CCE-CBD-213 - GP Exams

CASE INFORMATION

Case ID: FAT-001
Case Name: Mark Reynolds
Age: 45 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: A04 (General tiredness/fatigue)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes a safe and supportive consultation environment 1.2 Uses open-ended questions to explore fatigue and its impact 1.3 Provides clear, empathetic explanations about potential causes and management
2. Clinical Information Gathering and Interpretation	2.1 Conducts a structured history covering medical, psychological, and lifestyle factors 2.2 Performs an appropriate physical examination 2.3 Identifies red flags requiring urgent investigation
3. Diagnosis, Decision-Making and Reasoning	3.1 Formulates a broad differential diagnosis for fatigue 3.2 Uses clinical reasoning to determine the most likely cause 3.3 Orders and interprets appropriate investigations
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an individualised management plan addressing underlying causes 4.2 Provides lifestyle and psychological support where relevant 4.3 Recognises when referral to specialists is required
5. Preventive and Population Health	5.1 Identifies modifiable risk factors contributing to fatigue 5.2 Provides health promotion advice, including sleep hygiene and stress management
6. Professionalism	6.1 Demonstrates a patient-centred and non-judgmental approach
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and follow-up 7.2 Refers appropriately within clinical and regulatory guidelines
9. Managing Uncertainty	9.1 Recognises when fatigue remains unexplained and requires ongoing monitoring
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies serious causes of fatigue, including malignancy, cardiac disease, or autoimmune conditions

CASE FEATURES

Middle-aged male with persistent fatigue for 4 months.
Exploration of medical, psychological, and lifestyle factors.
Differentiation between organic vs functional causes.
Discussion of investigation pathways and management options.

CANDIDATE INFORMATION

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: Mark Reynolds
Age: 45 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Omeprazole 20 mg daily (for GORD)
Paracetamol PRN (for occasional headaches)

Past History

GORD, managed with PPI.
No history of diabetes, cardiovascular disease, or significant infections.

Social History

Works as a project manager, high-stress job with long hours.
Married with two children (aged 10 and 13).
Reports poor sleep quality, difficulty falling asleep.
Low physical activity, often skips meals.
Drinks 3-4 coffees per day and 4-6 alcoholic drinks per week.
No smoking or illicit drug use.

Family History

Father had ischaemic heart disease at 50 years.
Mother has hypothyroidism.

Vaccination and Preventative Activities

Up to date with routine health screenings.
No recent cardiovascular risk assessment.

SCENARIO

Mark, a 45-year-old project manager, presents with persistent fatigue for the past 4 months. He describes feeling exhausted despite getting 6-7 hours of sleep per night. He reports difficulty concentrating, occasional headaches, and feeling unmotivated at work.

He denies fever, weight loss, night sweats, or changes in appetite. He does not feel depressed but acknowledges that work stress and poor sleep quality may be contributing.

He is concerned that something serious, like cancer or heart disease, might be causing his fatigue.

Your role is to assess Mark’s fatigue, identify possible underlying causes, arrange appropriate investigations, and provide management advice.

EXAMINATION FINDINGS

General Appearance: Well-groomed but appears tired
Vital Signs: BP 125/80 mmHg, HR 78 bpm, RR 16 bpm, SpO₂ 98% on room air
Cardiovascular Examination: No murmurs, normal heart sounds
Respiratory Examination: Clear breath sounds
Abdominal Examination: Soft, non-tender
Neurological Examination: Normal tone, power, reflexes
Mental Health Screening: No major depressive features (PHQ-9 score: 3)

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess Mark’s fatigue and determine potential causes?

Prompt: What key aspects of history would you explore?
Prompt: How would you differentiate between medical, psychological, and lifestyle-related fatigue?

Q2. What investigations would you consider, and why?

Prompt: What baseline blood tests are necessary for evaluating fatigue?
Prompt: How do you ensure targeted investigations while avoiding unnecessary testing?

Q3. How would you manage Mark’s fatigue in a general practice setting?

Prompt: What lifestyle modifications and supportive strategies would you recommend?
Prompt: When would referral to a specialist be appropriate?

Q4. How would you counsel Mark about his concerns regarding serious illness?

Prompt: How do you provide reassurance while ensuring a thorough evaluation?
Prompt: How do you engage him in a shared management plan?

Q5. What long-term follow-up strategies would you implement?

Prompt: What review schedule is appropriate for monitoring progress?
Prompt: How do you reassess if fatigue persists despite initial management?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess Mark’s fatigue and determine potential causes?

