CASE INFORMATION

Case ID: CCE-2025-007
Case Name: Rebecca Clarke
Age: 37 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: T85 (Goitre), T86 (Hypothyroidism), T85.1 (Hyperthyroidism)

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 thyroid dysfunction and iodine deficiency.
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

A 37-year-old female presenting with a noticeable swelling in the neck over the past three months.
Reports mild discomfort and occasional difficulty swallowing, but no pain.
No weight changes, palpitations, or tremors, but feeling more fatigued than usual.
No heat or cold intolerance, hair changes, or menstrual irregularities.
Concerned about whether this could be something serious, like cancer.
Requires clinical reasoning to differentiate between benign multinodular goitre, autoimmune thyroid disease (Graves’ or Hashimoto’s), thyroid malignancy, and iodine deficiency goitre.

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.
Discuss your differential diagnosis with the patient.
Explain the investigations you will request and why.
Provide an initial management plan and follow-up advice.

SCENARIO

Rebecca Clarke, a 37-year-old teacher, presents to your clinic with a lump in her neck that she noticed about three months ago. She describes it as a slow-growing swelling at the front of her neck, which is not painful but makes her feel mildly uncomfortable when swallowing.

Rebecca is worried about whether this could be something serious, like thyroid cancer, and wants to know what tests she needs and whether treatment will be required.

PATIENT RECORD SUMMARY

Patient Details

Name: Rebecca Clarke
Age: 37 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 previous thyroid disease
No history of radiation exposure

Social History

Works as a teacher
No smoking, drinks alcohol occasionally

Family History

No family history of thyroid disorders or malignancy

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 noticed a lump in my neck for the past few months, and I’m starting to worry that it might be something serious, like cancer.”

General Information

(Freely Shared if Asked Open-Ended Questions)

You first noticed the lump about three months ago while looking in the mirror.
Since then, it has gradually increased in size, but you’re not sure if it’s still growing.
The lump is not painful, but you feel a little discomfort when swallowing, particularly with dry or large pieces of food.
You haven’t had any choking episodes or difficulty breathing.

Specific Information

(Only Revealed if the Candidate Asks Targeted Questions)

Background Information

You haven’t noticed any voice changes or hoarseness.
You feel more tired than usual, but you thought it was just work-related stress.
No weight loss, night sweats, or fever.
No heat intolerance, excessive sweating, or tremors.
No cold intolerance, constipation, or dry skin.
No significant hair loss, brittle nails, or changes in skin texture.
No palpitations or rapid heart rate.
Your menstrual cycles are regular, and you haven’t been pregnant recently.

Symptoms and Triggers

The lump is firm but not painful when you press on it.
You think it might have gotten slightly bigger, but you’re not sure if it’s growing rapidly.
You have not had any previous neck injuries or surgery.
You haven’t noticed swelling in other parts of your neck.
The lump doesn’t move when you swallow.
You haven’t had any episodes of dizziness, fainting, or sweating attacks.

Lifestyle & Risk Factors

You eat a balanced diet and don’t think you have an iodine deficiency.
You don’t smoke and drink alcohol only occasionally.
You are not taking any medications, including supplements.
You haven’t been exposed to radiation in the past, either medically or occupationally.
You haven’t travelled recently to areas with known iodine deficiency.
You don’t have a history of thyroid disorders.

Family History

No family history of thyroid disease, goitre, or thyroid cancer.
No known autoimmune conditions in the family.

Emotional Cues & Concerns

You are worried about thyroid cancer because you read about it online.
You want to know what tests are needed and whether this will require surgery.
You are anxious about needing long-term medication if your thyroid is removed.
You want reassurance that this isn’t something life-threatening.

Questions for the Candidate

(Drop these in naturally throughout the consultation)

“Do you think this is cancer? Should I be worried?”
“What tests do I need?”
“Could this affect my metabolism or make me gain weight?”
“Will I need surgery, or can this be treated with medication?”
“If this is a thyroid problem, will I have to take tablets for life?”
“What causes a goitre? Is there anything I could have done to prevent it?”
“If I don’t treat this, could it get worse?”

How to Respond Based on the Candidate’s Answers

If the Candidate Provides a Clear Explanation and Plan:

You feel somewhat reassured, but still want clear answers about the next steps.
You may ask for clarification on the follow-up plan:
- “So, you don’t think this is cancer, but we still need to do tests?”
- “How long will it take to get the results?”
You agree to the suggested investigations and follow-up plan.

