CASE INFORMATION

Case ID: CCE-CE-002
Case Name: Sarah Mitchell
Age: 38
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: A04 (Weakness/Tiredness General), P76 (Depressive Disorder), T90 (Diabetes, Non-Insulin-Dependent)

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 Provides clear explanations of potential diagnoses and management options
2. Clinical Information Gathering and Interpretation	2.1 Takes a thorough history to identify causes of fatigue 2.2 Identifies red flags and orders appropriate investigations 2.3 Interprets results to rule out serious conditions
3. Diagnosis, Decision-Making and Reasoning	3.1 Uses clinical reasoning to determine likely causes of fatigue 3.3 Considers and rules out alternative diagnoses
4. Clinical Management and Therapeutic Reasoning	4.2 Develops a management plan addressing reversible causes of fatigue 4.4 Provides evidence-based recommendations for lifestyle modifications and psychological support
5. Preventive and Population Health	5.2 Provides lifestyle advice on sleep, diet, and exercise to improve energy levels
6. Professionalism	6.2 Acknowledges the impact of fatigue on the patient’s well-being and work-life balance
7. General Practice Systems and Regulatory Requirements	7.1 Uses appropriate care planning for chronic disease management (e.g., GPMP, Team Care Arrangements)
9. Managing Uncertainty	9.1 Addresses patient anxiety about the cause of fatigue and need for further investigations
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and manages potential underlying depression or other significant illness

CASE FEATURES

Potential psychosocial contributors (stress, depression, poor sleep).
38-year-old woman presenting with persistent fatigue for the past 4 months.
No clear precipitating event.
Symptoms affecting work, family life, and mood.
Worried about underlying serious illness (e.g., cancer, autoimmune disease).
Recent diagnosis of Type 2 Diabetes Mellitus, struggling with lifestyle changes.

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 Mitchell, a 38-year-old accountant, presents to your general practice complaining of ongoing fatigue for the past four months. She describes feeling constantly exhausted, unmotivated, and unable to concentrate at work. Her energy levels have significantly declined, making it difficult to keep up with her job and take care of her two young children.

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Mitchell
Age: 38
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Metformin 500mg BD

Past History

Type 2 Diabetes Mellitus (diagnosed 3 months ago)

Social History

Occupation: Accountant

Family History

Mother: Type 2 Diabetes, Hypothyroidism
Father: Hypertension, Depression

Smoking

Never smoked

Alcohol

1-2 drinks per week

Vaccination and Preventative Activities

Last health check 6 months ago (HbA1c 7.2%)
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 don’t know what’s wrong with me. I feel exhausted all the time, and it’s really starting to affect my life.”

General Information

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

You have been feeling tired all the time for about four months, and it seems to be getting worse.
You wake up feeling exhausted, even after a full night’s sleep.
You used to have plenty of energy, but now even simple tasks like cooking dinner or playing with your kids feel overwhelming.
Your concentration has been terrible, and you’ve been making mistakes at work, which is unusual for you.
Your mood has been low, and you feel irritable and overwhelmed, but you’re not sure if it’s depression or just frustration.
You’ve noticed some occasional headaches and muscle aches, but nothing severe.

Specific Information

(Only Reveal When Asked Directly)

Fatigue and Daily Impact

Your energy levels have dropped significantly, making it hard to get through the workday.
You are falling behind at work because you can’t concentrate.
You come home from work completely exhausted, and you struggle to engage with your kids.
Your husband has noticed you’re more irritable and withdrawn.
You’ve stopped exercising because you don’t have the energy for it anymore.

Sleep and Rest

You are sleeping 7-8 hours a night, but you wake up feeling unrefreshed.
You sometimes wake up during the night but don’t know why.
You don’t take naps during the day, but you feel like you could if you had the chance.

Medical History and Symptoms

You were diagnosed with Type 2 Diabetes three months ago after a routine health check.
You started Metformin (500mg twice daily), but you’re not sure if it’s making a difference.
You don’t think you’ve lost weight, but you haven’t checked.
No fever, night sweats, or unexplained weight loss.
No joint swelling or pain.
No chest pain or shortness of breath.
No nausea, vomiting, or changes in bowel habits.

