CASE INFORMATION

Case ID: CCE-CE-007
Case Name: Michael Tran
Age: 42
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: D72 (Hepatitis Viral B), A04 (Weakness/Tiredness General), A05 (Jaundice)

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 assess risk factors and complications of hepatitis B 2.2 Identifies red flags for acute liver failure and chronic liver disease 2.3 Orders and interprets appropriate investigations to confirm diagnosis and assess liver function
3. Diagnosis, Decision-Making and Reasoning	3.1 Recognises clinical features suggestive of hepatitis B and considers it in the differential diagnosis 3.3 Differentiates between acute and chronic hepatitis B and determines need for specialist referral
4. Clinical Management and Therapeutic Reasoning	4.2 Provides appropriate counselling, lifestyle advice, and treatment options 4.4 Arranges specialist referral if indicated (e.g., hepatology or infectious diseases)
5. Preventive and Population Health	5.2 Provides education on transmission, vaccination, and long-term monitoring for hepatitis B
6. Professionalism	6.2 Demonstrates sensitivity in discussing a potentially stigmatised condition
7. General Practice Systems and Regulatory Requirements	7.1 Ensures compliance with hepatitis B screening, notification, and follow-up requirements
9. Managing Uncertainty	9.1 Addresses patient concerns about long-term prognosis and risk of liver cancer
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and initiates urgent management if signs of acute liver failure are present

CASE FEATURES

Concerned about long-term consequences, liver cancer, and transmission to family.
42-year-old man presenting with fatigue, nausea, and jaundice.
Recent blood test revealed positive hepatitis B surface antigen (HBsAg).
Unaware of prior hepatitis B status, no previous screening.
History of travel to an endemic country and possible perinatal transmission risk.

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

Michael Tran, a 42-year-old office worker, presents to your general practice with fatigue, nausea, and yellowing of the skin (jaundice) over the past two weeks.

His recent blood test showed a positive hepatitis B surface antigen (HBsAg), which was done as part of a general health check. He is shocked by this result and does not recall being vaccinated or previously diagnosed with hepatitis B.

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Tran
Age: 42
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 past medical history
No history of liver disease, jaundice, or previous hepatitis screening

Social History

Occupation: Office worker
No history of injecting drug use or high-risk sexual behaviour
Social drinker (3-4 drinks per week), no smoking

Family History

Mother had hepatitis B (never discussed in detail)
No known history of liver cancer or cirrhosis in the family

Vaccination and Preventative Activities

Up to date with other routine immunisations
Unclear hepatitis B vaccination status

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 got some blood test results, and they said I have hepatitis B. I don’t even know how I got it.”

General Information

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

You are shocked and confused because you had no idea you had hepatitis B.
You feel mostly well but have been very tired lately.
You have noticed your skin and eyes turning yellow over the past two weeks.

Specific Information

(Only Reveal When Asked Directly)

Background Information

You sometimes feel nauseated and don’t have much appetite.
Your stomach feels bloated but you have no pain.
You do not recall ever being tested for hepatitis B before.
You don’t drink heavily, just socially on weekends (3-4 drinks per week).

Risk Factors for Hepatitis B

You were born in Vietnam, an area where hepatitis B is common.
You migrated to Australia at age 5 and don’t remember getting vaccinated.
Your mother had hepatitis B, but she never really talked about it.
You have never used drugs, had tattoos, or engaged in high-risk sexual behaviour.
You have never had a blood transfusion.
You are married with two children (ages 8 and 10).

Symptoms and Current Health

Fatigue has been getting worse over the last few months, but you assumed it was just work stress.
Your appetite is poor, and you feel nauseated sometimes.
No vomiting, fever, or abdominal pain.
Your urine is darker than usual, but you thought it was because you weren’t drinking enough water.
No itching or bleeding problems.

Concerns and Emotional Reactions

You are worried that you might pass this on to your wife and kids.
You are afraid that you might develop liver cancer.
You feel embarrassed and don’t know if you need to tell anyone else.
You are concerned about how this will affect your work and if you need to tell your employer.
You don’t want to take lifelong medication if possible.

Concerns and Questions for the Candidate

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

“What does this result mean? Do I have liver damage?”
“Can I give this to my wife or kids?”
“Will I need treatment for this? Is there a cure?”
“Does this mean I’m going to get liver cancer?”
“Do I need to change my diet or lifestyle?”
“Should I tell my employer? Can this affect my work?”
“Can I still drink alcohol, or should I stop completely?”

Role-Playing Emotional Cues

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

Shock and Confusion: Look puzzled and shake your head when discussing the test results.
Anxiety: Furrow your brow and look concerned when asking about transmission and liver cancer.
Embarrassment: Speak more softly or hesitate when discussing whether to tell family and work.
Frustration: Cross your arms or sigh when discussing long-term monitoring or lifestyle changes.
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 worried and need reassurance.
To explain the test results clearly. You don’t understand what this means and need it broken down in simple terms.
To tell you what happens next. You want to know what further tests you need and if you need treatment.
To explain how this affects your family. You don’t want to pass this to your wife and kids and need to know if they need to be tested or vaccinated.
To be clear about your long-term health. You are worried about liver cancer and if you will need lifelong monitoring.
To discuss work and lifestyle changes. You want to know if this will impact your job or if you need to stop drinking alcohol.

