CASE INFORMATION

Case ID: CHC-001
Case Name: Lily Anderson
Age: 4 years
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: A98 (Preventive health examination), A97 (Child health check)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Communicates appropriately with parents and caregivers. 1.2 Engages parents to gather information about child development and health concerns. 1.3 Provides clear explanations in a parent-friendly manner.
2. Clinical Information Gathering and Interpretation	2.1 Takes a comprehensive history, including developmental milestones, diet, and immunisations. 2.2 Conducts age-appropriate screening.
3. Diagnosis, Decision-Making and Reasoning	3.1 Identifies red flags for developmental delay or health concerns.
4. Clinical Management and Therapeutic Reasoning	4.3 Provides appropriate anticipatory guidance on nutrition, sleep, and safety.
5. Preventive and Population Health	5.1 Ensures immunisations are up to date. 5.2 Discusses preventive health strategies, including oral hygiene and sun safety.
6. Professionalism	6.2 Engages in shared decision-making with parents.
7. General Practice Systems and Regulatory Requirements	7.1 Documents findings appropriately and provides referrals if necessary.
9. Managing Uncertainty	9.1 Addresses parental concerns regarding growth, behaviour, or development.

CASE FEATURES

Discussion on school readiness and behavioural expectations.
Routine 4-year-old child health check.
Parents express mild concerns about speech development.
Review of immunisation status, growth, diet, and sleep habits.
Screening for vision, hearing, and developmental milestones.
Parental concerns about fussy eating and toilet training.

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

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

Lily Anderson is a 4-year-old girl brought in by her mother, Emma Anderson, for a routine child health check. This is part of her 4-year-old immunisation visit under the National Immunisation Program (NIP).

Emma is generally happy with Lily’s development but has noticed that her speech is not as clear as some of her peers. She wants to know whether this is normal and whether Lily needs a speech therapist.

PATIENT RECORD SUMMARY

Patient Details

Name: Lily Anderson
Age: 4 years
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

None

Past History

Normal pregnancy and birth history
No hospitalisations or significant illnesses

Social History

Lives with both parents

Family History

No history of speech delay, hearing loss, or developmental concerns
No family history of chronic illness

Immunisation Status

Up to date but due for 4-year-old vaccinations today

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

“Hi, Doctor. We’re here for Lily’s 4-year-old check-up. She’s doing well, but I’ve been wondering about her speech development.”

General Information

Lily is a happy and active child who enjoys playing with her toys and interacting with family.
She attends daycare three days a week and enjoys it.
She eats a variety of foods but refuses some vegetables.
She sleeps well but still has occasional night-time accidents.
Immunisations are up to date, except for today’s vaccines.

Specific Information

(Only provide when asked)

Parent’s General Feelings

Overall, not too worried but has some questions about her development.
No major health concerns but wants to make sure she is on track for school next year.
Wants reassurance about her speech and eating habits.
Curious about whether bedwetting at night is normal at this age.

Speech and Language Development

Lily speaks in full sentences and has a good vocabulary.
Sometimes mispronounces words or doesn’t pronounce certain sounds clearly.
Other children her age seem clearer when speaking.
Daycare staff haven’t raised concerns but mentioned that some other kids speak more clearly.
She understands instructions well and follows multi-step directions.
No issues with hearing or responsiveness to sounds.

Diet and Nutrition

Eats fruits, dairy, and meats well, but avoids vegetables.
Prefers crunchy textures like crackers and toast over soft or leafy vegetables.
She drinks water and milk; doesn’t have juice or soft drinks often.
Doesn’t eat a lot of junk food but can be stubborn about trying new foods.
No digestive issues like diarrhoea or constipation.

Toilet Training and Sleep

Fully toilet trained during the day.
Has night-time accidents about twice a week.
Sleeps through the night most of the time, but if she has an accident, she wakes up distressed.
Doesn’t complain of pain or discomfort when passing urine.
No constipation or stool withholding behaviours.

Social and Behavioural Development

Loves playing pretend games and interacting with friends.
Shares and takes turns most of the time but gets frustrated when she doesn’t get her way.
Enjoys books and tries to “read” them on her own by making up stories from pictures.
Likes to copy older kids and wants to do things by herself (e.g., dressing herself).

School Readiness

Excited about starting kindergarten next year.
Can hold a pencil and draw simple shapes.
Knows some numbers and letters, but not all.
Can sit still for short periods, but gets distracted easily.

Emotional Cues and Body Language

Engaged and attentive when discussing Lily’s progress.
Smiles proudly when talking about Lily’s achievements.
Leans forward slightly when discussing concerns about speech and eating.
Looks relieved when reassured about common childhood behaviours.
Mildly concerned expression when discussing bedwetting.
Sits back comfortably when talking about Lily’s positive interactions at daycare.

Parental Concerns (Provide if Asked)

“Should I be worried about Lily’s speech?”
- Wants to know if she needs a speech therapist.
“How can I get her to eat more vegetables?”
- Worried that she’s not getting enough nutrients.
“Is it normal for her to still have night-time accidents?”
- Wondering if she should be fully dry by now.
“Is she ready for school next year?”
- Unsure if she’s at the right level for learning and behaviour.

Possible Additional Questions from Parent

“Are there any games or activities that can help her speech?”
“Should I limit how much milk she drinks if she’s not eating enough food?”
“Would a reward system work for toilet training at night?”
“Is there anything I should do to help her adjust to kindergarten?”

