CASE INFORMATION

Case ID: IBS-001
Case Name: Lisa Thompson
Age: 34
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: D93 – Irritable Bowel Syndrome

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Engages the patient to understand their concerns and expectations 1.2 Demonstrates active listening and empathy 1.4 Explains diagnosis and management in a patient-centred manner
2. Clinical Information Gathering and Interpretation	2.1 Takes a comprehensive history, including dietary, stress, and symptom triggers 2.2 Identifies red flags requiring further investigation
3. Diagnosis, Decision-Making and Reasoning	3.1 Establishes a working diagnosis based on history and clinical reasoning 3.2 Uses the Rome IV criteria to diagnose IBS 3.6 Differentiates IBS from other causes of chronic abdominal symptoms
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan 4.5 Provides dietary, lifestyle, and pharmacological recommendations 4.7 Educates the patient on long-term self-management
5. Preventive and Population Health	5.1 Provides dietary advice based on the low FODMAP diet 5.2 Addresses stress management and lifestyle factors
6. Professionalism	6.2 Provides reassurance and addresses patient concerns sensitively
7. General Practice Systems and Regulatory Requirements	7.1 Documents history and management plan appropriately
9. Managing Uncertainty	9.2 Recognises the impact of IBS on quality of life and discusses ongoing care 9.3 Discusses when further tests may be needed for atypical symptoms
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises when symptoms suggest alternative diagnoses (e.g., inflammatory bowel disease, malignancy)

CASE FEATURES

Chronic intermittent abdominal pain and bloating
Alternating bowel habits (diarrhoea and constipation)
No red flags (weight loss, rectal bleeding, nocturnal symptoms) but significant impact on quality of life
Patient anxious about long-term prognosis and cancer risk
Interest in dietary modifications and stress management strategies

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

Lisa Thompson, a 34-year-old office worker, presents with a 6-month history of recurrent bloating, abdominal cramps, and alternating diarrhoea and constipation. She reports worsening symptoms under stress and after certain meals.

Lisa is frustrated and anxious, fearing that she might have bowel cancer despite normal blood tests and an unremarkable stool test for faecal occult blood.

PATIENT RECORD SUMMARY

Patient Details

Name: Lisa Thompson
Age: 34
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Nil regular

Past History

No significant medical history

Social History

Works full-time as a marketing executive
High-stress job with irregular meal patterns
Exercises occasionally but finds it hard to maintain a routine

Family History

No family history of bowel cancer, coeliac disease, or inflammatory bowel disease

Smoking & Alcohol

Non-smoker
Drinks socially (1-2 drinks/week)

Vaccination and Preventative Activities

Up to date with immunisations
No recent colonoscopy or endoscopy

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 SCRIPTS

Opening Line

“Doctor, I’ve been having bloating and stomach pain for months now. My bowel movements are all over the place, and I’m worried it could be something serious.”

General Information

You have had on-and-off abdominal pain and bloating for about six months.
The pain is crampy, mostly in the lower abdomen, and comes and goes.
Sometimes, you feel better after passing wind or having a bowel motion.
Your stools vary between loose and hard, sometimes on the same day.

Specific Information

(Only Provide If Asked)

Background Information

You feel like you always have to know where the nearest toilet is, just in case.
Stress at work seems to make things worse.
Eating certain foods (garlic, onions, bread, dairy) triggers bloating.
You have not noticed blood in your stool, but sometimes it looks mucousy.
You have not lost weight unintentionally, but you feel drained and tired lately.

Symptoms

You usually wake up feeling okay, but the bloating gets worse throughout the day.
Sometimes, you feel a sharp cramp before needing to use the toilet.
Constipation days: You go only once every 2-3 days, and it takes effort to pass a stool.
Diarrhoea days: You have 3-4 loose bowel motions in a day, especially after stressful mornings.
Sometimes, you feel like you haven’t completely emptied your bowels after going.

Red Flags (None Present)

No unexplained weight loss.
No blood in the stool or black, tarry stools.
No waking up in the middle of the night with diarrhoea.
No persistent fevers.
No family history of bowel cancer or inflammatory bowel disease.

