CCE-CBD-023

Examiner Only Information

Questions

Q1. What key aspects of Emily’s history and examination suggest a vitamin or nutritional deficiency?

• Prompt: What symptoms and risk factors point towards iron or B12 deficiency?
• Prompt: What other deficiencies should be considered?

Q2. What investigations would you order to confirm the suspected deficiencies?

• Prompt: What blood tests are essential in this case?
• Prompt: When would you consider further investigations (e.g., coeliac screening)?

Q3. What is the appropriate management plan for Emily’s nutritional deficiency?

• Prompt: What dietary and supplement recommendations should be made?
• Prompt: How would you monitor treatment response?

Q4. How would you educate Emily about optimising her vegetarian diet to prevent future deficiencies?

• Prompt: What key dietary changes should she make?
• Prompt: What role do fortified foods or supplements play?

Q5. When would you consider specialist referral in this case?

• Prompt: What features would suggest the need for a gastroenterologist or dietitian?
• Prompt: When should haematology referral be considered?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What key aspects of Emily’s history and examination suggest a vitamin or nutritional deficiency?

The competent candidate should:

• Symptoms suggestive of iron or B12 deficiency:
  • Fatigue, dizziness, poor concentration – common in both deficiencies.
  • Hair thinning, brittle nails, and mouth ulcers – features of iron and B12 deficiency.
• Risk factors:
  • Vegetarian diet for 5 years, increasing the risk of iron, B12, and zinc deficiency.
  • Heavy menstrual periods, contributing to iron loss.
  • High-intensity endurance training, increasing iron demand.
• Examination findings supporting deficiency:
  • Mild conjunctival pallor – suggestive of iron deficiency anaemia.
  • Brittle nails with mild koilonychia – seen in iron deficiency.
  • Aphthous ulcer in oral cavity – could indicate B12 deficiency.

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Q2: What investigations would you order to confirm the suspected deficiencies?

The competent candidate should:

• Essential blood tests:
  • Full blood count (FBC) – to assess for microcytic anaemia (iron deficiency) or macrocytic anaemia (B12/folate deficiency).
  • Iron studies – ferritin, serum iron, transferrin saturation (low ferritin suggests iron deficiency).
  • Vitamin B12 and folate levels – to rule out B12/folate deficiency.
• Additional tests if clinically indicated:
  • Thyroid function tests (TFTs) – if fatigue persists despite correction of deficiencies.
  • Coeliac serology – if malabsorption is suspected (family history of iron deficiency anaemia).

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Q3: What is the appropriate management plan for Emily’s nutritional deficiency?

The competent candidate should:

• Iron deficiency management:
  • Oral iron supplementation (ferrous sulfate 325 mg every second day).
  • Take with vitamin C for better absorption; avoid tea/coffee around the time of ingestion.
• B12 deficiency (if present):
  • Oral cyanocobalamin or intramuscular B12 injections (if severe deficiency).
• Monitoring and follow-up:
  • Repeat FBC and iron studies in 6-8 weeks to assess response.
  • Monitor for gastrointestinal side effects from iron supplements.

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Q4: How would you educate Emily about optimising her vegetarian diet to prevent future deficiencies?

The competent candidate should:

• Iron sources for vegetarians:
  • Legumes, tofu, dark leafy greens, fortified cereals, nuts, and seeds.
  • Pair iron-rich foods with vitamin C (citrus, tomatoes) to improve absorption.
• B12 sources:
  • Eggs, dairy, fortified cereals, and nutritional yeast.
  • Consider B12 supplementation if dietary intake is insufficient.
• General dietary balance:
  • Ensure adequate protein intake (legumes, dairy, eggs).
  • Monitor calcium and vitamin D levels due to potential low intake.

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Q5: When would you consider specialist referral in this case?

The competent candidate should:

• Referral to a gastroenterologist if:
  • Iron or B12 deficiency does not improve despite supplementation.
  • Coeliac disease or inflammatory bowel disease is suspected.
• Referral to a dietitian if:
  • Emily needs guidance on balancing her vegetarian diet.
  • Persistent symptoms despite optimising nutritional intake.

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SUMMARY OF A COMPETENT ANSWER

• Recognises symptoms and risk factors for iron and B12 deficiency.
• Orders appropriate investigations, including FBC, iron studies, B12, and folate.
• Provides evidence-based supplementation and follow-up.
• Educates the patient on optimising vegetarian nutrition.
• Identifies when referral to a specialist is necessary.

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PITFALLS

• Failing to consider B12 deficiency in a vegetarian patient.
• Overlooking the impact of heavy menstrual bleeding on iron levels.
• Not addressing dietary modifications alongside supplementation.
• Missing an underlying cause such as coeliac disease.

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REFERENCES

• RACGP Guidelines on Nutritional Deficiencies
• National Institutes of Health on Iron and B12 Deficiency
• Dietitians Australia on Vegetarian Nutrition Guide

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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 Engages the patient in a supportive discussion about dietary habits.

2. Clinical Information Gathering and Interpretation

2.1 Identifies iron and B12 deficiency risk factors through history and examination.

3. Diagnosis, Decision-Making and Reasoning

3.1 Orders appropriate investigations to confirm deficiency.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides iron and/or B12 supplementation with appropriate follow-up.

5. Preventive and Population Health

5.2 Educates on maintaining a nutritionally balanced vegetarian diet.

6. Professionalism

6.3 Provides patient-centred care and addresses concerns.

7. General Practice Systems and Regulatory Requirements

7.2 Ensures appropriate monitoring and referral if needed.

9. Managing Uncertainty

9.1 Recognises when further investigations are warranted.

10. Identifying and Managing the Patient with Significant Illness

10.3 Identifies when deficiencies may indicate an underlying condition.

Competency at Fellowship Level

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