Potential Curveballs

(Optional, if the Candidate Handles the Basics Well)

“If my mum had hepatitis B, does that mean I was born with it?”
“I read online that some people clear hepatitis B on their own. Could that happen to me?”
“I’ve been feeling really tired. Could this mean I already have liver damage?”
“I’m worried my wife will be upset. Do I have to tell her?”
“Do I need to stop eating certain foods to protect my liver?”

End of Consultation

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

“Okay, that makes sense. I just want to make sure I stay healthy and that my family is safe. I’ll do the tests and follow your advice.”

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 explore the patient’s symptoms, duration, and severity.
Identify red flag symptoms such as profound jaundice, altered mental state, bleeding tendency (suggesting liver failure).
Assess for risk factors for hepatitis B, including:
- Birthplace in an endemic country (Vietnam in this case).
- Perinatal transmission (mother with hepatitis B).
- Sexual and household contacts, previous blood transfusions, IV drug use, tattoos, or occupational exposure.
Explore social and lifestyle factors, including alcohol intake, medications, and comorbidities.
Assess the impact on daily life and emotional response, including concerns about transmission, stigma, and long-term health risks.

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

The competent candidate should:

Consider acute hepatitis B vs chronic hepatitis B:
- Acute hepatitis B presents with jaundice, fatigue, nausea, and anorexia.
- Chronic hepatitis B is often asymptomatic until complications develop.
Discuss other potential causes of liver disease, including:
- Other viral hepatitis (A, C, D, E).
- Alcohol-related liver disease.
- Non-alcoholic fatty liver disease (NAFLD).
- Autoimmune hepatitis or metabolic liver disorders.
Identify red flags requiring urgent referral, such as:
- Signs of liver failure (confusion, bleeding, severe jaundice, ascites).
- Concern for hepatocellular carcinoma (HCC) in chronic hepatitis B.

Task 3: Address the patient’s concerns regarding his diagnosis, prognosis, and transmission risk.

The competent candidate should:

Acknowledge the patient’s shock and anxiety about the diagnosis.
Provide clear, non-judgemental education about transmission and natural history:
- Perinatal transmission is the most common cause of chronic hepatitis B.
- Most adult-acquired hepatitis B infections clear spontaneously.
- Chronic hepatitis B requires long-term monitoring but is manageable.
Discuss transmission risks and the need for:
- Testing family members (wife and children) for hepatitis B.
- Vaccination for close contacts if they are not immune.
Address concerns about liver cancer risk, explaining that regular monitoring reduces complications.

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

The competent candidate should:

Confirm hepatitis B status and stage of disease:
- Hepatitis B serology: HBsAg, HBeAg, anti-HBc, anti-HBs.
- Liver function tests (LFTs): Assess for liver injury.
- HBV DNA viral load: Determines viral replication.
- Ultrasound liver +/- alpha-fetoprotein (AFP): Screening for HCC.
Determine need for antiviral therapy:
- Refer to a hepatologist if viral load is high or liver damage is present.
- Patients with normal liver function may not need treatment but require lifelong monitoring.
Lifestyle modifications:
- Avoid alcohol and hepatotoxic medications.
- Healthy diet and exercise to prevent fatty liver disease.
Prevent transmission:
- Household contacts and sexual partners should be tested and vaccinated if needed.
- Advise on safe practices (e.g., avoid sharing personal items like razors and toothbrushes).
Long-term follow-up:
- Six-monthly LFTs and viral load testing.
- Liver ultrasound and AFP every 6 months if at risk for liver cancer.
- Annual GP review to monitor for complications.

SUMMARY OF A COMPETENT ANSWER

Comprehensive history-taking, including risk factors, symptoms, and social impact.
Clear differential diagnosis, considering acute vs chronic hepatitis B and other liver diseases.
Empathetic communication, addressing concerns about transmission, stigma, and long-term outcomes.
Evidence-based management plan, including testing, monitoring, referral, and lifestyle advice.
Clear patient-centred approach, ensuring family testing, vaccination, and regular follow-up.

PITFALLS

Failing to assess red flags for acute liver failure (confusion, bleeding, ascites, severe jaundice).
Not distinguishing between acute and chronic hepatitis B, leading to inappropriate management.
Providing inaccurate reassurance without confirming disease status (e.g., assuming the infection will resolve).
Failing to discuss family screening and vaccination, missing an opportunity for prevention.
Not addressing patient concerns about liver cancer, leading to anxiety and misinformation.
Lack of clear follow-up plan, increasing the risk of missed complications.

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 assess risk factors and complications of hepatitis B.
2.2 Identifies red flags for acute liver failure and chronic liver disease.
2.3 Orders and interprets appropriate investigations to confirm diagnosis and assess liver function.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises clinical features suggestive of hepatitis B and considers it in the differential diagnosis.
3.3 Differentiates between acute and chronic hepatitis B and determines need for specialist referral.

4. Clinical Management and Therapeutic Reasoning

4.2 Provides appropriate counselling, lifestyle advice, and treatment options.
4.4 Arranges specialist referral if indicated (e.g., hepatology or infectious diseases).

5. Preventive and Population Health

5.2 Provides education on transmission, vaccination, and long-term monitoring for hepatitis B.

6. Professionalism

6.2 Demonstrates sensitivity in discussing a potentially stigmatised condition.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures compliance with hepatitis B screening, notification, and follow-up requirements.

9. Managing Uncertainty

9.1 Addresses patient concerns about long-term prognosis and risk of liver cancer.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and initiates urgent management if signs of acute liver failure are present.

Competency at Fellowship Level

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