Diet & Lifestyle

You skip meals when busy at work and often grab a sandwich or takeaway food.
You drink two coffees per day and sometimes feel jittery or get loose stools afterward.
You drink alcohol socially (1-2 drinks per week).
You try to eat “healthy” foods like lentils and apples, but they sometimes seem to make the bloating worse.
You don’t exercise regularly, but you walk to work when the weather is nice.
You want to know if a low FODMAP diet could help but don’t know where to start.
You’ve read about probiotics but are unsure if they actually work.

Emotional & Psychological State

You feel frustrated because no one takes your symptoms seriously.
Your partner thinks you worry too much, but they don’t understand how uncomfortable you feel.
You are worried that this could be something serious like bowel cancer.
You feel embarrassed when you get bloated in meetings and often have to undo your belt after lunch.
You are tired of feeling anxious about where the nearest toilet is.

Concerns & Expectations

“I just want to know what’s wrong with me. Is it serious?”
“Do I need a colonoscopy? My friend had one for similar symptoms.”
“Could it be bowel cancer? I keep reading things online that make me scared.”
“Will I have to change my diet forever?”
“Are probiotics, fibre supplements, or peppermint oil helpful?”

Possible Questions for the Candidate

“Is there a test that can confirm IBS?”
“Are my symptoms normal for this condition?”
“If it’s stress-related, does that mean it’s all in my head?”
“What can I do to stop the bloating? It makes me look pregnant some days!”
“Can I still eat my favourite foods?”
“What should I do if I have a bad flare-up?”
“Is there a cure for IBS, or will I have to deal with this forever?”

Role-Playing Tips for the Candidate Assessment

You are slightly anxious but open to reassurance.
You are frustrated about your symptoms but not aggressive.
If the candidate is dismissive or vague, you should push for clear answers.
If the candidate is empathetic, you should respond positively to reassurance.
If the candidate mentions dietary changes, you should ask practical questions (e.g., “How do I know which foods to avoid?”).
If the candidate brings up medications, you should ask about side effects and whether they actually work.

How to Respond to the Candidate’s Explanations

If the candidate explains IBS well and reassures you, say:
“Okay, that makes sense. So, it’s not dangerous, but I need to learn how to manage it?”
If they mention stress as a trigger, say:
“So you think my symptoms are because of stress? But they feel real to me…”
If they suggest dietary changes, say:
“That sounds good, but where do I even start with a low FODMAP diet?”
If they recommend medications, ask:
“Are there any side effects? I don’t want to rely on pills forever.”
If they dismiss your concerns about cancer, push back slightly:
“I understand that IBS isn’t cancer, but how can you be sure?”

Final Line (If the Candidate Handles the Case Well)

“Thank you, Doctor. I feel a bit more reassured now. I’ll give the dietary changes a go and try to manage my stress better. But if things get worse, I’ll come back, right?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including dietary habits, stress levels, and symptom triggers.

The competent candidate should:

Use open-ended questions to explore the patient’s abdominal symptoms, including onset, duration, severity, aggravating and relieving factors, and associated features (e.g., bloating, altered bowel habits).
Clarify stool characteristics: frequency, consistency, urgency, incomplete evacuation, presence of mucus, and any rectal bleeding.
Screen for red flags suggesting alternative diagnoses (e.g., inflammatory bowel disease, colorectal cancer), including unexplained weight loss, nocturnal symptoms, family history of bowel disease, and persistent rectal bleeding.
Assess the impact of stress, anxiety, or psychological factors on symptoms.
Take a detailed dietary history, particularly high-FODMAP foods, caffeine, alcohol, and intake of fibre or processed foods.
Explore lifestyle factors, including meal timing, hydration, sleep, exercise, and medication use (e.g., laxatives, antacids, NSAIDs).
Address the patient’s ideas, concerns, and expectations, particularly regarding the possibility of cancer or serious illness.

Task 2: Discuss your differential diagnosis and explain how IBS is diagnosed.

