CCE-CE-190

CASE INFORMATION

Case ID: PB-006
Case Name: Emily Carter
Age: 35
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: X76 (Breast Pain)​

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient with empathy and active listening
1.2 Explains clinical findings and management clearly
1.5 Uses appropriate language to alleviate anxiety and concerns
2. Clinical Information Gathering and Interpretation2.1 Conducts a structured history focusing on breast pain characteristics, risk factors, and red flags
2.2 Identifies relevant physical examination findings to guide diagnosis
3. Diagnosis, Decision-Making and Reasoning3.1 Forms an appropriate differential diagnosis
3.2 Identifies red flag symptoms requiring urgent investigation
4. Clinical Management and Therapeutic Reasoning4.2 Develops a patient-centred management plan
4.3 Provides reassurance, lifestyle advice, and treatment options as appropriate
5. Preventive and Population Health5.1 Identifies and addresses modifiable risk factors for breast pain
5.3 Provides education on breast self-examination and screening
6. Professionalism6.2 Maintains patient confidentiality and establishes a supportive relationship
7. General Practice Systems and Regulatory Requirements7.3 Ensures appropriate documentation and referral in line with guidelines
9. Managing Uncertainty9.1 Recognises when imaging or specialist referral is required
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies red flag features suggestive of significant pathology

CASE FEATURES

  • 35-year-old female presenting with unilateral breast pain for 3 weeks.
  • No palpable lump, but concerned about breast cancer.
  • No nipple discharge or skin changes, but some tenderness on examination.
  • Cyclical pattern of pain, worsening before menstruation.
  • Mildly anxious about breast cancer, as her aunt had breast cancer at 50.
  • Discussion of benign vs. concerning breast pain causes, including fibrocystic changes, mastalgia, infection, and malignancy.
  • Reassurance, education, and appropriate safety netting required.

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 a physical 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

Emily Carter, a 35-year-old office worker, presents with right breast pain for three weeks. She describes the pain as dull and achy, occurring mostly in the outer upper quadrant of her breast. The pain seems to worsen a few days before her period and improves after menstruation.

She seeks reassurance and wants to know if she needs imaging.

PATIENT RECORD SUMMARY

Patient Details

  • Name: Emily Carter
  • Age: 35
  • Gender: Female
  • Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • None currently

Past History

  • No previous breast issues or surgeries

Social History

  • Works in an office job with high stress levels.

Family History

  • Maternal aunt diagnosed with breast cancer at age 50.
  • No other significant family history.

Smoking & Alcohol

  • Non-smoker.
  • Minimal alcohol intake.

Vaccination and Preventive 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 pain in my right breast for the last few weeks, and I’m really worried it could be cancer.”

General Information

(Freely Shared if Asked Open-Ended Questions)

  • The pain started about three weeks ago and is mostly in the outer upper quadrant of my right breast.
  • The pain is dull and achy, and sometimes feels like a heaviness or tenderness.
  • The pain seems to come and go, but I’ve noticed it gets worse just before my period and then improves afterward.
  • No lump, no nipple discharge, and no skin changes (no dimpling, puckering, or redness).

Specific Information

(Only If Asked Targeted Questions)

Background Information

  • No fever or feeling generally unwell.
  • Pressing on the area makes it feel more sore.
  • My bras feel a little tighter than usual, but I haven’t changed my size.
  • I’ve been feeling more stressed lately because of work, and I feel like that has made me more aware of the pain.

Menstrual and Hormonal History

  • I have regular periods every 28 days, lasting about 5 days.
  • I do not take the pill or any hormonal contraception.
  • I have noticed breast tenderness before my period before, but this time it’s more noticeable and just in one breast, which is making me worried.

Risk Factors and Red Flags

  • I have no personal history of breast lumps, cysts, or biopsies.
  • I have no unexplained weight loss, night sweats, or fatigue.
  • I do not smoke and only drink socially (1–2 drinks per week).
  • My maternal aunt had breast cancer at age 50, which makes me nervous.
  • I do not have a BRCA gene mutation (not tested) and no one else in my family has had breast cancer.

