CASE INFORMATION

Case ID: CCE-CE-001
Case Name: David Carter
Age: 42
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A04 (Weakness/Tiredness General), A29 (Chronic Fatigue Syndrome)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their concerns and expectations 1.2 Uses active listening and empathy to explore the patient’s illness experience 1.5 Explains complex medical conditions in a patient-centred manner
2. Clinical Information Gathering and Interpretation	2.1 Elicits a detailed history, including onset, duration, and impact of symptoms 2.2 Identifies red flags for alternative diagnoses 2.3 Orders appropriate investigations to exclude other conditions
3. Diagnosis, Decision-Making and Reasoning	3.1 Uses clinical reasoning to determine the likelihood of Chronic Fatigue Syndrome (CFS) 3.3 Considers and rules out other differential diagnoses (e.g., hypothyroidism, depression, sleep apnoea)
4. Clinical Management and Therapeutic Reasoning	4.2 Develops a multi-disciplinary management plan including non-pharmacological approaches 4.4 Provides evidence-based treatment recommendations for CFS
5. Preventive and Population Health	5.2 Provides lifestyle modification advice, including graded exercise therapy and sleep hygiene
6. Professionalism	6.2 Recognises and addresses the impact of CFS on the patient’s personal and professional life
7. General Practice Systems and Regulatory Requirements	7.1 Uses appropriate care planning (e.g., GP Management Plan, Team Care Arrangements)
9. Managing Uncertainty	9.1 Addresses patient frustration regarding diagnostic uncertainty and lack of definitive treatment
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies patients at risk of psychological distress or depression due to chronic illness

CASE FEATURES

Opportunity to explore a holistic, multi-modal management plan
Middle-aged man with chronic fatigue symptoms persisting for six months
No clear organic cause identified despite prior investigations
Symptoms significantly impacting work and daily life
Patient frustrated by lack of clear diagnosis or effective treatment
Concerns regarding potential disability and long-term prognosis

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

David Carter, a 42-year-old accountant, presents to your general practice with persistent fatigue lasting over six months. He describes feeling constantly exhausted, even after a full night’s sleep, and struggles with concentration and memory. He has stopped his regular exercise due to post-exertional malaise, and his work performance has declined.

PATIENT RECORD SUMMARY

Patient Details

Name: David Carter
Age: 42
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Perindopril 5mg daily

Past History

Mild hypertension

Social History

Occupation: Accountant

Family History

Father: Type 2 Diabetes
Mother: Hypothyroidism

Smoking

Never smoked

Alcohol

Occasional (2-3 drinks per week)

Vaccination and Preventative Activities

Last health check: Two years ago
Up to date with routine immunisations

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 just feel so exhausted all the time. I can’t concentrate, I can’t exercise, and I’m struggling to get through work. What’s wrong with me?”

General Information

(Can be shared freely if the candidate asks open-ended questions such as “Tell me more about that”)

You have been feeling fatigued for about six months. It started gradually, and it has gotten worse over time.
The exhaustion is constant, and no matter how much you sleep or rest, it doesn’t seem to help.
You used to be quite active, going to the gym a few times a week, but now even mild activity leaves you feeling worse for days.
You feel like you have a permanent flu-like feeling—achy muscles, headaches, and sometimes even a sore throat.
Your memory and concentration have been noticeably worse. You find yourself forgetting things and struggling to focus, especially at work.
You have no motivation to do things you used to enjoy.

Specific Information

(Only reveal when directly asked about these areas)

Symptoms and Impact on Daily Life

Your work performance has declined. You’ve been making mistakes at work, which is not like you.
You feel mentally foggy, like your brain isn’t working properly.
You wake up feeling just as tired as when you went to bed, no matter how much sleep you get.
Your wife has noticed you sometimes snore, but you haven’t had trouble breathing at night.
You struggle to find the energy to play with your kids or help around the house.
You have stopped exercising completely because it makes you feel worse. Even simple things like going for a walk can leave you feeling terrible the next day.

