CASE INFORMATION

Case ID: CCE-CE-008
Case Name: David Wilson
Age: 48
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: D73 (Hepatitis Viral C), 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 C 2.2 Identifies red flags for chronic liver disease and cirrhosis 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 C and considers it in the differential diagnosis 3.3 Determines disease staging and need for antiviral treatment
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, harm reduction, and screening recommendations
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 C screening, notification, and follow-up requirements
9. Managing Uncertainty	9.1 Addresses patient concerns about long-term prognosis and treatment success
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises and initiates urgent management if signs of liver decompensation are present

CASE FEATURES

Concerned about liver damage, transmission to his partner, and long-term health.
48-year-old man presenting with fatigue and mild jaundice.
Recent routine blood tests revealed positive hepatitis C antibodies.
Unaware of prior hepatitis C status, no previous screening.
History of past intravenous drug use in his early 20s, now reformed.

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

David Wilson, a 48-year-old truck driver, presents to your general practice with fatigue and mild jaundice. He recently had a routine blood test, which unexpectedly revealed positive hepatitis C antibodies.

PATIENT RECORD SUMMARY

Patient Details

Name: David Wilson
Age: 48
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular medications

Past History

No known history of liver disease
No previous hepatitis screening

Social History

Occupation: Truck driver
Past IV drug use in early 20s but stopped over 20 years ago
Occasionally drinks alcohol (4-6 drinks per week)

Family History

No family history of liver disease or liver cancer

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 just got my blood test results back, and they said I have hepatitis C. I don’t understand how—I feel fine.”

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 C.
You feel mostly well, but you have been more tired than usual over the past few months.
You haven’t had any recent illnesses or major health problems.

Specific Information

(Only Reveal When Asked Directly)

Background Information

You have noticed some mild yellowing of your skin, but it isn’t very obvious.
You don’t have any abdominal pain, but you feel bloated sometimes.
You don’t drink heavily, just socially (4-6 drinks per week, usually on weekends).
You have never been tested for hepatitis C before and weren’t aware you were at risk.

Risk Factors for Hepatitis C

You used IV drugs briefly in your early 20s but stopped over 20 years ago.
You shared needles a few times back then, but you never thought about it much afterward.
You have never had a blood transfusion or tattoos.
You have been in a monogamous relationship for the past 10 years.
You have never worked in healthcare or had a needle-stick injury.
You have no history of jail time or other known risk factors.

Symptoms and Current Health

You feel fine most of the time, apart from being a bit more tired than usual.
You have no nausea, vomiting, or loss of appetite.
Your urine is sometimes darker than usual, but you assumed it was because you weren’t drinking enough water.
You haven’t had any weight loss or itching.

Concerns and Emotional Reactions

You are shocked and confused by this diagnosis because you didn’t think you were at risk.
You feel guilty about your past and worried that your partner will judge you.
You are scared about what this means for your future—do you have liver damage or cirrhosis?
You are worried about transmission—can you give this to your partner through sex, kissing, or sharing food?
You don’t want to tell your partner yet because you don’t know what this means for her health.
You want to know if this can be cured or if you will need lifelong treatment.
You are concerned about work—will this affect your job as a truck driver?

Concerns and Questions for the Candidate

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

“What does this test result mean? Does this mean I have liver damage?”
“Is hepatitis C the same as hepatitis B? What’s the difference?”
“Can I give this to my partner? Should she get tested?”
“Will I need treatment? Is there a cure?”
“Does this mean I’ll get liver cancer?”
“Do I need to stop drinking alcohol?”
“Can I still work as a truck driver?”
“Should I tell my employer?”

