CASE INFORMATION
Case ID: CCE-CE-004
Case Name: Mark Stevenson
Age: 47
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: B73 (Lymphoma), 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 lymphoma 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 lymphoma 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 concerned about cancer.
- 47-year-old man presenting with persistent fatigue, weight loss, and night sweats.
- Progressive painless swelling of cervical lymph nodes over three months.
- Intermittent fevers with no clear infection source.
- Recent episodes of pruritus (itching) without rash.
- 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
Mark Stevenson, a 47-year-old engineer, presents to your general practice with fatigue, unexplained weight loss (6 kg in 3 months), and night sweats. He has been experiencing persistent swelling in the left side of his neck for the past three months, which is painless and gradually enlarging.
He reports intermittent fevers but denies any recent infections. Over the past few weeks, he has also noticed generalised itching without a rash.
PATIENT RECORD SUMMARY
Patient Details
- Name: Mark Stevenson
- Age: 47
- 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: Engineer
- Non-smoker
- Occasional alcohol use (2-3 drinks/week)
Family History
- Father: Passed away at 72 from cardiovascular disease
- Mother: Alive, history of 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 had this swelling in my neck for months now, and I’ve been feeling really run down. I’m starting to get worried.”
General Information
(Can be shared freely if the candidate asks open-ended questions like “Tell me more about that.”)
- The lump in your neck appeared about three months ago and has been slowly getting bigger.
- It is firm, painless, and does not seem to be going away.
- You initially thought it was a swollen gland from a cold, but you haven’t been sick recently.
- You feel more tired than usual and often struggle to get through the workday.
Specific Information
(Only Reveal When Asked Directly)
Background Information
- You have been losing weight—about 6 kg in three months—without changing your diet or exercise.
- You wake up soaked in sweat, even when the room is cool.
- You have intermittent fevers, but no clear infection symptoms.
- Your skin has been very itchy, but there is no rash.
Fatigue and Weakness
- You feel exhausted all the time, even after a full night’s sleep.
- You have been napping more on weekends, which is unusual for you.
- You sometimes feel lightheaded or short of breath when climbing stairs.
Lymph Node Swelling
- The lump is in your left neck, but you haven’t checked for others elsewhere.
- No sore throat, dental pain, or recent infections.
- No pain or tenderness in the lump.
Other Symptoms
- You feel full quickly after eating, but no major appetite changes.
- No cough, chest pain, or difficulty swallowing.
- No changes in bowel habits or blood in stool.
Emotional and Psychological State
- You are increasingly anxious that this could be cancer.
- Your wife is worried about your weight loss and night sweats.
- You read online that lymphoma could be a cause, and that has really scared you.
- You feel frustrated that you have been feeling unwell for months without a clear explanation.
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 bad signs.”
- “What kind of tests do I need? Will I need a biopsy?”
- “Is there any chance this is just an infection or something minor?”
- “How serious is lymphoma if that’s what I have?”
- “What happens next if my blood tests come back abnormal?”
- “How quickly do I need to act on this? Should I take time off work?”
- “If this is lymphoma, will I need chemotherapy? What are my chances?”
Role-Playing Emotional Cues
(Act these out realistically to simulate a real patient encounter.)
- Anxiety: Look tense, fidget with your hands, or sigh when discussing serious concerns.
- Frustration: Shake your head or cross your arms when expressing how long this has been going on.
- Fear: Speak more softly, hesitate when asking about cancer, or avoid eye contact.
- Skepticism: Raise an eyebrow or tilt your head if the doctor suggests it could be something minor.
- Relief (if reassured well): Breathe out deeply, sit up straighter, and nod when the doctor explains things clearly.
What You Are Expecting From the Doctor (Candidate)
- To take your concerns seriously. You are genuinely worried and need them to acknowledge that.
- To give a clear explanation. You want to understand what could be causing your symptoms.
- To order the right tests. You expect blood tests and scans to investigate further.
- To provide a plan. You need to know what happens next and how quickly things will move.
- To acknowledge your anxiety. You are worried about cancer, and you need reassurance.
Potential Curveballs
(Optional, if the Candidate Handles the Basics Well)
- “A friend of mine had similar symptoms and it turned out to be tuberculosis. Could that be what I have?”
- “Should I take supplements or change my diet? Maybe it’s something nutritional.”
- “Do I need to stop working? I feel exhausted all the time.”
- “If this is lymphoma, will I lose my hair from treatment?”
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, lymph node swelling, and pruritus.
- Identify red flag symptoms, such as persistent unexplained fevers, drenching night sweats, and significant weight loss.
- Assess for associated systemic symptoms, including shortness of breath, bone pain, abdominal discomfort (splenomegaly), and persistent infections.
- Take a comprehensive medical history, including prior illnesses, infections (EBV, HIV), medication use, smoking, alcohol, and occupational exposures.
- Explore family history of haematological malignancies or autoimmune disorders.
- Assess psychosocial impact, including concerns about work, relationships, and mental well-being.
- Address the patient’s ideas, concerns, and expectations (ICE) about the possibility of cancer.
Task 2: Outline your differential diagnosis, discussing the most likely causes and serious considerations.
The competent candidate should:
- Consider lymphoma as a leading diagnosis, based on:
- Painless, progressive lymphadenopathy.
- B symptoms (fever, weight loss, night sweats).
- Generalised pruritus, which can occur in Hodgkin lymphoma.
- Discuss other differential diagnoses, including:
- Chronic infections (e.g., tuberculosis, EBV, HIV, toxoplasmosis).
- Autoimmune diseases (e.g., SLE, sarcoidosis).
- Leukaemia – may present similarly with systemic symptoms and lymphadenopathy.
- Metastatic solid malignancies (e.g., lung, melanoma, gastrointestinal cancers).
- Benign reactive lymphadenopathy – secondary to viral illness.
- Justify why urgent haematology referral is required given red flag symptoms and prolonged duration.
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, explaining that while lymphoma is a possibility, there are other treatable causes.
- Explain the role of further testing, including blood tests, imaging, and possible biopsy.
- Empathise with uncertainty, validating the patient’s emotional response and providing support.
- Clarify that early detection and treatment improve outcomes, reducing anxiety.
- Offer psychological support, suggesting support groups or counselling if needed.
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 – assess for anaemia, leukocytosis, or blasts.
- Peripheral blood smear – evaluate abnormal white cells.
- Inflammatory markers (ESR, CRP) – often elevated in lymphoma.
- Liver function tests (LFTs), renal function, calcium levels.
- LDH and uric acid – markers of lymphoma activity.
- HIV, EBV, and tuberculosis screening, if indicated.
- Arrange urgent referral to a haematologist for:
- Excisional lymph node biopsy (gold standard for lymphoma diagnosis).
- Imaging (CT or PET scan) to assess spread.
- Bone marrow biopsy, if required.
- Manage symptomatically, including:
- Addressing fatigue and pruritus while awaiting results.
- Providing safety-netting advice on when to seek urgent care.
- Offering emotional support and follow-up within 48-72 hours for test results.
SUMMARY OF A COMPETENT ANSWER
- Thorough history-taking, covering lymphadenopathy, B symptoms, infections, and autoimmune risk factors.
- Clear differential diagnosis, prioritising lymphoma while ruling out infections, autoimmune disease, and metastatic cancer.
- 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 lymphoma.
- 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
- RACGP Guidelines on Haematological Malignancies in General Practice
- Cancer Council Australia on Lymphoma Overview
- Better Health Channel on Lymphoma Symptoms and Diagnosis
- GP Exams – Lymphoma
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 lymphoma.
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 lymphoma 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