CASE INFORMATION

Case ID: CCE-PARKINSON-001
Case Name: Mr. John Andrews
Age: 72
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: N87 (Parkinsonism)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Communicates appropriately in the sociocultural context. 1.2 Engages the patient to gather information about their symptoms, concerns, and expectations. 1.4 Communicates effectively in routine and difficult situations.
2. Clinical Information Gathering and Interpretation	2.1 Gathers a comprehensive history, including motor and non-motor symptoms. 2.2 Assesses medication effectiveness and side effects.
3. Diagnosis, Decision-Making, and Reasoning	3.1 Diagnoses Parkinsonism based on clinical features. 3.2 Differentiates Parkinson’s disease from other causes of tremor or movement disorders.
4. Clinical Management and Therapeutic Reasoning	4.1 Provides appropriate pharmacological and non-pharmacological management. 4.2 Adjusts medications based on symptom progression and side effects.
5. Preventive and Population Health	5.1 Educates the patient and family about disease progression and prognosis. 5.2 Provides fall prevention strategies and lifestyle advice.
6. Professionalism	6.1 Demonstrates empathy and patient-centred care in discussing a chronic progressive illness.
7. General Practice Systems and Regulatory Requirements	7.1 Refers appropriately to neurologists, physiotherapists, occupational therapists, and speech pathologists.
9. Managing Uncertainty	9.1 Recognises when symptoms are atypical and require further specialist input.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies the impact of Parkinsonism on daily function and quality of life.

CASE FEATURES

Concerned about driving ability and future prognosis.
72-year-old male with progressive tremor, rigidity, and bradykinesia over 2 years.
Recently worsening mobility with occasional near-falls at home.
On Sinemet (levodopa/carbidopa) with fluctuating symptom control.
Reports difficulty swallowing and mild cognitive impairment.
Wife is his primary carer, but carer strain is increasing.

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

Mr. John Andrews, a 72-year-old retired school teacher, presents with progressive tremor, slowness, and stiffness over the past two years. Initially mild, his symptoms have gradually worsened, making daily activities more difficult. His wife, Mary, who accompanies him, reports that he now struggles with fine motor tasks such as buttoning his shirt and handling cutlery.

PATIENT RECORD SUMMARY

Patient Details

Name: John Andrews
Age: 72
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Sinemet (levodopa/carbidopa) 100/25 mg – 3 times daily
Aspirin 100 mg – daily
Atorvastatin 20 mg – daily

Past History

Hypertension
Hypercholesterolaemia
Osteoarthritis (mild, affecting knees)

Social History

Retired school teacher

Family History

No known family history of Parkinson’s disease

Smoking

Nil

Alcohol

Occasional glass of wine

Vaccination and Preventative Activities

Up to date

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 hands are getting worse, and I feel like I’m slowing down. My wife is worried too.”

General Information

John Andrews is a 72-year-old retired school teacher who was diagnosed with Parkinson’s disease a year ago. His symptoms initially responded well to Sinemet (levodopa/carbidopa), but recently, the effectiveness seems to be wearing off before the next dose. He has difficulty with fine motor tasks, such as buttoning his shirt and handling cutlery, and his walking has become more unsteady.

Specific Information

(Only if asked appropriately)

Background Information

John is becoming frustrated with his increasing difficulty in daily activities. He values his independence, but he is beginning to feel like a burden to his wife, Mary, who is his primary carer. They have been managing well, but Mary is becoming exhausted and has expressed concern about his safety at home.

John has mild swallowing issues, and he occasionally forgets things, but he is unsure whether this is just age-related or something more concerning.

He has not fallen yet, but he has frozen mid-step a few times, particularly when walking through doorways or narrow spaces.

He is worried about driving and wants advice on whether he is still fit to drive. He also wants to discuss what to expect as the disease progresses.

Motor Symptoms

Tremor started on his right hand and has gradually worsened. Now, his left hand is also slightly affected.
Bradykinesia (slowness of movement) makes daily activities like dressing, eating, and writing more difficult.
Rigidity in his muscles makes his movements feel stiff and effortful.
Has freezing episodes, mainly when walking through doorways or turning.
Worsening balance with occasional near-falls.
Not using a walking aid yet but considering a cane.

Non-Motor Symptoms

Mild cognitive changes: occasionally forgets names or misplaces things.
Mild swallowing difficulties: sometimes coughs or chokes when eating.
Constipation has become a regular issue.
Mood: Occasionally feels low, but no significant depression.
Sleep issues: Sometimes wakes up at night and has difficulty falling back asleep.

Current Medications and Effectiveness

Sinemet (levodopa/carbidopa) 100/25 mg, three times a day:
- Initially worked well but now wearing off too soon.
- Experiencing “off” periods, where symptoms return before the next dose.
- Has noticed some involuntary movements (dyskinesia) when the medication is at its peak.