Lifestyle Factors and Other Symptoms

  • I do not exercise regularly, but I don’t think my weight has changed recently.
  • I don’t drink much caffeine—just one coffee in the morning.
  • I usually sleep on my right side, which I wondered if it might be making it worse.
  • I haven’t started any new medications or supplements recently.

Emotional Cues & Reactions

  • Mildly anxious, mostly because of my family history of breast cancer.
  • A bit embarrassed that I might be overreacting, but I’d rather be sure.
  • Worried about needing a mammogram, as I’ve never had one before.
  • Relieved if the doctor explains that breast pain is often benign, but still wants to be reassured about what to do next.

Questions the Patient Might Ask

  1. “Do you think this could be cancer?”
  2. “Do I need a mammogram or any tests?”
  3. “What could be causing this pain?”
  4. “Is there anything I can do to help with the pain?”
  5. “When should I come back if it doesn’t improve?”
  6. “Should I be doing breast self-examinations?”
  7. “Does my family history increase my risk?”

How to Play the Role

Opening Scene (First Few Minutes)

  • Appear mildly anxious but not overly distressed.
  • Speak calmly but with slight concern, especially when mentioning family history.
  • Maintain eye contact but occasionally touch your breast area lightly to show discomfort.

If the Doctor Explores Symptoms and History Thoroughly:

  • Gradually feel reassured, but still want to understand what’s causing the pain.
  • Be open to explanations about cyclical breast pain and hormonal influences.
  • Express relief if the doctor explains why cancer is unlikely, but still seek advice on when to follow up.

If the Doctor Dismisses the Concerns Too Quickly:

  • Look unconvinced and slightly frustrated.
  • Say, “But it’s just in one breast, and that worries me. Are you sure?”
  • Ask more questions about family history and the need for tests.

If the Doctor Discusses Mammograms or Further Tests:

  • Look slightly nervous but open to reassurance.
  • Ask, “Wouldn’t a mammogram be too painful if my breast is already sore?”
  • Ask, “Is it normal to get a mammogram at my age?”

If the Doctor Recommends Lifestyle Modifications or Reassurance:

  • Listen attentively and ask follow-up questions about how long it will take to get better.
  • Agree to try non-medical options (e.g., wearing a supportive bra, reducing caffeine, stress management).

Ending the Consultation (Final Reaction Depending on the Doctor’s Approach)

If the Doctor Provides a Clear Plan and Reassurance:

  • Look relieved and nod in understanding.
  • Say, “That makes sense. I’ll try these things and keep an eye on it.”
  • Agree to follow up in a few weeks if symptoms persist.

If the Doctor Is Unclear or Does Not Address Concerns Fully:

  • Appear hesitant and still slightly anxious.
  • Say, “I just don’t want to miss anything serious. Maybe I should get a second opinion?”
  • Less likely to follow the recommended management plan.

Key Features for the Examiner to Observe

  • How well the candidate explores the history of the breast pain, including cyclical patterns.
  • Ability to differentiate between benign and concerning causes of breast pain.
  • Empathetic and reassuring communication, addressing cancer concerns.
  • Providing clear management advice, including when imaging is necessary.
  • Explaining breast self-examination and screening recommendations.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a detailed history of the breast pain, including duration, characteristics, and risk factors.

The competent candidate should:

  • Elicit the key characteristics of the breast pain, including:
    • Onset, duration, and progression (when it started and if it has worsened).
    • Location (unilateral or bilateral, localised or diffuse).
    • Nature and severity (sharp, dull, aching, burning).
    • Cyclical or non-cyclical pattern (relation to the menstrual cycle).
    • Aggravating and relieving factors (compression, exercise, caffeine, stress).
  • Assess associated symptoms, including:
    • Presence of lumps, nipple discharge, skin changes.
    • Fever, redness, swelling (suggestive of infection).
    • Weight loss, fatigue, night sweats (red flags for malignancy).
  • Explore personal and family history, including:
    • Past breast issues, previous imaging, or biopsies.
    • Family history of breast cancer or genetic conditions (e.g., BRCA mutations).
  • Assess hormonal and lifestyle factors, including:
    • Menstrual cycle, hormone therapy, contraception.
    • Caffeine, alcohol, smoking, and exercise levels.
  • Check patient’s concerns and expectations, including anxiety about breast cancer.

