CCE-CBD-067

CASE INFORMATION

Case ID: GI-009
Case Name: Lisa Grant
Age: 42
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: D12 – Constipation

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 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.
1.4 Communicates effectively in routine and difficult situations.
2. Clinical Information Gathering and Interpretation2.1 Systematically collects and records relevant information.
2.2 Elicits and interprets findings from history and examination.
3. Diagnosis, Decision-Making and Reasoning3.1 Generates and prioritises a differential diagnosis.
3.2 Demonstrates rational and evidence-based decision making.
4. Clinical Management and Therapeutic Reasoning4.1 Develops and implements management plans.
4.2 Selects and implements appropriate treatment, including pharmacological and non-pharmacological.
5. Preventive and Population Health5.1 Considers lifestyle factors and implements prevention strategies.
6. Professionalism6.3 Shows commitment to patient-centred care.
7. General Practice Systems and Regulatory Requirements7.2 Follows guidelines and policies for appropriate referrals and investigations.
9. Managing Uncertainty9.1 Recognises when to seek further information or specialist input.
10. Identifying and Managing the Patient with Significant Illness10.2 Recognises symptoms requiring urgent investigation or intervention.

CASE FEATURES

  • Concerned about possible bowel cancer as her mother was diagnosed with colon cancer at age 65.
  • 42-year-old female presenting with chronic constipation over the past 6 months.
  • Reports infrequent bowel motions (1-2 times per week), straining, and a sense of incomplete evacuation.
  • Mild bloating and occasional lower abdominal discomfort.
  • Denies weight loss, rectal bleeding, or significant changes in appetite.
  • Works as an accountant, leads a sedentary lifestyle, low fibre intake, and limited water consumption.
  • History of hypothyroidism, currently on thyroxine.

INSTRUCTIONS

Review the following patient record summary and scenario.

Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time for each question will be managed by the examiner.

The time allocation for each question is roughly as follows:

  • Question 1 – 3 minutes
  • Question 2 – 3 minutes
  • Question 3 – 3 minutes
  • Question 4 – 3 minutes
  • Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Lisa Grant
Age: 42
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Thyroxine 100 mcg daily

Past History

  • Hypothyroidism (diagnosed 5 years ago, stable on medication)
  • No previous gastrointestinal illnesses

Social History

  • Sedentary occupation (accountant)
  • Married, lives with husband and two children
  • Non-smoker
  • Alcohol: Occasional (1-2 drinks per week)
  • Diet low in fibre, limited vegetable and fruit intake
  • Low water intake (~1L per day)

Family History

  • Mother diagnosed with colorectal cancer at age 65
  • No family history of inflammatory bowel disease

Vaccination and Preventive Activities

  • Up to date with cervical screening
  • No history of colorectal screening

SCENARIO

Lisa Grant, a 42-year-old accountant, presents to the clinic complaining of chronic constipation. She describes straining, hard stools, and having bowel motions only 1-2 times per week over the last 6 months. She sometimes feels bloated and notes a sense of incomplete evacuation.
Lisa denies any rectal bleeding, mucus, unintentional weight loss, or change in appetite. She reports no fevers or night sweats.
She mentions that her mother was diagnosed with bowel cancer at age 65, and she is worried about a possible serious cause for her symptoms.
Lisa leads a sedentary lifestyle, consumes a low-fibre diet, and admits she does not drink enough water most days.
She has hypothyroidism, but reports she is compliant with her medication and feels otherwise well.

EXAMINATION FINDINGS

General Appearance: Well-appearing, healthy BMI
Abdominal Examination: Soft, mild tenderness in the lower abdomen, no masses, no organomegaly
Rectal Examination: No fissures or haemorrhoids, normal anal tone, no palpable masses
Vitals: BP 120/75 mmHg, HR 72 bpm, Temp 36.8°C, BMI 26 kg/m²

INVESTIGATION FINDINGS

Blood Results:

  • TSH: 1.8 mIU/L (normal 0.4-4.0)
  • FBC: Normal
  • CRP: Normal
  • Iron studies: Normal

Faecal Occult Blood Test (FOBT): Negative

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you explain the likely cause of Lisa’s constipation and address her concerns about bowel cancer?

  • Prompt: Provide reassurance while acknowledging her family history.
  • Prompt: Explain lifestyle factors contributing to her symptoms.

Q2. What further investigations or screening would you recommend at this stage?

  • Prompt: Consider age-appropriate cancer screening.
  • Prompt: Address need for colonoscopy if indicated.

Q3. Outline your management plan for Lisa’s chronic constipation.

  • Prompt: Include both non-pharmacological and pharmacological strategies.
  • Prompt: Provide realistic expectations on treatment outcomes.

Q4. How would you address Lisa’s lifestyle factors contributing to her symptoms?

  • Prompt: Dietary advice (fibre and hydration).
  • Prompt: Physical activity recommendations.

Q5. When would you consider referral or further specialist input for Lisa?

  • Prompt: Identify red flags requiring urgent attention.
  • Prompt: Discuss criteria for gastroenterology referral.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you explain the likely cause of Lisa’s constipation and address her concerns about bowel cancer?

