CASE INFORMATION

Case ID: CCE-CE-003
Case Name: James Reynolds
Age: 52
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: B72 (Leukaemia), A04 (Weakness/Tiredness General), B74 (Lymphadenopathy)

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 and sensitive explanations of potential diagnoses and management options
2. Clinical Information Gathering and Interpretation	2.1 Takes a thorough history to identify red flags for leukaemia 2.2 Identifies concerning symptoms and orders appropriate initial investigations 2.3 Interprets results to guide referral and management
3. Diagnosis, Decision-Making and Reasoning	3.1 Recognises clinical features suggestive of leukaemia and considers it in the differential diagnosis 3.3 Considers and rules out alternative causes of symptoms
4. Clinical Management and Therapeutic Reasoning	4.2 Arranges urgent haematology referral for further assessment 4.4 Provides initial symptomatic management and supportive care
5. Preventive and Population Health	5.2 Discusses lifestyle measures to optimise general health before and during treatment
6. Professionalism	6.2 Demonstrates sensitivity in delivering a potentially serious diagnosis
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate referral pathways and follow-up care
9. Managing Uncertainty	9.1 Addresses patient anxiety about the possible diagnosis and next steps
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and initiates urgent investigation and referral for suspected haematological malignancy

CASE FEATURES

Patient is anxious and worried about cancer.
52-year-old man presenting with persistent fatigue, bruising, and night sweats.
Noticed progressive weakness and weight loss over the past three months.
Reports frequent infections over the last few months.
Recently developed painless cervical lymphadenopathy.
Mild splenomegaly noted on examination.

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

James Reynolds, a 52-year-old teacher, presents to your general practice with fatigue, easy bruising, and night sweats. He has noticed gradual weight loss (5 kg in three months) and has had frequent infections, including a recent sinus infection and an episode of oral thrush.

On examination, he has cervical lymphadenopathy, mild splenomegaly, and scattered bruises on his arms.

PATIENT RECORD SUMMARY

Patient Details

Name: James Reynolds
Age: 52
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular medications

Past History

No significant medical history

Social History

Occupation: High school teacher
Non-smoker
Occasional alcohol use (2-3 drinks/week)

Family History

Father: Passed away at 78 from cardiovascular disease
Mother: Alive, hypertension

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’ve been feeling exhausted for months now, and I just don’t know what’s wrong with me. I’m getting really worried.”

General Information

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

You have been feeling very tired and weak for the past three months, and it seems to be getting worse.
You wake up feeling exhausted, no matter how much you sleep.
You have noticed significant weight loss of about 5 kg over the past three months without trying.
You have night sweats almost every night, enough to soak your sheets.

Specific Information

(Only Reveal When Asked Directly)

Background Information

You have been bruising easily, finding unexplained bruises on your arms and legs.
You have had several infections recently, including a sinus infection last month and oral thrush a few weeks ago.
About three weeks ago, you noticed a painless lump in your neck, which hasn’t gone away.

Fatigue and Weakness

You feel like you have no energy at all, struggling to get through the workday.
You are having difficulty concentrating and feel mentally foggy.
You sometimes feel lightheaded if you stand up too quickly.
You feel short of breath with mild exertion, like walking up stairs.

Bruising and Bleeding

You have noticed more bruises on your arms and legs than usual.
You also had some minor nosebleeds recently, which is unusual for you.

Lumps and Lymph Nodes

You first noticed a small lump on the left side of your neck about three weeks ago.
It doesn’t hurt, but it feels firm and hasn’t gone away.
You haven’t noticed any lumps anywhere else.

Other Symptoms

You don’t have a fever, but you feel hot and sweaty at night.
You sometimes feel fullness in your upper left abdomen, like a bloated or heavy sensation after eating.
You haven’t had any rashes, itching, or joint pain.
You don’t have any trouble swallowing or changes in appetite, but you are eating less than usual.

Emotional and Psychological State

You feel anxious and scared because your symptoms have lasted for months.
You’re worried this could be something serious like cancer.
You have been having trouble focusing at work, and your fatigue is affecting your daily life.
You have been snapping at your family more than usual, and your partner is worried about you.

Concerns and Questions for the Candidate

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

“Could this be cancer? I’ve read that night sweats and weight loss are warning signs.”
“Why am I getting so many infections lately? I’ve never had this happen before.”
“What tests do I need? Should I be seeing a specialist?”
“Is there a chance this is just stress or something minor?”
“What happens if it’s leukaemia? What are the next steps?”

Role-Playing Emotional Cues

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

Anxiety: Look tense, furrow your brow, and speak quickly when discussing serious concerns.
Frustration: Shake your head and sigh when talking about how long this has been going on.
Fear: Look visibly distressed and worried when discussing cancer or leukaemia.
Skepticism: Raise an eyebrow if the doctor suggests it could be something minor.
Relief (if reassured well): Breathe out, sit up straighter, and nod when the doctor 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 symptoms.
To order the right tests. You want to know what tests will help find the answer.
To provide a plan. You need to know what happens next and when you’ll get results.
To acknowledge your concerns. You are worried about something serious, and you need reassurance.

