CASE INFORMATION

Case ID: CCE-2025-003
Case Name: Sarah Thompson
Age: 34 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: D09 (Nausea), A88 (Pregnancy-related condition), D73 (Gastro-oesophageal reflux disease), D99 (Functional gastrointestinal disorder)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their ideas, concerns, and expectations. 1.2 Develops a respectful and empathetic doctor-patient relationship. 1.4 Provides appropriate patient-centred explanations.
2. Clinical Information Gathering and Interpretation	2.1 Gathers relevant history, including systemic and red flag symptoms. 2.2 Selects and interprets appropriate investigations.
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops a differential diagnosis based on clinical findings. 3.5 Identifies red flag symptoms requiring urgent referral.
4. Clinical Management and Therapeutic Reasoning	4.1 Formulates a safe and evidence-based management plan. 4.3 Provides appropriate follow-up and monitoring.
5. Preventive and Population Health	5.2 Addresses modifiable risk factors for gastrointestinal and metabolic conditions.
6. Professionalism	6.1 Maintains patient confidentiality and professional integrity.
7. General Practice Systems and Regulatory Requirements	7.1 Orders appropriate tests in accordance with MBS guidelines.
9. Managing Uncertainty	9.2 Develops a plan for a patient with an unclear diagnosis.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and acts on life-threatening conditions.

CASE FEATURES

Young female presenting with four weeks of persistent nausea.
Reports no vomiting but a feeling of queasiness throughout the day.
Has missed her last menstrual period and is sexually active but has not taken a pregnancy test.
No abdominal pain, diarrhoea, or fever.
Has noticed increased fatigue over the past two weeks.
Concerned about possible pregnancy, reflux, or food intolerance.
Requires clinical reasoning to differentiate between pregnancy, gastrointestinal, metabolic, and functional causes.

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 34-year-old female, presents to your clinic complaining of persistent nausea for the past four weeks. She describes it as a constant queasy feeling, without vomiting, that occurs throughout the day. She hasn’t had any significant dietary changes and denies abdominal pain, fever, or diarrhoea.

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Thompson
Age: 34 years
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular medications

Past History

No known gastrointestinal disorders
No significant medical conditions

Social History

Works as a primary school teacher
No smoking or recreational drug use
Drinks socially (1-2 drinks per week)

Family History

Mother: Irritable bowel syndrome (IBS)
Father: Type 2 diabetes
No family history of autoimmune or gastrointestinal disorders

Vaccination and Preventative Activities

Up to date with vaccinations
Last health check two years ago

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.

SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, I’ve been feeling nauseous for the past month, and it’s not going away. I just feel queasy all the time, especially in the mornings. I don’t know what’s causing it, and I’m getting worried.”

General Information

(Freely Shared if Asked Open-Ended Questions)

The nausea started about four weeks ago and has been persistent throughout the day.
You have not vomited, but you feel a constant queasy sensation that worsens after eating.
You have noticed that certain smells, like coffee or perfume, make it worse.
You haven’t had any significant dietary changes.

Specific Information

(Only Revealed if the Candidate Asks Targeted Questions)

Background Information

You are feeling more tired than usual but have been sleeping normally.
You missed your last period, but your cycle is sometimes irregular.
You and your partner are not actively trying for pregnancy but have not been using contraception consistently.
You have not taken a pregnancy test yet.
You do not have abdominal pain, bloating, fever, or diarrhoea.
You are worried about pregnancy but also concerned that it might be something more serious.

Symptoms and Triggers

The nausea is worst in the mornings but persists throughout the day.
You feel more sensitive to strong smells lately, such as perfume and food odours.
You have not been vomiting, but food sometimes makes you feel worse.
You have had occasional mild bloating but no sharp or persistent pain.
No dizziness, headaches, or vision changes.

Lifestyle & Risk Factors

You are a primary school teacher and have a relatively active lifestyle.
You drink 1-2 standard drinks per week, mostly on weekends.
You do not smoke or use recreational drugs.
You exercise occasionally but have been feeling too tired recently to maintain your usual activity.
You eat a balanced diet, but some foods seem to make the nausea worse.
You have not travelled recently and have no history of food poisoning.

Medical & Family History

You have no past medical conditions, including no history of reflux, gastritis, or peptic ulcers.
You take no regular medications.
Your mother has irritable bowel syndrome (IBS), but you have never had gut issues before.
Your father has type 2 diabetes, but you have never had any issues with your blood sugar.

Emotional Cues & Concerns

You are worried about pregnancy but also anxious that this could be a sign of something serious.
You feel frustrated and uncomfortable because the nausea is affecting your appetite and daily activities.
You want reassurance that this is not a sign of a major health issue.
You are concerned about how long this nausea will last and what can be done to manage it.

Questions for the Candidate

(Drop these in naturally throughout the consultation)

“Could this be pregnancy, or could it be something else?”
“What tests do I need? Should I be worried about something serious?”
“If I’m pregnant, what do I do next?”
“If I’m not pregnant, what could be causing this nausea?”
“Is there anything I can do to feel better?”
“How long will this last?”
“Do I need to see a specialist, or can this be managed here?”

How to Respond Based on the Candidate’s Answers

If the Candidate Provides a Clear Explanation and Plan:

You feel relieved but still a little anxious.
You might ask for clarification on next steps:
- “So you think it’s more likely pregnancy than something serious?”
- “And if I follow the plan you’ve suggested, I should start feeling better?”
You agree to the investigations and follow-up plan.

If the Candidate is Unclear or Dismissive:

You become more anxious and insistent on further testing.
You might push for more reassurance or immediate answers:
- “I just don’t want to take any chances. Can we do all the tests now?”
- “If this gets worse, should I go to the hospital?”
- “I need to know for sure what’s going on.”