Mental and Emotional Well-being

You feel frustrated that you don’t have an answer for why you feel this way.
You sometimes feel overwhelmed and teary, but you’re not sure if it’s a mood disorder or just stress.
You worry you’re letting your family down because you don’t have the energy to do what you used to.

Work and Lifestyle Factors

You work full-time as an accountant, and you find your job mentally draining.
Your work has been especially stressful lately, with long hours and tight deadlines.
Your husband helps out at home, but you feel guilty about not doing as much as you used to.

Concerns and Expectations

(Express these emotions naturally throughout the consultation)

“I’m really worried this could be something serious like cancer.” (Express anxiety, looking concerned and fidgeting.)
“Could my diabetes be causing this? I thought things would improve after starting medication, but I still feel awful.” (Frustration and disappointment.)
“I don’t know if I should push through or take time off work. What do you think?” (Seeking guidance and reassurance.)
“What if I never feel normal again? I can’t live like this forever.” (Fear and hopelessness.)

Questions for the Candidate

(Ask these naturally during the consultation, especially when discussing diagnosis or management.)

“Do you think I need more blood tests? Maybe I have an iron or thyroid problem?”
“Should I see a specialist? Would a neurologist or endocrinologist be able to help?”
“Is this depression? Or is it just because I’m tired all the time?”
“What can I do to feel better? I need something that works.”
“Do I need to change my diet or exercise routine?”
“Could this be chronic fatigue syndrome?”
“Are there any supplements or vitamins that could help?”

Role-Playing Emotional Cues

(Act these out realistically to simulate a real patient encounter.)

Frustration: Shake your head, sigh, or look annoyed when discussing how long this has been going on.
Anxiety: Look worried, furrow your brow, and fidget when expressing concerns about serious conditions.
Hopelessness: Speak softly, slump slightly in your chair, and express uncertainty about getting better.
Skepticism: Raise an eyebrow or tilt your head when discussing psychological factors (if the candidate suggests stress or mood as a cause).
Relief (if reassured well): Breathe out, sit up straighter, and nod when the candidate explains things clearly and provides a plan.

What You Are Expecting From the Doctor (Candidate)

To take you seriously. You don’t want to be dismissed or told “it’s just stress.”
To give a clear explanation. You want to understand what could be causing your fatigue.
To provide a plan. You don’t expect an immediate cure, but you want practical steps to help you improve.
To acknowledge your concerns. You’re scared this might be something serious, and you need reassurance.
To discuss work and lifestyle. You want to know if you need to rest more or push through.

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

“I read online that extreme fatigue could be due to adrenal fatigue. Is that real?”
“A friend of mine was diagnosed with Lyme disease overseas. Do you think I could have that?”
“Should I try taking vitamins or herbal supplements?”
“If this is all stress-related, does that mean I need to see a psychologist?”

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

“Okay, that makes sense. I just want to feel like myself again. I’ll try what you suggested and see how it goes.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, exploring the patient’s fatigue and associated symptoms.

The competent candidate should:

Use open-ended questions to allow the patient to describe their fatigue in detail.
Explore onset, duration, severity, and variability of fatigue.
Assess for associated symptoms, including sleep disturbances, cognitive changes, mood alterations, weight loss, muscle/joint pain, headaches, and stress levels.
Screen for red flags such as unexplained weight loss, night sweats, chronic infections, or neurological symptoms.
Take a comprehensive psychosocial history, including work stress, family responsibilities, and mental health.
Ask about previous investigations, treatments, and patient expectations regarding their fatigue.
Explore lifestyle factors such as exercise, diet, and sleep hygiene.
Address the patient’s concerns and ideas about potential serious illnesses (e.g., cancer, autoimmune disease).

Task 2: Outline your differential diagnosis, discussing the most likely causes and ruling out serious conditions.

