medical history for systemic conditions that could contribute (e.g., autoimmune diseases, diabetes, allergies).
Ask about current treatments the patient has tried and their effectiveness.

Task 2: Outline your differential diagnoses

The competent candidate should:

Identify likely causes of the patient’s symptoms, including:
- Dry eye syndrome (occupational exposure, environmental triggers)
- Conjunctivitis (viral, allergic, bacterial)
- Pterygium or pinguecula (associated with sun exposure)
- Blepharitis (chronic eyelid inflammation)
- Corneal foreign body or abrasion (consider given occupation)
Consider less common but serious causes, such as keratitis, uveitis, or early glaucoma.
Justify the likelihood of each differential diagnosis based on history and examination findings.

Task 3: Develop a management plan

The competent candidate should:

Provide symptomatic relief:
- Prescribe lubricating eye drops for dry eye symptoms.
- Recommend cold compresses if inflammation is suspected.
Address environmental and occupational factors:
- Encourage the use of protective eyewear at work.
- Advise regular eye hydration and breaks from dust/wind exposure.
Prescribe appropriate treatment if indicated:
- Antihistamine eye drops for allergic conjunctivitis.
- Topical antibiotics if bacterial infection is suspected.
Educate on red flag symptoms that require urgent review (e.g., sudden vision loss, severe pain, photophobia).
Consider referral to an ophthalmologist if there are uncertain findings, persistent symptoms, or suspicion of a serious condition.

SUMMARY OF A COMPETENT ANSWER

Elicits a detailed history, including occupational and environmental exposure.
Considers a broad differential diagnosis, with appropriate justifications.
Develops a patient-centred management plan, addressing both symptom relief and preventive measures.
Provides clear safety-netting advice and explains when to seek urgent care.

PITFALLS

Failing to explore occupational exposure, missing an important contributing factor.
Overlooking systemic causes, such as autoimmune conditions.
Not considering serious eye conditions, such as keratitis or glaucoma.
Neglecting to discuss preventive measures, such as protective eyewear.
Providing treatment without safety-netting, failing to advise when to return for review.

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, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Applies a structured approach to history-taking and risk assessment.
2.2 Selects and applies appropriate diagnostic strategies.

3. Diagnosis, Decision-Making and Reasoning

3.1 Synthesises information to formulate a differential diagnosis.
3.2 Justifies clinical decisions based on evidence and patient context.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a safe and effective management plan tailored to the patient.
4.2 Provides education and preventive advice.

5. Preventive and Population Health

5.1 Identifies risk factors and provides preventive interventions.

6. Professionalism

6.1 Demonstrates patient-centred care and ethical practice.

7. General Practice Systems and Regulatory Requirements

7.1 Recognises when referral is appropriate and ensures continuity of care.

9. Managing Uncertainty

9.1 Addresses diagnostic uncertainty while ensuring patient safety.

Competency at Fellowship Level

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