Red Flags (Important Clues That Must Be Elicited)

No fevers, night sweats, or unexplained weight loss.
No joint swelling, redness, or morning stiffness.
No recent travel or known infections before the fatigue started.
No history of depression, but you are feeling down about your situation.
No major stressors in your life before this started.

Concerns and Emotional Reactions (Express these emotions naturally throughout the consultation)

You feel frustrated and hopeless because you’ve already seen another doctor who ordered blood tests, and everything came back normal.
You are worried that this could be something serious like multiple sclerosis or a thyroid problem.
You are scared that you will never feel normal again and that you might have to stop working if this continues.
You feel guilty because your wife has been picking up more responsibilities at home while you struggle just to get through the day.
You are angry that there doesn’t seem to be an answer or a cure for what’s happening to you.
You want to know if you will ever get better.

Questions for the Candidate (Ask these naturally during the consultation, especially when discussing diagnosis or management)

“Is this Chronic Fatigue Syndrome? How do you actually diagnose it?”
“What if this is something serious? Could it be something like multiple sclerosis or an autoimmune disease?”
“Is there a treatment for this, or am I just going to feel like this forever?”
“Should I stop working? I’m barely getting through the day as it is.”
“Do I need more tests? I feel like we might have missed something important.”
“I’ve read online that some doctors don’t believe in Chronic Fatigue Syndrome. What if this is all in my head?”
“Are there any specialists I should see? Should I see a neurologist or a rheumatologist?”

Role-Playing Emotional Cues (Act these out realistically to simulate a real patient encounter)

Frustration: Furrow your brow, sigh, shake your head when discussing previous medical visits.
Anxiety: Look worried, fidget, rub your forehead when talking about serious conditions.
Hopelessness: Speak slowly, slouch slightly, and sound discouraged when discussing the impact on your life.
Skepticism: Raise an eyebrow or look unconvinced if the candidate talks about psychological aspects of the condition.
Relief (if reassured well): Look visibly more relaxed and nod when the candidate explains things clearly.

What You Are Expecting From the Doctor (Candidate)

To take you seriously. You are frustrated by previous vague answers and need someone who will listen properly.
To explain things in a clear, structured way. You don’t want medical jargon—just an understandable explanation.
To offer a management plan. Even if there is no cure, you want some kind of plan to help you feel better.
To acknowledge the emotional impact. You need empathy, not just a list of medical facts.
To discuss work and daily life adjustments. You’re worried about how this will affect your career.

Potential Curveballs (Optional, if the Candidate Handles the Basics Well)

“I read online about some supplements for Chronic Fatigue Syndrome. Should I try them?”
“A friend of mine says this could be Lyme disease. Do I need testing for that?”
“If this is all stress-related, does that mean I need to see a psychologist?”
“My wife thinks I should quit my job and rest completely. Do you think that would help?”

End of Consultation (If the candidate provides a clear plan and reassurance, respond positively.)

“Okay, that actually makes sense. I feel a bit better knowing that we have a plan. I just want to feel like myself again.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history to explore the nature and impact of the patient’s fatigue.

The competent candidate should:

Use open-ended questions to allow the patient to describe their symptoms in detail.
Explore onset, duration, severity, and variability of fatigue.
Assess for post-exertional malaise (PEM), a hallmark of Chronic Fatigue Syndrome (CFS).
Investigate associated symptoms such as cognitive impairment (“brain fog”), unrefreshing sleep, muscle/joint pain, headaches, dizziness, and sore throat.
Screen for red flags (e.g., weight loss, night sweats, fever, lymphadenopathy) that may indicate alternative diagnoses.
Take a comprehensive psychosocial history, including impact on work, relationships, and mental health.
Ask about previous investigations and treatments attempted.
Explore the patient’s ideas, concerns, and expectations (ICE) about their symptoms.

Task 2: Outline your differential diagnosis and the key features supporting or refuting CFS.