Emotional Reactions to Different Responses from the Doctor

If reassured about speech development:
- Nods and relaxes slightly.
- “Okay, that makes sense. I guess kids develop at different rates.”
If given practical tips on encouraging vegetable intake:
- Looks relieved and might laugh lightly.
- “That sounds like something we could try. She does like helping in the kitchen!”
If reassured about bedwetting:
- Sighs with relief and leans back slightly.
- “That’s good to know! I wasn’t sure if we should be worried.”
If discussing school readiness:
- Thoughtful expression, might ask more about how to prepare Lily.
- “We’ve been working on letters and numbers, but I’ll try those extra activities too.”

Final Closing Line

“Thank you for answering all my questions. This has been really helpful. I’ll try the suggestions, and we’ll see how Lily goes with her vegetables and night-time toilet training!”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Conduct a comprehensive child health check for Lily, including growth, development, and immunisations

The competent candidate should:

Establish rapport with the parent and child, ensuring a child-friendly approach.
Take a thorough history, including:
- Growth and nutrition (dietary intake, feeding habits, concerns about food refusal).
- Developmental milestones (speech, motor skills, social skills, school readiness).
- Sleep patterns, toilet training progress, and social interactions.
Assess for red flags in development, such as:
- Speech delay (concerns about pronunciation, vocabulary, or comprehension).
- Fine and gross motor skills appropriate for age.
- Behavioural concerns such as difficulty in social settings or emotional regulation.
Review vaccination status and provide recommendations based on the Australian Immunisation Schedule.
Perform a targeted examination (height, weight, BMI, vision, hearing, general physical exam).
Offer anticipatory guidance for school readiness, nutrition, and behavioural expectations.
Address any parental concerns appropriately.

Task 2: Address the parent’s concerns about speech development and determine if a referral is needed

The competent candidate should:

Acknowledge and validate the parent’s concerns regarding speech clarity.
Take a detailed speech and language history, including:
- Age at which Lily started speaking (first words, sentence formation).
- Clarity of speech and ability to form full sentences.
- Understanding and following multi-step instructions.
- Interaction with peers and daycare staff reports.
Assess for red flags such as:
- Limited vocabulary or difficulty forming sentences.
- Difficulty following commands.
- Parental concern about social interaction or comprehension.
Explain the variation in speech development among children.
Provide strategies to support language development, including:
- Reading books together.
- Encouraging interactive conversation.
- Using correct pronunciation without direct correction.
Determine if a referral to a speech therapist is needed based on findings.

Task 3: Discuss nutrition and strategies to improve vegetable intake

The competent candidate should:

Take a detailed dietary history, including:
- Types of foods consumed.
- Family meal routines and food preferences.
- Any sensory preferences (e.g., crunchy vs. soft foods).
Identify if the child has picky eating versus a more concerning issue like food aversion.
Provide strategies to increase vegetable intake, such as:
- Role modelling by parents.
- Offering a variety of vegetables in different textures.
- Involving the child in food preparation.
- Not forcing the child to eat but offering repeatedly.
Assess if any nutritional supplementation is needed (e.g., iron deficiency risk).

Task 4: Provide advice on bedwetting and when intervention is needed

The competent candidate should:

Reassure the parent that bedwetting at age 4 is common and often resolves naturally.
Assess for underlying medical conditions, such as:
- Urinary tract infection.
- Constipation contributing to bladder issues.
- Sleep disorders.
Discuss management strategies, including:
- Limiting fluids before bedtime.
- Encouraging regular toileting before sleep.
- Positive reinforcement (reward charts).
Outline when to seek further assessment:
- Bedwetting persists beyond age 6-7.
- Daytime wetting occurs.
- Signs of underlying medical conditions.

SUMMARY OF A COMPETENT ANSWER

Comprehensive child health assessment, addressing growth, development, and immunisation.
Validated and assessed speech concerns, providing clear guidance on whether referral is needed.
Practical nutrition advice to support vegetable intake and balanced diet.
Reassuring but informative approach to bedwetting, outlining normal patterns and red flags.
Used clear communication, adapting to a parent-centred and child-friendly approach.

PITFALLS

Failing to acknowledge parental concerns, especially about speech or diet.
Not performing a full developmental assessment, missing potential red flags.
Giving generalised reassurance without clear advice or strategies.
Over-investigating minor concerns, causing unnecessary parental anxiety.
Ignoring school readiness factors, such as social and behavioural skills.

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 parent to gather information about their child’s symptoms, ideas, concerns, and expectations.
1.4 Communicates effectively in routine and complex situations.

2. Clinical Information Gathering and Interpretation

2.1 Collects relevant growth and development history.
2.3 Identifies red flags requiring further assessment or referral.

3. Diagnosis, Decision-Making and Reasoning

3.2 Uses clinical reasoning to determine if speech delay or bedwetting needs further assessment.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an age-appropriate and evidence-based management plan.

5. Preventive and Population Health

5.1 Ensures immunisation status is complete and provides preventative health guidance.

6. Professionalism

6.1 Provides empathetic, patient-centred care.

7. General Practice Systems and Regulatory Requirements

7.1 Follows RACGP child health guidelines and immunisation protocols.

9. Managing Uncertainty

9.1 Reassures parent appropriately while monitoring areas of concern.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies red flags requiring referral (speech therapy, audiology, paediatrics) if needed.

Competency at Fellowship Level

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