EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for Mark’s rectal bleeding?

• Prompt: How do you differentiate between haemorrhoids and more serious conditions?
• Prompt: What red flags require further investigation?

Q2. What further history and investigations would be useful in this case?

• Prompt: What risk factors increase suspicion for colorectal cancer or inflammatory conditions?
• Prompt: When would you consider referral for colonoscopy?

Q3. How would you explain the diagnosis and next steps to Mark?

• Prompt: How do you reassure him while ensuring red flags are addressed?
• Prompt: What lifestyle modifications and treatment options would you recommend?

Q4. Outline your management plan for Mark’s haemorrhoids.

• Prompt: What conservative treatments are effective?
• Prompt: When would you consider procedural intervention?

Q5. What preventive strategies should Mark follow to reduce recurrence?

• Prompt: What dietary and lifestyle changes are most effective?
• Prompt: When should he seek medical attention for worsening symptoms?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for Mark’s rectal bleeding?

A structured approach is required to differentiate between haemorrhoids and other causes of rectal bleeding.

• Benign Anorectal Conditions (Most Likely in This Case):
  • Haemorrhoids – Bright red bleeding on toilet paper, painless or mild discomfort, worse with straining.
  • Anal fissure – Sharp pain with defecation, bright red bleeding, visible tear on examination.
• Inflammatory and Malignant Conditions (Must Exclude):
  • Colorectal cancer – Change in bowel habits, weight loss, family history, iron deficiency anaemia.
  • Inflammatory bowel disease (IBD) – Diarrhoea, abdominal pain, mucous in stools, systemic symptoms.
  • Diverticular disease – Painless bleeding, possible left-sided abdominal pain.
• Other Causes:
  • Rectal polyps – Intermittent painless bleeding.
  • Proctitis (infectious, radiation, autoimmune) – Tenesmus, urgency, bloody diarrhoea.

A competent candidate prioritises haemorrhoids while ensuring serious conditions are ruled out.

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Q2: What further history and investigations would be useful in this case?

• Further History:
  • Bleeding characteristics – Colour, quantity, association with defecation.
  • Systemic symptoms – Weight loss, night sweats, fatigue, fevers.
  • Bowel habits – Chronic constipation, recent change in stool frequency or calibre.
  • Family history – Colorectal cancer, IBD, polyps.
• Investigations:
  • Digital rectal examination (DRE) – Assess for masses, fissures, thrombosed haemorrhoids.
  • Proctoscopy – Visualise internal haemorrhoids.
  • Faecal occult blood test (FOBT) – Screening if no red flags.
  • Full blood count (FBC) – Assess for anaemia.
  • Colonoscopy – If red flags present (family history, age >40 with persistent symptoms, weight loss, iron deficiency).

A competent candidate gathers a thorough history and orders appropriate investigations based on risk factors.

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Q3: How would you explain the diagnosis and next steps to Mark?

1. Acknowledge concerns:
   • “I understand that rectal bleeding can be worrying, especially given your family history.”
2. Explain likely diagnosis:
   • “Your symptoms and examination findings suggest haemorrhoids, which are swollen blood vessels in the rectum that can bleed, especially with constipation or straining.”
3. Address cancer concerns:
   • “Your symptoms are reassuring as they lack red flags like weight loss, change in bowel habits, or anaemia. However, I recommend routine bowel cancer screening given your family history.”
4. Discuss next steps:
   • “We will start with conservative management, including diet and lifestyle changes.”
   • “If symptoms persist, we can consider procedures like rubber band ligation.”
5. Provide safety-netting advice:
   • “If you develop severe pain, worsening bleeding, or changes in bowel habits, please return for further evaluation.”

A competent candidate explains the condition clearly while ensuring the patient feels reassured but appropriately monitored.

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Q4: Outline your management plan for Mark’s haemorrhoids.

1. Conservative Management (First-Line Treatment):
   • Increase dietary fibre and fluid intake – Prevents constipation and reduces straining.
   • Topical treatments – Hydrocortisone cream, witch hazel, or local anaesthetic for symptom relief.
   • Sitz baths – Warm water soaks to relieve discomfort.
   • Avoid prolonged sitting or straining – Take breaks if sitting for long periods.
2. Pharmacological Management (If Symptoms Persist):
   • Oral stool softeners (e.g., psyllium, docusate) – Reduce straining.
   • Topical vasoconstrictors (e.g., phenylephrine) – Reduce swelling.
3. Procedural Interventions (If Refractory Symptoms or Large Haemorrhoids):
   • Rubber band ligation – First-line for internal haemorrhoids.
   • Sclerotherapy – Injecting sclerosant for bleeding haemorrhoids.
   • Surgical haemorrhoidectomy – For severe, recurrent, or thrombosed haemorrhoids.

A competent candidate prioritises conservative measures while recognising when procedural intervention is needed.

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Q5: What preventive strategies should Mark follow to reduce recurrence?

1. Dietary and Lifestyle Modifications:
   • Increase fibre intake – Whole grains, fruits, vegetables (25–30g/day).
   • Adequate hydration – 2–3 litres of water per day.
   • Regular exercise – Prevents constipation and improves bowel motility.
2. Bowel Habits:
   • Avoid straining – Use stool softeners if needed.
   • Respond to natural urges – Don’t delay bowel movements.
3. When to Seek Medical Attention:
   • If bleeding persists despite treatment.
   • If pain worsens or new symptoms develop (e.g., weight loss, bowel habit changes).

A competent candidate provides practical, sustainable lifestyle changes to prevent recurrence.

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SUMMARY OF A COMPETENT ANSWER

• Recognises haemorrhoids as the likely diagnosis, while screening for serious conditions like colorectal cancer.
• Takes a structured history, assessing risk factors, bleeding characteristics, and bowel habits.
• Orders appropriate investigations, prioritising DRE, proctoscopy, and FOBT if no red flags.
• Clearly explains the condition and next steps, ensuring reassurance while addressing concerns about cancer.
• Develops a structured management plan, including dietary modifications, topical treatments, and procedural options if needed.
• Provides preventive strategies, focusing on fibre intake, hydration, and bowel habit adjustments.

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PITFALLS

• Failing to assess red flag symptoms, leading to missed colorectal cancer diagnosis.
• Overprescribing topical steroids, increasing risk of skin thinning with prolonged use.
• Not addressing dietary and lifestyle modifications, leading to recurrence.
• Overlooking patient concerns, especially regarding cancer fears due to family history.
• Delaying referral for persistent symptoms, missing opportunities for early intervention.

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REFERENCES

• RACGP – RACGP Guidelines on Gastrointestinal Conditions
• GP Exams – Haemorrhoids

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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 Communicates effectively and appropriately to provide quality care.
1.3 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information effectively.
2.3 Identifies red flags and important diagnostic features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Applies a structured approach to making a diagnosis.
3.3 Identifies and manages urgent and serious conditions.

Competency at Fellowship Level

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