The competent candidate should:

Consider CFS as a leading diagnosis, supported by:
- Fatigue lasting >6 months, unexplained by other conditions.
- Post-exertional malaise, cognitive dysfunction, and unrefreshing sleep.
- Impact on daily functioning.
Rule out common alternative causes, including:
- Endocrine: Hypothyroidism, adrenal insufficiency.
- Neurological: Multiple sclerosis, myasthenia gravis.
- Psychiatric: Depression, anxiety, somatisation disorder.
- Sleep disorders: Sleep apnoea, restless leg syndrome.
- Chronic infections: Epstein-Barr virus, Lyme disease (if relevant travel history).
Justify why CFS is most likely, given normal investigations and characteristic symptomatology.

Task 3: Address the patient’s concerns regarding diagnosis, prognosis, and management.

The competent candidate should:

Validate the patient’s distress and frustration, acknowledging the legitimacy of CFS.
Address fears about serious conditions, explaining why these have been ruled out.
Provide realistic but hopeful reassurance, explaining that many patients improve over time with management.
Discuss uncertainties around CFS, including the lack of a definitive test and variability in prognosis.
Offer support and resources, including support groups and patient education materials.

Task 4: Provide a structured management plan, including lifestyle advice, referrals, and follow-up.

The competent candidate should:

Develop a multimodal management plan including:
- Pacing strategies to prevent post-exertional crashes.
- Sleep hygiene education.
- Cognitive behavioural therapy (CBT) and graded exercise therapy (GET) (if tolerated and evidence-based).
- Pharmacological options for symptom relief, such as analgesia for myalgia or melatonin for sleep disturbances.
Discuss referral options, including allied health (e.g., physiotherapy, psychology, occupational therapy).
Arrange follow-up, ensuring regular reviews to monitor progress.
Consider a GP Management Plan (GPMP) and Team Care Arrangement (TCA) for long-term multidisciplinary care.

SUMMARY OF A COMPETENT ANSWER

Thorough history-taking, exploring fatigue patterns, associated symptoms, psychosocial impact, and red flags.
Clear differential diagnosis, ruling out organic and psychiatric causes.
Empathetic and patient-centred communication, addressing concerns about prognosis and management.
Structured, multimodal management plan, including pacing, sleep strategies, psychological support, and symptom relief.
Appropriate use of guidelines and evidence-based care, including consideration of GPMP/TCA for long-term support.

PITFALLS

Failure to explore post-exertional malaise (PEM), which is a key feature of CFS.
Over-reliance on investigations, rather than clinical history, for diagnosis.
Dismissing the patient’s symptoms as purely psychological without considering the holistic impact.
Neglecting mental health screening, missing comorbid depression or anxiety.
Providing unrealistic expectations, such as promising a “cure” rather than focusing on symptom management.
Not addressing the patient’s concerns adequately, leading to frustration and dissatisfaction.

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 Elicits a detailed history, including onset, duration, and impact of symptoms.
2.2 Identifies red flags for alternative diagnoses.

3. Diagnosis, Decision-Making and Reasoning

3.1 Uses clinical reasoning to determine the likelihood of Chronic Fatigue Syndrome.
3.3 Considers and rules out other differential diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops a multi-disciplinary management plan including non-pharmacological approaches.
4.4 Provides evidence-based treatment recommendations for CFS.

5. Preventive and Population Health

5.2 Provides lifestyle modification advice, including pacing strategies and sleep hygiene.

6. Professionalism

6.2 Recognises and addresses the impact of CFS on the patient’s personal and professional life.

7. General Practice Systems and Regulatory Requirements

7.1 Uses appropriate care planning (e.g., GPMP, Team Care Arrangements).

9. Managing Uncertainty

9.1 Addresses patient frustration regarding diagnostic uncertainty and lack of definitive treatment.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies patients at risk of psychological distress or depression due to chronic illness.

Competency at Fellowship Level

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