CASE INFORMATION

Case ID: CCE-2025-008
Case Name: Emma Lawson
Age: 29 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: N86 (Multiple Sclerosis), N99 (Neurological disorder NOS)

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 and supports long-term disease management.
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 progressive or disabling neurological conditions.

CASE FEATURES

Young woman presenting with intermittent neurological symptoms over the past year.
Complains of numbness and tingling in her right arm and leg, which lasted a few weeks and then resolved.
Reports a recent episode of blurry vision in her right eye, which improved after two weeks.
No history of trauma or infection, and no family history of neuromuscular or autoimmune disorders.
Concerned about whether these symptoms could indicate something serious like multiple sclerosis (MS).
Requires clinical reasoning to differentiate between MS, other demyelinating disorders, and mimics such as stroke, B12 deficiency, or functional neurological disorders.

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

Emma Lawson, a 29-year-old woman, presents to your clinic with concerns about intermittent neurological symptoms over the past year. She describes numbness and tingling in her right arm and leg, which lasted about three weeks before resolving completely.

More recently, she experienced blurry vision in her right eye, which lasted two weeks and has now improved. She did not have any eye pain, double vision, or headaches.

PATIENT RECORD SUMMARY

Patient Details

Name: Emma Lawson
Age: 29 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 history of neurological conditions, stroke, or autoimmune disease.

Social History

Works as a marketing manager.
Non-smoker, drinks alcohol occasionally.

Family History

No family history of multiple sclerosis, autoimmune diseases, or neurological conditions.

Vaccination and Preventative Activities

Up to date with vaccinations.
Last health check one year 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 having strange symptoms over the past year, and I’m really worried that I might have multiple sclerosis.”

General Information

(Freely Shared if Asked Open-Ended Questions)

The first symptom happened about a year ago. You woke up with numbness and tingling in your right arm and leg, which lasted about three weeks before completely resolving.
You didn’t do anything specific to treat it; it just went away on its own.
About a month ago, you noticed blurry vision in your right eye, which lasted two weeks and has since improved.
The vision problem was not painful, but things looked washed out or dim, especially in bright light.

Specific Information

(Only Revealed if the Candidate Asks Targeted Questions)

Background Information

You have had no weakness, loss of balance, tremors, or trouble speaking.
No headaches, dizziness, seizures, or fainting episodes.
No bowel or bladder issues, although you do sometimes feel like you need to go to the toilet quickly.
You don’t recall any recent infections, viral illnesses, or high fevers.
You have never had symptoms like this before these two episodes.
You are otherwise healthy, with no long-term medical conditions.

Symptoms and Triggers

The numbness and tingling started gradually over a couple of days and then disappeared after about three weeks.
The blurry vision in your right eye came on over a few days, and at first, you thought it was just eye strain.
No double vision, eye pain, or difficulty moving your eyes.
No trouble with swallowing or speaking.
No sharp shooting pains down your spine when bending your neck forward (Lhermitte’s sign).
You haven’t noticed any muscle twitches, weakness, or trouble walking.
You don’t recall any recent stress, trauma, or unusual environmental exposures before these episodes.

Lifestyle & Risk Factors

You don’t smoke and drink alcohol only socially (1-2 drinks per week).
You work as a marketing manager, and your job is mostly desk-based.
You live with your partner and have a supportive family.
You haven’t travelled overseas recently, especially to areas with a high risk of infections affecting the nervous system.
You haven’t been bitten by ticks (concern for Lyme disease).
You take no recreational drugs and haven’t been exposed to industrial chemicals or heavy metals.

Family History

You have no family history of multiple sclerosis.
No family history of autoimmune diseases like lupus, rheumatoid arthritis, or thyroid disorders.

Emotional Cues & Concerns

You are very anxious that this could be MS, because you read that MS often starts with numbness and vision problems.
You want to know if MS can be diagnosed early, and if there’s a way to prevent it from getting worse.
You are worried about how this might affect your career and daily life, especially if it leads to long-term disability.
You wonder if you will need to take medications for life if diagnosed.
You are concerned about pregnancy and whether MS could affect your ability to have children or pass it on genetically.
You want to know if there are any lifestyle changes that could help.

Questions for the Candidate

(Drop these in naturally throughout the consultation)

“Do you think this is MS? Should I be worried?”
“What tests do I need to confirm or rule this out?”
“If I have MS, does that mean I’ll be in a wheelchair one day?”
“Can MS be treated? Will I need to take medication forever?”
“Does this mean I shouldn’t have children?”
“Is there anything I can do to prevent it from getting worse?”
“Could this be something else and not MS?”