The competent candidate should:

Explain that IBS is a functional gastrointestinal disorder, diagnosed clinically based on the Rome IV criteria:
- Recurrent abdominal pain at least once a week for the past three months, associated with two or more of the following:
  - Related to defecation.
  - Associated with a change in stool frequency.
  - Associated with a change in stool form (appearance).
Differentiate IBS from other conditions such as:
- Inflammatory bowel disease (IBD) – red flags include bloody stools, weight loss, nocturnal diarrhoea, fever, or family history.
- Coeliac disease – can mimic IBS, warrants serological testing if symptoms are suggestive.
- Lactose or fructose intolerance – symptoms related to dairy or high-fructose foods.
- Small intestinal bacterial overgrowth (SIBO) – symptoms similar to IBS, exacerbated by carbohydrate-rich foods.
Explain that IBS does not increase the risk of serious disease such as cancer.
Justify limited investigations (e.g., FBE, CRP, coeliac serology) only if clinically indicated.

Task 3: Reassure the patient and address their concerns about cancer risk and long-term health.

The competent candidate should:

Acknowledge and validate the patient’s worry about cancer, reassuring them that IBS is not linked to an increased cancer risk.
Explain that IBS is a chronic but manageable condition, and symptoms can improve with dietary and lifestyle modifications.
Address the patient’s fears of long-term illness and disability by explaining that IBS does not cause malnutrition, organ damage, or progressive disease.
Discuss the role of stress and gut-brain interaction, ensuring the patient does not feel dismissed or misunderstood.
Provide written resources (e.g., RACGP IBS fact sheets) and offer a follow-up plan to ensure ongoing support.

Task 4: Develop a management plan, including lifestyle, dietary, and pharmacological options.

The competent candidate should:

Discuss dietary strategies, including:
- Low FODMAP diet – trial under dietitian guidance.
- Gradual fibre modification, depending on symptom type (soluble fibre for diarrhoea, insoluble for constipation).
- Avoid triggers such as caffeine, alcohol, carbonated drinks, and high-fat foods.
Advise on lifestyle modifications:
- Regular exercise.
- Adequate hydration.
- Stress management – mindfulness, cognitive behavioural therapy (CBT).
Discuss pharmacological options:
- Antispasmodics (e.g., mebeverine, hyoscine) for abdominal pain.
- Loperamide for diarrhoea-predominant IBS.
- Fibre supplements (psyllium) for constipation-predominant IBS.
- Probiotics – limited evidence but may be trialled.
- SSRIs or tricyclic antidepressants (TCAs) for visceral hypersensitivity and co-existing mood symptoms.
Ensure ongoing monitoring with a structured follow-up plan.

SUMMARY OF A COMPETENT ANSWER

Takes a comprehensive history, including symptoms, dietary habits, and stressors.
Uses the Rome IV criteria to establish an IBS diagnosis and rules out red flags.
Provides reassurance about IBS not being a serious or progressive illness.
Explains the rationale behind a limited investigation approach.
Develops a holistic management plan, covering diet, lifestyle, and pharmacological therapy.
Addresses patient concerns empathetically, ensuring a follow-up plan is in place.

PITFALLS

Failing to assess red flags such as weight loss, nocturnal symptoms, or rectal bleeding.
Over-investigating or ordering unnecessary tests (e.g., colonoscopy without indications).
Dismissing the patient’s concerns or attributing symptoms solely to stress without proper explanation.
Not providing a structured management plan, leading to uncertainty for the patient.
Failing to individualise dietary advice, such as simply recommending a “high-fibre diet” without consideration of symptom patterns.
Not explaining the importance of psychological factors in IBS management, which can lead to patient misunderstanding.

REFERENCES

MARKING

Each competency area is rated 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 Engages the patient to understand their concerns and expectations.
1.2 Demonstrates active listening and empathy.
1.4 Explains diagnosis and management in a patient-centred manner.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history, including dietary, stress, and symptom triggers.
2.2 Identifies red flags requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Establishes a working diagnosis based on history and clinical reasoning.
3.2 Uses the Rome IV criteria to diagnose IBS.
3.6 Differentiates IBS from other causes of chronic abdominal symptoms.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.5 Provides dietary, lifestyle, and pharmacological recommendations.
4.7 Educates the patient on long-term self-management.

5. Preventive and Population Health

5.1 Provides dietary advice based on the low FODMAP diet.
5.2 Addresses stress management and lifestyle factors.

Competency at Fellowship Level

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