Role-Playing Emotional Cues

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

Shock and Confusion: Shake your head and look puzzled 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 past drug use and whether to tell your partner.
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 partner. You don’t want to pass this to her and need to know if she needs to be tested.
To be clear about your long-term health. You are worried about liver cancer and cirrhosis and whether you 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 I got this from IV drug use 25 years ago, why am I only finding out now?”
“If I clear this virus, can I get it again?”
“Can I still drink alcohol, or do I have to stop completely?”
“I’ve been feeling tired a lot—does this mean my liver is already damaged?”
“Can hepatitis C cause problems for my heart or kidneys?”
“Do I need to change my diet 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 partner 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 jaundice, weight loss, abdominal pain, gastrointestinal bleeding, or confusion (suggesting advanced liver disease or cirrhosis).
Assess for risk factors for hepatitis C, including:
- Past intravenous drug use (even if remote history).
- Tattoos, blood transfusions before 1992, past incarceration, history of needle-stick injuries.
- Unprotected sexual contact with a known hepatitis C carrier.
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 chronic hepatitis C vs spontaneously cleared infection:
- Anti-HCV positivity indicates past exposure, but confirmation with HCV RNA testing is required.
- Chronic hepatitis C can be asymptomatic or present with fatigue, mild jaundice, and elevated liver enzymes.
Discuss other potential causes of liver disease, including:
- 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 decompensated cirrhosis (ascites, variceal bleeding, encephalopathy).
- Concern for hepatocellular carcinoma (HCC) in chronic hepatitis C.

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

The competent candidate should:

Acknowledge the patient’s shock and anxiety about the diagnosis.
Provide clear, non-judgemental education about transmission and natural history:
- Hepatitis C is mainly bloodborne and unlikely to spread through casual contact.
- Sexual transmission risk is low in monogamous relationships.
- Hepatitis C is now curable with direct-acting antivirals (DAAs), which are well-tolerated.
Discuss testing requirements for:
- HCV RNA to confirm active infection.
- Liver fibrosis assessment (e.g., FibroScan, APRI score, elastography).
Address concerns about liver cancer risk, explaining that early treatment significantly reduces complications.

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

The competent candidate should:

Confirm hepatitis C status and stage of disease:
- HCV RNA PCR: Confirms active infection.
- Liver function tests (LFTs): Assess for liver damage.
- FBC, INR, albumin: Evaluate liver synthetic function.
- Hepatitis B and HIV serology: Assess co-infections.
- Liver fibrosis assessment (FibroScan or APRI score).
Initiate direct-acting antiviral (DAA) therapy if chronic infection is confirmed:
- Pangenotypic DAAs (e.g., sofosbuvir/velpatasvir) are first-line treatments.
- Treatment duration is usually 8–12 weeks with cure rates exceeding 95%.
Lifestyle modifications:
- Avoid alcohol to reduce liver disease progression.
- Maintain a healthy diet and weight to prevent fatty liver disease.
Prevent transmission:
- Household members and partners do not need routine testing unless high-risk exposure (e.g., shared needles, blood contact).
- Avoid sharing razors, toothbrushes, or injecting equipment.
Long-term follow-up:
- If cirrhosis is present, lifelong surveillance for HCC is required.
- Liver function monitoring 6-12 months post-treatment.
- No need for routine monitoring if successfully cured without cirrhosis.

SUMMARY OF A COMPETENT ANSWER

Comprehensive history-taking, including risk factors, symptoms, and social impact.
Clear differential diagnosis, considering chronic vs cleared hepatitis C and other liver diseases.
Empathetic communication, addressing concerns about transmission, stigma, and treatment outcomes.
Evidence-based management plan, including testing, antiviral therapy, and lifestyle advice.
Clear patient-centred approach, ensuring family education, harm reduction, and follow-up care.

PITFALLS

Failing to assess red flags for advanced liver disease (ascites, jaundice, hepatic encephalopathy, variceal bleeding).
Not distinguishing between past exposure and chronic infection, leading to inappropriate reassurance or treatment delays.
Providing inaccurate reassurance without confirming HCV RNA status.
Failing to discuss treatment options, missing an opportunity for cure.
Not addressing patient concerns about transmission, leading to misinformation and anxiety.
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 C.
2.2 Identifies red flags for chronic liver disease and cirrhosis.
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 C and considers it in the differential diagnosis.
3.3 Determines disease staging and need for antiviral treatment.

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, harm reduction, and screening recommendations.

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 C screening, notification, and follow-up requirements.

9. Managing Uncertainty

9.1 Addresses patient concerns about long-term prognosis and treatment success.

10. Identifying and Managing the Patient with Significant Illness

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

Competency at Fellowship Level

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