Task 2: Formulate an appropriate differential diagnosis, considering red flags.

The competent candidate should:

  • Consider common causes of breast pain, including:
    • Cyclical mastalgia (hormonal, related to menstrual cycle).
    • Non-cyclical mastalgia (chronic breast pain, structural changes).
    • Fibrocystic breast changes (nodularity, tenderness).
    • Musculoskeletal pain (costochondritis, referred pain).
    • Infection (mastitis, abscess) (redness, warmth, fever).
  • Identify red flag conditions requiring urgent assessment, including:
    • Inflammatory breast cancer (skin changes, peau d’orange, rapid progression).
    • Breast malignancy (persistent unilateral pain, lump, skin/nipple retraction).
    • Paget’s disease of the breast (nipple eczema, discharge, ulceration).
  • Differentiate between benign and concerning breast pain, considering history and examination findings.

Task 3: Provide an explanation of possible causes and discuss when imaging or referral is needed.

The competent candidate should:

  • Explain likely benign causes, particularly cyclical mastalgia, and why cancer is unlikely.
  • Discuss indications for further investigation, including:
    • Persistent, localised pain without obvious cause.
    • Associated lump, nipple changes, or skin changes.
    • Pain that does not improve with conservative measures.
  • Outline appropriate investigations, including:
    • Clinical breast examination (to assess for lumps or structural changes).
    • Ultrasound (first-line for younger women under 40).
    • Mammogram (if over 40, strong family history, or concerning findings).
  • Reassure the patient that most cases of breast pain are non-cancerous and explain the role of monitoring and follow-up.

Task 4: Develop a patient-centred management plan, including reassurance, lifestyle modifications, and follow-up.

The competent candidate should:

  • Provide reassurance that cyclical breast pain is common and often self-limiting.
  • Recommend lifestyle modifications, including:
    • Well-fitted supportive bra.
    • Reducing caffeine and dietary fat intake (as per evidence-based guidance).
    • Stress management techniques (exercise, relaxation).
  • Discuss pharmacological options if pain is persistent, including:
    • Simple analgesia (paracetamol, NSAIDs).
    • Topical NSAIDs for localised tenderness.
    • Hormonal modulation (tamoxifen, evening primrose oil) in select cases.
  • Provide clear safety netting advice, including when to return for review:
    • If the pain worsens, persists beyond 3 months, or new symptoms develop.
  • Follow-up plan, either to reassess symptoms or discuss imaging results if needed.

SUMMARY OF A COMPETENT ANSWER

  • Thorough history-taking, covering pain characteristics, menstrual cycle influence, and risk factors.
  • Comprehensive differential diagnosis, distinguishing benign from concerning causes.
  • Clear explanation of likely causes, providing reassurance where appropriate.
  • Discussion of indications for imaging and specialist referral, avoiding unnecessary investigations.
  • Holistic management plan, including lifestyle modifications, simple analgesia, and follow-up advice.
  • Empathetic and patient-centred communication, addressing concerns about breast cancer.

PITFALLS

  • Failing to ask about cyclical vs. non-cyclical patterns, missing hormonal influence.
  • Overlooking red flag symptoms, such as nipple retraction or peau d’orange.
  • Over-reliance on imaging without clinical indication, leading to unnecessary anxiety.
  • Not addressing patient anxiety, particularly around family history of breast cancer.
  • Providing vague reassurance without a structured management plan.
  • Neglecting 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, expectations of healthcare, and the full impact of their illness experience.
1.5 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a structured history focusing on breast pain characteristics, risk factors, and red flags.
2.2 Identifies relevant physical examination findings to guide diagnosis.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms an appropriate differential diagnosis.
3.2 Identifies red flag symptoms requiring urgent investigation.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops a patient-centred management plan.
4.3 Provides reassurance, lifestyle advice, and treatment options as appropriate.

5. Preventive and Population Health

5.1 Identifies and addresses modifiable risk factors for breast pain.
5.3 Provides education on breast self-examination and screening.

9. Managing Uncertainty

9.1 Recognises when imaging or specialist referral is required.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies red flag features suggestive of significant pathology.

Competency at Fellowship Level

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