Ending the Consultation

If the Candidate Has Done Well:

You feel somewhat reassured and agree to the plan.
You might still confirm:
- “So I’ll come back in two weeks unless something changes?”
- “You’ll call me when the test results are in?”
You thank the doctor and leave with a clear idea of what to do next.

If the Candidate Has Not Addressed Your Concerns Well:

You remain doubtful and uneasy.
You may say:
- “I think I might get a second opinion. I just want to be sure.”
- “I’m still not sure if this is something serious.”
You leave feeling frustrated and uncertain about your next steps.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including red flag symptoms and relevant risk factors.

The competent candidate should:

Use open-ended questions to explore the patient’s symptoms, then targeted questions to clarify key details.
Establish onset, duration, frequency, and severity of the nausea.
Determine associated symptoms, including vomiting, abdominal pain, fever, bloating, reflux, food intolerance, dizziness, weight loss, or neurological symptoms.
Identify red flag symptoms, such as persistent vomiting, significant weight loss, haematemesis, altered bowel habits, neurological deficits, or signs of metabolic dysfunction.
Explore the patient’s menstrual history, including last menstrual period (LMP), cycle regularity, and contraceptive use, given her concern about pregnancy.
Assess dietary habits, recent travel, medication use, and alcohol consumption, which could contribute to nausea.
Evaluate stress levels and psychological factors, considering functional or anxiety-related causes.
Address the patient’s ideas, concerns, and expectations, particularly regarding pregnancy and other possible causes.
Summarise findings to ensure accuracy and demonstrate active listening.

Task 2: Discuss your differential diagnosis with the patient.

The competent candidate should:

Explain that nausea has multiple possible causes, and investigations may be needed to confirm the diagnosis.
Discuss most likely differentials:
- Pregnancy-related nausea (early pregnancy or hyperemesis gravidarum): Given her missed period and morning nausea.
- Gastro-oesophageal reflux disease (GORD): Postprandial nausea, bloating, and food triggers.
- Functional dyspepsia or irritable bowel syndrome (IBS): Chronic nausea without structural disease.
- Vestibular disorders (e.g., labyrinthitis, Ménière’s disease): If associated with vertigo.
- Infections (e.g., gastroenteritis, H. pylori, hepatitis): If there was a relevant history of fever, travel, or diarrhoea.
- Metabolic/endocrine conditions (e.g., diabetes, thyroid dysfunction, adrenal insufficiency): If systemic symptoms are present.
Address the patient’s concern about pregnancy by explaining why this is a key differential.
Explain the need for investigations to rule out concerning causes and to guide management.

Task 3: Explain the investigations you will request and why.

The competent candidate should:

Justify initial investigations, including:
- Urine pregnancy test (UPT): First-line to rule out pregnancy.
- Full blood count (FBC): To assess for anaemia, infection, or chronic disease.
- Urea, electrolytes, and creatinine (UEC): To check for dehydration or metabolic derangements.
- Liver function tests (LFTs) and bilirubin: To assess for liver or gallbladder disease.
- Thyroid function tests (TFTs): If thyroid dysfunction is suspected.
- Blood glucose/HbA1c: To assess for diabetes or ketosis.
- H. pylori stool antigen or breath test: If GORD or gastritis is suspected.
Explain that if pregnancy is confirmed, further assessment and obstetric referral may be needed.
Provide clear timeframes for results and follow-up.

Task 4: Provide an initial management plan and follow-up advice.

The competent candidate should:

Develop a management plan tailored to the likely diagnosis:
- If pregnancy-related nausea: Lifestyle modifications, dietary changes (small frequent meals), and first-line antiemetics (e.g., pyridoxine ± doxylamine).
- If GORD: Dietary modifications, trial of proton pump inhibitors (PPIs) or H2 blockers.
- If functional nausea: Address lifestyle factors, stress management, and dietary triggers.
- If metabolic/endocrine disorder: Referral for further evaluation based on test results.
Address patient concerns, ensuring reassurance while providing safety-netting for red flag symptoms.
Arrange a follow-up appointment to review test results and symptom progression.

SUMMARY OF A COMPETENT ANSWER

Conducts a structured, patient-centred history, covering red flags and differential diagnoses.
Provides a clear and logical differential diagnosis based on clinical reasoning.
Orders appropriate evidence-based investigations to confirm the diagnosis.
Develops a safe, patient-centred management plan with clear follow-up.
Uses empathetic communication to address the patient’s concerns.

PITFALLS

Failure to elicit red flag symptoms, such as persistent vomiting or significant weight loss.
Over-reassurance without appropriate investigations to rule out serious conditions.
Focusing only on pregnancy without considering other differentials.
Missing metabolic or endocrine causes such as thyroid dysfunction or diabetes.
Not addressing the patient’s concerns regarding pregnancy or other possible diagnoses.

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 on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets relevant history, including red flags.
2.2 Selects and justifies appropriate investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms a logical differential diagnosis based on history and findings.
3.5 Identifies red flag symptoms requiring urgent referral.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based, patient-centred management plan.
4.3 Provides structured follow-up and safety-netting.

5. Preventive and Population Health

5.2 Addresses modifiable risk factors for gastrointestinal and metabolic conditions.

6. Professionalism

6.1 Maintains confidentiality and professional integrity.

7. General Practice Systems and Regulatory Requirements

7.1 Orders appropriate tests in line with MBS guidelines.

9. Managing Uncertainty

9.2 Develops a structured approach to a patient with an unclear diagnosis.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and acts on potentially serious conditions.

Competency at Fellowship Level

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