How to Respond Based on the Candidate’s Answers

If the Candidate Provides a Clear Explanation and Plan:

You feel somewhat reassured but still have some lingering concerns.
You might ask for clarification on next steps:
- “So, you don’t think it’s definite, but we need to do tests to check?”
- “How long will it take to get the results?”
You agree to the suggested investigations and are willing to follow the plan.

If the Candidate is Unclear or Dismissive:

You become more anxious and insistent on further testing.
You might push for an urgent MRI or specialist referral:
- “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 neurologist for this?”
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 symptoms and concerns, followed by targeted questions to assess key clinical features.
Establish onset, duration, and pattern of symptoms (e.g., episodic vs progressive, remitting vs persistent).
Identify red flag symptoms, including rapidly progressing neurological deficits, severe headaches, seizures, persistent vomiting, or altered consciousness.
Assess for symptoms suggestive of multiple sclerosis (MS), such as optic neuritis, sensory disturbances, motor weakness, bladder/bowel dysfunction, and fatigue.
Consider differential diagnoses, including stroke, B12 deficiency, functional neurological disorder, transverse myelitis, or other autoimmune diseases.
Review family history of MS or other autoimmune conditions.
Evaluate lifestyle factors, including smoking, stress, recent infections, and environmental exposures.
Address the patient’s fears about MS, disability, and long-term prognosis.

Task 2: Discuss your differential diagnosis with the patient.

The competent candidate should:

Explain that neurological symptoms can have multiple causes, and further assessment is needed.
Discuss most likely differentials:
- Multiple sclerosis (MS): Relapsing-remitting pattern, optic neuritis, sensory and motor deficits.
- B12 deficiency or other metabolic causes: Subacute combined degeneration, peripheral neuropathy.
- Cerebrovascular event (stroke, TIA): Less likely due to transient nature and young age.
- Functional neurological disorder: Consider if symptoms are inconsistent or atypical.
- Other autoimmune conditions (e.g., lupus, neuromyelitis optica): If systemic symptoms are present.
Address the patient’s concern about MS, explaining that it is a possibility but not the only explanation.
Explain that investigations will help clarify the diagnosis and guide management.

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

The competent candidate should:

Justify initial investigations, including:
- MRI of the brain and spine: To assess for demyelinating plaques.
- Lumbar puncture (if required): To check for oligoclonal bands in cerebrospinal fluid (CSF), supporting MS diagnosis.
- Blood tests:
  - Full blood count (FBC), urea/electrolytes, liver function tests (LFTs): To exclude systemic illness.
  - Vitamin B12, folate, and thyroid function tests (TFTs): To rule out metabolic causes.
  - Autoimmune screen (ANA, ENA, anti-phospholipid antibodies): If connective tissue disease is suspected.
Explain that MS is a clinical diagnosis supported by investigations and that a neurology referral is required for confirmation.
Provide clear timeframes for follow-up and test review.

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

The competent candidate should:

Develop a management plan based on findings:
- If MS is confirmed: Referral to a neurologist for disease-modifying therapy, symptom management, and support services.
- If alternative cause is found: Tailor treatment accordingly (e.g., B12 supplementation, stroke prevention).
- If diagnosis remains unclear: Arrange further specialist review and monitor for symptom progression.
Provide supportive care, including fatigue management, physiotherapy, and psychological support.
Address lifestyle modifications, including smoking cessation, optimising diet, and regular exercise.
Provide safety-netting advice, advising review for worsening neurological symptoms, new relapses, or functional decline.
Arrange a follow-up appointment to review test results and discuss next steps.

SUMMARY OF A COMPETENT ANSWER

Takes a structured, patient-centred history, covering neurological deficits, red flags, and differential diagnoses.
Provides a clear and logical differential diagnosis, addressing MS, metabolic, autoimmune, and vascular causes.
Orders appropriate investigations, including MRI, lumbar puncture, and blood tests.
Develops a safe, patient-centred management plan, including neurology referral and supportive care.
Uses empathetic and reassuring communication, addressing the patient’s concerns about MS, disability, and long-term treatment.

PITFALLS

Failure to identify red flag symptoms, missing serious neurological or systemic conditions.
Over-reassurance without appropriate investigations, delaying MS diagnosis.
Omitting MRI or lumbar puncture, missing essential diagnostic criteria for MS.
Not considering other differentials, such as B12 deficiency or functional neurological disorder.
Lack of clear safety-netting, leaving the patient unsure when to seek urgent care.

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 and supports long-term disease management.

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 progressive or disabling neurological conditions.

Competency at Fellowship Level

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