Potential Curveballs

(Optional, if the Candidate Handles the Basics Well)

“A friend of mine had similar symptoms and was diagnosed with lymphoma. Could that be what I have?”
“I read online that fatigue can be caused by vitamin deficiencies. Should I just take supplements?”
“Do I need to take time off work? I’m struggling to keep up.”
“If this is leukaemia, what are my chances of survival?”

End of Consultation

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

“Okay, that makes sense. I just want to know what’s happening, and I appreciate you explaining it all to me. I’ll get the tests done as soon as possible.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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

The competent candidate should:

Use open-ended questions to allow the patient to describe their symptoms in detail.
Explore onset, duration, severity, and progression of fatigue, weight loss, night sweats, and bruising.
Identify red flag symptoms, including recurrent infections, lymphadenopathy, splenomegaly, and bleeding tendencies.
Assess for associated systemic symptoms, such as bone pain, neurological symptoms, or shortness of breath.
Take a comprehensive medical history, including family history of haematological malignancies, medication use, and previous health status.
Explore psychosocial factors, including impact on work and daily life, and assess the patient’s ideas, concerns, and expectations (ICE).
Ask about modifiable risk factors, including smoking, alcohol use, and occupational exposures.

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

The competent candidate should:

Consider leukaemia as a high-priority diagnosis, based on:
- Persistent fatigue, weight loss, night sweats, easy bruising, infections, and lymphadenopathy.
- Presence of splenomegaly and abnormal bruising, suggestive of haematological dysfunction.
Discuss other differential diagnoses, including:
- Lymphoma – overlapping B symptoms, lymphadenopathy.
- Aplastic anaemia or myelodysplastic syndrome – cytopenias without malignancy.
- Autoimmune diseases (e.g., SLE, vasculitis) – systemic symptoms with immune dysfunction.
- Chronic infections (e.g., tuberculosis, HIV, EBV) – weight loss and lymphadenopathy.
Justify why urgent haematological assessment is required, given the constellation of symptoms.

Task 3: Address the patient’s concerns regarding their symptoms and possible diagnosis.

The competent candidate should:

Acknowledge the patient’s fears regarding cancer and serious illness.
Provide structured reassurance by explaining that a range of conditions can cause these symptoms, but urgent investigation is needed.
Empathise with uncertainty, validating the emotional impact of waiting for test results.
Explain the role of blood tests and imaging, including a full blood count (FBC), blood film, and bone marrow biopsy if indicated.
Discuss the importance of early detection, ensuring the patient understands that prompt investigation may improve outcomes.
Offer psychological support, normalising the patient’s anxiety and encouraging them to involve family in decision-making.

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

The competent candidate should:

Order urgent investigations, including:
- Full blood count (FBC) and blood film – to assess for blasts or cytopenias.
- Peripheral blood smear – to look for abnormal white cells.
- Liver function tests (LFTs), renal function, and inflammatory markers.
- Lactate dehydrogenase (LDH) and uric acid – markers of haematological malignancy.
- Coagulation studies – to assess for bleeding risk.
Refer urgently to a haematologist for:
- Bone marrow biopsy and immunophenotyping to confirm diagnosis.
- Further imaging (e.g., CT scan) if lymphoma is suspected.
Manage symptomatically, including:
- Addressing fatigue and infections while awaiting results.
- Discussing safety-netting advice – when to seek immediate medical attention (e.g., fevers, worsening bleeding).
- Ensuring follow-up within 48-72 hours to review results and discuss next steps.

SUMMARY OF A COMPETENT ANSWER

Thorough history-taking, covering fatigue, weight loss, infections, bruising, and lymphadenopathy.
Clear differential diagnosis, prioritising leukaemia while ruling out other serious conditions.
Empathetic and structured reassurance, addressing patient concerns about cancer and uncertainty.
Urgent, evidence-based management plan, including appropriate investigations, haematology referral, and symptomatic care.
Timely follow-up plan, ensuring the patient is supported throughout the diagnostic process.

PITFALLS

Failure to recognise red flag symptoms, leading to delayed diagnosis of leukaemia.
Over-reassurance without adequate investigation, dismissing serious pathology.
Ordering excessive non-targeted investigations, delaying appropriate referral.
Not addressing the patient’s concerns adequately, leading to dissatisfaction and anxiety.
Failure to arrange urgent specialist referral, delaying potential treatment.
Not providing safety-netting advice, missing the opportunity for early intervention.

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 and sensitive explanations of potential diagnoses and management options.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough history to identify red flags for leukaemia.
2.2 Identifies concerning symptoms and orders appropriate initial investigations.
2.3 Interprets results to guide referral and management.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises clinical features suggestive of leukaemia and considers it in the differential diagnosis.
3.3 Considers and rules out alternative causes of symptoms.

4. Clinical Management and Therapeutic Reasoning

4.2 Arranges urgent haematology referral for further assessment.
4.4 Provides initial symptomatic management and supportive care.

5. Preventive and Population Health

5.2 Discusses lifestyle measures to optimise general health before and during treatment.

6. Professionalism

6.2 Demonstrates sensitivity in delivering a potentially serious diagnosis.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate referral pathways and follow-up care.

9. Managing Uncertainty

9.1 Addresses patient anxiety about the possible diagnosis and next steps.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and initiates urgent investigation and referral for suspected haematological malignancy.

Competency at Fellowship Level

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