Emotional Cues and Body Language

Frustrated and concerned about worsening symptoms.
Tries to remain positive but feels discouraged about his future.
Occasionally looks to his wife for reassurance.
Shifts in his chair and rubs his hands together, as if trying to ease stiffness.
Mild hand tremor visible, particularly when resting his right hand.
Pauses briefly when speaking, sometimes searching for words.

Concerns and Expectations

Concerns About Disease Progression

“How quickly will this get worse? I don’t want to become completely dependent on my wife.”
“Is there anything else I can do to slow this down?”
“What happens if my memory gets worse?”

Concerns About Medication

“Do I need a higher dose of medication?”
“Is there a better treatment?”
“What are the side effects of increasing my medication?”

Safety Concerns

“Am I still safe to drive?”
“Should I be using a walking aid?”
“What can I do to prevent falls at home?”

Carer Strain

“My wife does everything for me, and I feel guilty about it. Is there any support for her?”
“What happens when she can’t look after me anymore?”

Questions for the Doctor

“Should I see a neurologist again?”
“Do I need to change my medication?”
“What do I do if my swallowing gets worse?”
“Is there a physiotherapist who can help me?”
“What is my life going to look like in five years?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient regarding his Parkinson’s disease and its impact on his daily life.

The competent candidate should:

Use open-ended questions to explore the patient’s main concerns, including motor and non-motor symptoms.
Identify medication response patterns, including wearing-off effects, dyskinesia, and freezing episodes.
Assess for non-motor symptoms, such as mood changes, cognitive impairment, constipation, and swallowing difficulties.
Evaluate functional impact, including difficulties with activities of daily living (ADLs) and the burden on his wife as a carer.
Explore safety concerns, including falls risk and fitness to drive.

Task 2: Outline your differential diagnosis and explain the likely progression of Parkinson’s disease to the patient.

The competent candidate should:

Acknowledge the progressive nature of Parkinson’s disease.
Discuss differentials, including atypical Parkinsonism (e.g., multiple system atrophy, progressive supranuclear palsy) if red flags are present.
Explain the staging of Parkinson’s disease, using simple terms.
Address the patient’s concerns about worsening symptoms, cognition, and dependence.
Reassure that multidisciplinary care and medication optimisation can help maintain function and quality of life.

Task 3: Develop a patient-centred management plan, including medication adjustment, allied health referrals, and support for the carer.

The competent candidate should:

Consider adjusting levodopa dosing to manage wearing-off effects or introducing a dopamine agonist, COMT inhibitor, or MAO-B inhibitor.
Recommend physiotherapy for gait and balance training, occupational therapy for daily activities, and speech therapy for swallowing and speech issues.
Address carer strain, offering carer support services and respite care options.
Advise home modifications (e.g., removing trip hazards, installing grab rails) to reduce fall risk.
Provide driving safety advice and discuss referral to an occupational therapy driving assessment.

SUMMARY OF A COMPETENT ANSWER

Comprehensive history-taking, covering motor and non-motor symptoms.
Clear explanation of disease progression and differential diagnoses.
Multidisciplinary management, including medication adjustments and allied health referrals.
Patient-centred care, addressing safety concerns and carer support.
Guidance on fitness to drive and home safety modifications.

PITFALLS

Failing to assess non-motor symptoms (e.g., mood, cognition, swallowing).
Overlooking carer burden and not offering support options.
Not considering medication adjustments despite reported wearing-off symptoms.
Failing to discuss driving and fall prevention strategies.
Using overly technical explanations instead of patient-friendly language.

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

2. Clinical Information Gathering and Interpretation

2.1 Gathers relevant clinical, psychological, and social information.
2.2 Identifies important patterns and red flags.

3. Diagnosis, Decision-Making, and Reasoning

3.1 Forms a rational differential diagnosis.
3.3 Uses appropriate clinical reasoning to guide management.

4. Clinical Management and Therapeutic Reasoning

4.2 Selects appropriate pharmacological and non-pharmacological interventions.
4.3 Provides a patient-centred management plan.

5. Preventive and Population Health

5.1 Identifies risks related to disease progression and falls prevention.

6. Professionalism

6.2 Recognises carer burden and ethical considerations in long-term care.

7. General Practice Systems and Regulatory Requirements

7.1 Provides appropriate referrals and care coordination.

8. Procedural Skills

8.1 Recognises need for allied health interventions (e.g., physiotherapy, speech therapy).

9. Managing Uncertainty

9.1 Handles prognosis discussions with empathy and realism.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises progressive neurodegenerative conditions and palliative considerations.

Competency at Fellowship Level

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