The competent candidate should:

Consider common causes of fatigue, including:
- Endocrine/metabolic: Type 2 Diabetes Mellitus, hypothyroidism, adrenal insufficiency.
- Psychiatric: Depression, anxiety, adjustment disorder.
- Sleep disorders: Obstructive sleep apnoea, insomnia.
- Nutritional deficiencies: Iron, B12, vitamin D.
- Chronic infections: Post-viral syndrome, chronic Epstein-Barr virus.
- Medication side effects: Metformin, antihypertensives, sedatives.
Rule out serious conditions, such as:
- Haematological malignancies (via absence of weight loss, night sweats, lymphadenopathy).
- Autoimmune diseases (e.g., SLE, rheumatoid arthritis) if there are no joint symptoms or rashes.
- Neurological disorders (e.g., multiple sclerosis) if there are no focal neurological signs.
Justify why psychosocial stress, sleep issues, and metabolic factors are the most likely contributors in this case.

Task 3: Address the patient’s concerns regarding her fatigue and its potential impact.

The competent candidate should:

Validate the patient’s frustration and anxiety, acknowledging the impact on her life.
Provide clear and structured reassurance, explaining why serious conditions are unlikely based on the history and examination findings.
Address her concerns about diabetes, explaining that poor glycaemic control, medication side effects, and lifestyle changes could contribute to fatigue.
Discuss the role of stress, poor sleep, and possible low mood in worsening fatigue.
Encourage a stepwise approach to identifying contributing factors and improving symptoms.
Offer realistic expectations, acknowledging that improvements may take time with lifestyle changes and targeted management.

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

The competent candidate should:

Develop a holistic, multimodal management plan:
- Optimise diabetes management, ensuring glycaemic control and minimising medication side effects.
- Address sleep hygiene: Maintain regular sleep schedule, reduce screen time, consider sleep study if obstructive sleep apnoea suspected.
- Mental health support: Screening for depression/anxiety, referral to psychology if required.
- Lifestyle modifications: Encourage graded exercise, balanced diet, and stress management techniques.
- Consider supplementation: Check for iron, B12, vitamin D deficiency and replace if needed.
- Referral options: Consider dietitian, exercise physiologist, psychologist based on findings.
Schedule a follow-up appointment to reassess symptoms and review investigations.

SUMMARY OF A COMPETENT ANSWER

Thorough history-taking, exploring fatigue patterns, associated symptoms, psychosocial impact, and red flags.
Clear differential diagnosis, ruling out metabolic, psychiatric, sleep-related, and serious conditions.
Empathetic and structured reassurance, addressing patient concerns about serious illness.
Comprehensive management plan, incorporating lifestyle changes, sleep strategies, psychological support, and medical interventions.
Appropriate use of guidelines and evidence-based care, including consideration of referrals for allied health support.

PITFALLS

Failure to explore psychosocial factors, focusing only on physical causes of fatigue.
Over-investigating without clinical indications, leading to unnecessary tests and patient anxiety.
Dismissing the patient’s concerns too quickly, rather than acknowledging their distress.
Neglecting the role of sleep disorders and mental health, missing important contributors to fatigue.
Providing vague or unrealistic advice, rather than a clear, structured management plan.
Not arranging appropriate follow-up, failing to monitor symptoms and treatment response.

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.
1.5 Provides clear explanations of potential diagnoses and management options.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough history to identify causes of fatigue.
2.2 Identifies red flags and orders appropriate investigations.
2.3 Interprets results to rule out serious conditions.

3. Diagnosis, Decision-Making and Reasoning

3.1 Uses clinical reasoning to determine likely causes of fatigue.
3.3 Considers and rules out alternative diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops a management plan addressing reversible causes of fatigue.
4.4 Provides evidence-based recommendations for lifestyle modifications and psychological support.

5. Preventive and Population Health

5.2 Provides lifestyle advice on sleep, diet, and exercise to improve energy levels.

6. Professionalism

6.2 Acknowledges the impact of fatigue on the patient’s well-being and work-life balance.

7. General Practice Systems and Regulatory Requirements

7.1 Uses appropriate care planning for chronic disease management (e.g., GPMP, Team Care Arrangements).

9. Managing Uncertainty

9.1 Addresses patient anxiety about the cause of fatigue and need for further investigations.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages potential underlying depression or other significant illness.

Competency at Fellowship Level

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