1. Comprehensive History-Taking

Onset and duration: 4 months, worsening over time.
Pattern and severity: Constant vs intermittent, impact on daily life.
Associated symptoms:
- Medical causes: Weight loss, night sweats (malignancy); polyuria, polydipsia (diabetes).
- Sleep disturbances: Snoring, daytime sleepiness (obstructive sleep apnoea).
- Mood-related symptoms: Low mood, anhedonia (depression).
- Lifestyle factors: Stress, poor sleep hygiene, diet, caffeine intake.

2. Physical Examination

Vital signs: BP, HR (cardiac causes), BMI (metabolic causes).
Thyroid exam: Goitre, tremor.
Lymphadenopathy: Malignancy or chronic infection.
Neurological exam: Muscle weakness, coordination issues.

3. Categorising Fatigue

Physiological: Overwork, poor sleep, deconditioning.
Medical: Endocrine (hypothyroidism, diabetes), chronic infections.
Psychological: Depression, anxiety, burnout.

Conclusion: Mark’s fatigue is likely multifactorial, with contributions from stress, poor sleep, and lifestyle factors.

Q2: What investigations would you consider, and why?

1. Baseline Blood Tests

FBC: Anaemia, infection, malignancy.
Iron studies: Iron deficiency anaemia.
TSH, T4: Rule out hypothyroidism.
HbA1c, fasting glucose: Screen for diabetes.
U&E, LFTs: Assess renal/hepatic function.

2. Additional Tests Based on Clinical Suspicion

CRP, ESR: Inflammatory markers.
Coeliac serology: If gastrointestinal symptoms.
Sleep study: If obstructive sleep apnoea suspected.

3. Avoid Over-Investigation

Routine cancer screening only if red flags present.
No need for exhaustive infectious disease panels.

Conclusion: A targeted approach to investigations minimises unnecessary testing.

Q3: How would you manage Mark’s fatigue in a general practice setting?

1. Address Lifestyle Factors

Sleep hygiene: Fixed bedtime, limiting caffeine.
Exercise: Graded activity to improve energy levels.
Nutrition: Balanced diet, reducing processed foods.

2. Manage Psychological Contributors

CBT referral if work-related stress is significant.
Mindfulness or stress-reduction techniques.

3. Treat Identified Medical Conditions

Iron supplementation if deficient.
Thyroid replacement if hypothyroid.
CPAP if OSA diagnosed.

4. When to Refer

Persistent, unexplained fatigue despite intervention.
Concern for serious medical pathology (e.g., malignancy, autoimmune disease).

Conclusion: A holistic, stepwise approach improves outcomes in fatigue management.

Q4: How would you counsel Mark about his concerns regarding serious illness?

1. Validate His Concerns

Acknowledge anxiety: “It’s understandable to worry about serious illness.”
Explain that fatigue is common and usually multifactorial.

2. Provide Reassurance with Clinical Findings

“Your examination and initial tests are reassuring”.
“We will investigate appropriately but also focus on lifestyle improvements.”

3. Engage Him in a Shared Management Plan

Set realistic expectations: “Fatigue often improves gradually with small lifestyle changes.”
Discuss follow-up: Monitoring progress over weeks-months.

Conclusion: A patient-centred approach reassures Mark while maintaining diagnostic vigilance.

Q5: What long-term follow-up strategies would you implement?

1. Regular GP Reviews

Reassess symptoms every 4-6 weeks.
Monitor response to lifestyle changes and treatments.

2. Adjust Management Based on Response

Further investigations if symptoms persist.
Referral if red flags or no improvement.

3. Preventative Health Measures

Routine cardiovascular risk screening.
Encouraging sustainable lifestyle modifications.

Conclusion: Ongoing follow-up ensures progressive improvement and early identification of serious conditions.

SUMMARY OF A COMPETENT ANSWER

Takes a structured history covering medical, psychological, and lifestyle factors.
Orders appropriate, targeted investigations.
Develops a holistic management plan with lifestyle, psychological, and medical interventions.
Provides reassurance while ensuring thorough follow-up.
Recognises when referral is necessary for persistent or unexplained fatigue.

PITFALLS

Failing to explore psychological contributors to fatigue.
Over-investigating without clear clinical indications.
Neglecting sleep quality and lifestyle factors.
Not providing structured follow-up for unresolved symptoms.
Dismissing patient concerns about serious illness without adequate reassurance.

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

Competency at Fellowship Level

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