The competent candidate should:

  • Acknowledge Lisa’s concern regarding her family history of bowel cancer and provide empathetic reassurance.
  • Explain that chronic constipation is common, particularly in individuals with sedentary lifestyles, low-fibre diets, and insufficient hydration—all of which apply to Lisa.
  • Highlight that hypothyroidism, although currently well-managed, can also contribute to constipation.
  • Discuss that the absence of red flags—such as unintentional weight loss, rectal bleeding, or significant change in bowel habits—makes a sinister cause less likely.
  • Explain that screening tests (including a negative FOBT and normal bloods) are reassuring.
  • Reassure Lisa that based on her age and guidelines, bowel cancer screening typically starts at age 50 or earlier if high-risk. Her mother’s diagnosis at 65 years places her at moderate risk, so we can consider a colonoscopy for reassurance.
  • Encourage open communication about any new or worsening symptoms in the future.

Q2: What further investigations or screening would you recommend at this stage?

The competent candidate should:

  • Explain that Lisa’s negative FOBT is reassuring.
  • Discuss the National Bowel Cancer Screening Program recommends biennial FOBT from age 50; however, due to her family history, colonoscopy may be appropriate.
  • Suggest referring Lisa for a baseline colonoscopy because her mother was diagnosed with colorectal cancer at 65 years.
  • Discuss that additional tests are not required at this point as there are no red flags and blood tests are normal.
  • Recommend rechecking thyroid function periodically to ensure stability.
  • Provide safety-netting advice regarding red flags such as rectal bleeding, unintentional weight loss, or persistent abdominal pain.

Q3: Outline your management plan for Lisa’s chronic constipation.

The competent candidate should:

  • Develop a comprehensive management plan including lifestyle modifications and pharmacological options.
  • Educate Lisa about increasing dietary fibre to 25-30g/day (fruits, vegetables, whole grains).
  • Advise on adequate hydration, aiming for 2-2.5L of water per day.
  • Encourage regular physical activity (at least 30 minutes of moderate activity most days).
  • Consider a bulk-forming laxative (e.g., psyllium husk) as a first-line pharmacological option if lifestyle changes are insufficient.
  • If ineffective, suggest an osmotic laxative (e.g., lactulose or macrogol).
  • Discuss short-term stimulant laxative use cautiously (e.g., senna) if required for symptom relief.
  • Address expectations that improvements may take several weeks.
  • Offer review in 4-6 weeks to monitor response and adjust treatment as needed.

Q4: How would you address Lisa’s lifestyle factors contributing to her symptoms?

The competent candidate should:

  • Discuss her low-fibre diet, and educate her on how to gradually increase fibre intake through whole foods.
  • Advise increasing water consumption to assist with fibre efficacy and improve stool consistency.
  • Recommend gradual introduction of exercise, starting with low-impact activities like walking, to stimulate bowel motility.
  • Explore workplace ergonomics to minimise prolonged sitting and encourage movement breaks.
  • Address behavioural modifications, such as regular toileting habits and avoiding delaying defecation urges.
  • Provide patient education resources or refer to a dietitian for further guidance if appropriate.

Q5: When would you consider referral or further specialist input for Lisa?

The competent candidate should:

  • Discuss the need for referral to a gastroenterologist if:
    • Red flag symptoms develop (e.g., rectal bleeding, weight loss, anaemia).
    • There is persistent constipation despite optimal medical and lifestyle management.
    • There is concern regarding underlying pathology requiring colonoscopic evaluation.
  • Suggest colonoscopy referral based on moderate familial risk (first-degree relative diagnosed after 55).
  • Discuss referral to a dietitian for comprehensive nutritional management if dietary interventions are challenging.
  • Consider pelvic floor dysfunction and referral to a pelvic floor physiotherapist if appropriate symptoms are present (e.g., obstructive defecation).

SUMMARY OF A COMPETENT ANSWER

  • Explains common causes of constipation in Lisa’s context (diet, hydration, inactivity).
  • Addresses family history and reassures regarding negative findings.
  • Recommends appropriate screening (colonoscopy consideration).
  • Outlines a stepwise management plan with lifestyle and pharmacological components.
  • Provides clear safety-netting and criteria for specialist referral.
  • Demonstrates patient-centred communication and empathy.

PITFALLS

  • Failing to acknowledge Lisa’s anxiety regarding family history of bowel cancer.
  • Omitting colonoscopy discussion despite family history.
  • Neglecting lifestyle factors in the management plan.
  • Over-reliance on laxatives without addressing underlying causes.
  • Not providing safety-netting advice regarding red flags.
  • Lack of follow-up planning to monitor treatment response.

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.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Systematically collects and records relevant information.
2.2 Elicits and interprets findings from history and examination.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises a differential diagnosis.
3.2 Demonstrates rational and evidence-based decision making.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Selects and implements appropriate treatment, including pharmacological and non-pharmacological.

5. Preventive and Population Health

5.1 Considers lifestyle factors and implements prevention strategies.

6. Professionalism

6.3 Shows commitment to patient-centred care.

7. General Practice Systems and Regulatory Requirements

7.2 Follows guidelines and policies for appropriate referrals and investigations.

9. Managing Uncertainty

9.1 Recognises when to seek further information or specialist input.

10. Identifying and Managing the Patient with Significant Illness

10.2 Recognises symptoms requiring urgent investigation or intervention.

Competency at Fellowship Level

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