If the Candidate is Unclear or Dismissive:

You become more anxious and start to insist on more tests.
You may press for urgent referral to a specialist or a biopsy:
- “I don’t want to take any risks. Can we just do all the tests now?”
- “What if this turns out to be something serious and we don’t catch it early?”
- “I want to make sure we’re not missing anything.”

Ending the Consultation

If the Candidate Has Done Well:

You feel more reassured and are willing to follow the plan.
You might still confirm:
- “So, I should come back after the test results, unless something changes?”
- “Will I need to see a specialist, or can this be managed here?”
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 still don’t know if this is serious or not.”
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 concerns about the neck swelling, followed by targeted questions to assess the nature of the goitre.
Determine onset, duration, and progression of the swelling.
Identify red flag symptoms, including rapid growth, dysphagia, hoarseness, difficulty breathing, or systemic symptoms like night sweats or unexplained weight loss.
Assess for hypothyroid symptoms (fatigue, weight gain, cold intolerance, constipation, dry skin, bradycardia).
Assess for hyperthyroid symptoms (palpitations, tremors, heat intolerance, weight loss, diarrhoea, anxiety).
Explore family history of thyroid disorders or malignancy.
Evaluate risk factors including smoking, iodine deficiency, previous radiation exposure, or recent pregnancy.
Address psychosocial concerns, particularly fear of cancer or need for surgery.

Task 2: Discuss your differential diagnosis with the patient.

The competent candidate should:

Explain that goitre is a broad term for thyroid gland enlargement and has multiple possible causes.
Discuss most likely differentials:
- Benign multinodular goitre: Most common, slow-growing, can be euthyroid, hypothyroid, or hyperthyroid.
- Autoimmune thyroid disease: Hashimoto’s thyroiditis (hypothyroid) or Graves’ disease (hyperthyroid).
- Iodine deficiency goitre: Less common in Australia but still possible.
- Thyroid nodule (benign or malignant): Requires evaluation to exclude malignancy.
- Thyroid cancer: Rare, but should be suspected if rapid growth, hoarseness, dysphagia, or family history are present.
Address the patient’s concern about cancer, explaining risk factors and when further investigation is needed.

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

The competent candidate should:

Justify initial investigations, including:
- Thyroid function tests (TFTs): To assess for hyperthyroidism or hypothyroidism.
- Thyroid ultrasound: To evaluate size, structure, and presence of nodules.
- Thyroid autoantibodies (TPO, TRAb): If autoimmune thyroid disease is suspected.
- Fine-needle aspiration biopsy (FNAB): If nodules >1 cm or ultrasound suggests malignancy.
- Serum calcium and PTH: If there are signs of parathyroid involvement.
- Iodine studies (if indicated): If iodine deficiency is suspected.
Explain that most cases are benign, but testing is necessary to confirm the diagnosis.
Provide clear timeframes for follow-up and review of results.

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

The competent candidate should:

Develop a management plan based on investigation findings:
- If euthyroid benign goitre: Monitor size and symptoms; iodine supplementation if deficient.
- If hypothyroid (e.g., Hashimoto’s): Start thyroxine replacement therapy.
- If hyperthyroid (e.g., Graves’): Refer for endocrinology input, beta-blockers, anti-thyroid medications, or radioiodine therapy.
- If malignancy suspected: Refer to an endocrine surgeon for further assessment.
Address lifestyle factors, including smoking cessation and dietary iodine adequacy.
Provide safety-netting advice, advising review for worsening symptoms, rapid growth, or new pressure symptoms.
Arrange a follow-up appointment to review test results and discuss next steps.

SUMMARY OF A COMPETENT ANSWER

Conducts a structured, patient-centred history, covering thyroid dysfunction symptoms and red flags.
Provides a clear differential diagnosis, explaining benign vs serious causes of goitre.
Orders appropriate investigations, ensuring a stepwise diagnostic approach.
Develops a safe, patient-centred management plan, including follow-up and lifestyle advice.
Uses empathetic and reassuring communication, addressing the patient’s concerns about cancer and treatment options.

PITFALLS

Failure to identify red flag symptoms, missing signs of malignancy or obstructive goitre.
Over-reassurance without proper investigation, leading to delayed diagnosis.
Omitting thyroid function testing, missing hyperthyroidism or hypothyroidism.
Not considering iodine deficiency, particularly in at-risk populations.
Lack of clear safety-netting, leaving the patient unsure of 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 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 thyroid dysfunction and iodine deficiency.

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