CASE INFORMATION

Case ID: CCE-CE-005
Case Name: Robert Dawson
Age: 64
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: B79 (Multiple Myeloma), A04 (Weakness/Tiredness General), L18 (Back Pain)

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 myeloma 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 multiple myeloma 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 worried about a serious underlying condition, possibly cancer.
64-year-old man presenting with persistent fatigue, bone pain, and weight loss.
Chronic lower back pain worsening over the past few months, now affecting mobility.
Recent history of recurrent infections (sinusitis, chest infections).
Mild anaemia noted in recent routine blood tests.

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

Robert Dawson, a 64-year-old retired school principal, presents to your general practice with persistent fatigue, lower back pain, and weight loss (5 kg over the past four months).

A recent routine blood test showed mild anaemia, but no further investigations were done at the time.

PATIENT RECORD SUMMARY

Patient Details

Name: Robert Dawson
Age: 64
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Paracetamol PRN for back pain

Past History

Hypertension (well-controlled)

Social History

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

Family History

Father: Died at 75 from a stroke
Mother: Alive, osteoporosis

Vaccination and Preventative Activities

Last health check six months 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 extremely tired lately, and my back pain is getting worse. I’m starting to worry something serious is going on.”

General Information

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

The back pain started about four months ago and has been gradually getting worse.
It is a constant, dull ache in the lower back, sometimes spreading to your ribs.
Pain is worse at night, and it does not get better with rest or simple painkillers like paracetamol.

Specific Information

(Only Reveal When Asked Directly)

Background Information

You feel more fatigued than usual, even after a full night’s sleep.
Over the past four months, you have lost about 5 kg without trying.
You’ve had two chest infections and a sinus infection in the last six months, all needing antibiotics.
You feel like your legs are weaker, and you sometimes feel unsteady when walking.

Back Pain and Bone Symptoms

The pain has not been triggered by an injury.
You haven’t had any recent falls or accidents.
Sometimes, you feel like you have a pressure or tightness in your ribs.
Lifting things, even light objects, sometimes makes the pain worse.
You haven’t noticed any swelling in the back or ribs.

Fatigue and General Health

You feel physically weaker than usual.
Your energy levels have dropped, making it hard to do your usual daily activities.
Your appetite has been poor, but you haven’t had nausea or vomiting.
You’ve noticed that your skin looks paler, and your wife has commented that you look “washed out.”

Other Symptoms

You have had no fevers or night sweats.
No shortness of breath, apart from when you had infections.
No bowel or bladder incontinence, but you feel like you need to urinate more often.

Emotional and Psychological State

You feel worried that this could be something serious like cancer.
Your wife is also concerned, especially about the weight loss and how pale you look.
You are anxious about your future, especially whether you will lose your mobility.
You’ve always been independent and active, and the thought of being limited by pain or illness frightens 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 back pain and weight loss can be warning signs.”
“What kind of tests do I need? Will I need an MRI or a biopsy?”
“Why am I getting so many infections lately? I’ve never had this happen before.”
“Is this just old age, or should I be really worried?”
“If this is multiple myeloma, what does treatment involve?”
“Will I be able to live a normal life if I have this?”
“Do I need to stop doing certain activities? Should I be resting more?”

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 when explaining how long this has been going on without answers.
Fear: Speak softly or hesitate when asking about cancer, avoiding eye contact.
Skepticism: Raise an eyebrow if the doctor suggests this 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, imaging, and possibly a biopsy.
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 something serious, 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 osteoporosis. Could that be what I have?”
“Should I be taking calcium or vitamin D? Maybe it’s just a deficiency.”
“Do I need to stop exercising? I don’t want to make things worse.”
“If this is myeloma, what’s my life expectancy?”

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, back pain, weight loss, and recurrent infections.
Identify red flag symptoms, such as persistent back pain that worsens at night, weakness, fractures, and anaemia.
Assess for associated systemic symptoms, including renal dysfunction, polyuria, and cognitive changes.
Take a comprehensive medical history, including prior fractures, osteoporosis risk factors, medication use (NSAIDs, steroids), smoking, alcohol, and family history of malignancy.
Evaluate the impact on daily activities, mobility, and quality of life.
Address the patient’s ideas, concerns, and expectations (ICE), particularly regarding cancer and long-term prognosis.

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

The competent candidate should:

Consider multiple myeloma as a leading diagnosis, supported by:
- Bone pain (worse at night, not relieved by rest).
- Unintentional weight loss.
- Fatigue, anaemia, and recurrent infections.
Discuss other differential diagnoses, including:
- Metastatic bone disease – consider in a patient with weight loss and persistent back pain.
- Osteoporotic vertebral fractures – older age, back pain, but less systemic features.
- Chronic kidney disease – can cause fatigue, bone pain, and anaemia.
- Primary bone tumours or spinal metastases – need imaging for exclusion.
- Chronic infections (e.g., tuberculosis, osteomyelitis) – can cause constitutional symptoms and bone pain.
Justify why urgent haematology referral is required, given red flag symptoms and possible haematological malignancy.

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

The competent candidate should:

Acknowledge the patient’s anxiety about cancer and serious illness.
Provide structured reassurance, explaining that multiple causes could contribute to symptoms, but further testing is needed.
Explain the role of blood tests, imaging, and possibly a bone marrow biopsy in confirming the diagnosis.
Empathise with uncertainty, validating the emotional impact of waiting for test results.
Discuss that early detection can improve management options and quality of life.
Offer psychological support, encouraging involvement of family and possible referrals to 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) – assess for anaemia.
- Renal function and electrolytes – assess kidney function (hypercalcaemia).
- Serum calcium and albumin – hypercalcaemia common in myeloma.
- Serum protein electrophoresis (SPEP) and urine Bence-Jones proteins – assess for monoclonal gammopathy.
- Beta-2 microglobulin and LDH – markers of myeloma disease burden.
- Skeletal survey or whole-body MRI – detect lytic bone lesions.
Arrange urgent haematology referral for:
- Bone marrow biopsy to confirm myeloma.
- Further imaging (CT/MRI spine) if cord compression is suspected.
Manage symptomatically, including:
- Analgesia for pain management – avoid NSAIDs due to potential renal impairment.
- Hydration and bisphosphonates if hypercalcaemia present.
- Prompt intervention for infections given immunosuppression risk.
Ensure follow-up within 48-72 hours to review results and coordinate specialist care.

SUMMARY OF A COMPETENT ANSWER

Thorough history-taking, covering bone pain, systemic symptoms, renal function, and infection risk.
Clear differential diagnosis, prioritising multiple myeloma while ruling out metastases, osteoporosis, and chronic infections.
Empathetic and structured reassurance, addressing patient concerns about cancer and prognosis.
Urgent, evidence-based management plan, including targeted investigations, specialist 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 multiple myeloma.
Over-reassurance without appropriate investigations, missing 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 considering myeloma-related complications, such as renal impairment or hypercalcaemia.

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 myeloma.
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 multiple myeloma 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