CCE-CBD-214 - GP Exams

CASE INFORMATION

Case ID: LEU-001
Case Name: Daniel Thompson
Age: 32 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: B73 (Leukaemia)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes a supportive and empathetic environment when discussing serious illness 1.2 Uses clear, jargon-free explanations to discuss the condition and necessary investigations 1.3 Engages the patient in shared decision-making regarding next steps
2. Clinical Information Gathering and Interpretation	2.1 Takes a structured history covering systemic symptoms, risk factors, and red flags 2.2 Conducts an appropriate physical examination, including lymphatic and haematological assessment 2.3 Recognises abnormal findings requiring urgent investigation
3. Diagnosis, Decision-Making and Reasoning	3.1 Identifies leukaemia as a potential cause of symptoms and abnormal blood results 3.2 Prioritises urgent referral for haematology review 3.3 Uses clinical reasoning to differentiate leukaemia from other causes of fatigue, bruising, and infection
4. Clinical Management and Therapeutic Reasoning	4.1 Initiates urgent diagnostic workup and specialist referral 4.2 Provides supportive care and symptomatic management 4.3 Prepares the patient for potential hospital admission and further investigations
5. Preventive and Population Health	5.1 Discusses modifiable risk factors and health optimisation during treatment 5.2 Provides guidance on infection prevention and vaccinations if immunosuppression is anticipated
6. Professionalism	6.1 Demonstrates sensitivity when discussing serious or life-threatening conditions
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate and timely referral to haematology and oncology 7.2 Documents discussions, referrals, and safety-netting advice clearly
9. Managing Uncertainty	9.1 Recognises when a non-specific presentation requires urgent escalation
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies red flags suggesting haematological malignancy and acts appropriately

CASE FEATURES

Young adult male presenting with fatigue, bruising, and recurrent infections.
Findings suggestive of haematological malignancy requiring urgent assessment.
Discussion about the need for specialist referral and hospital admission.
Counselling on next steps, prognosis, and support 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: Daniel Thompson
Age: 32 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

None regularly

Past History

Generally fit and well, no chronic illnesses.
No known family history of malignancy.

Social History

Works as an accountant, reports high work stress and long hours.
Non-smoker, drinks 3-4 alcoholic drinks per week.
No recreational drug use.
Lives with his partner, no children.

Family History

No known history of haematological malignancy or autoimmune disease.

Vaccination and Preventative Activities

Up to date with routine vaccinations.
No recent screening tests performed.

SCENARIO

Daniel, a 32-year-old accountant, presents with progressive fatigue over the past 3 months, easy bruising, and frequent infections. He recently had a prolonged upper respiratory tract infection that lasted two weeks, which he found unusual. He also noticed small, painless lumps in his neck and occasional night sweats.

He initially attributed his symptoms to stress and poor sleep but is now concerned that something more serious may be wrong.

Your role is to assess Daniel’s symptoms, recognise red flags, arrange appropriate investigations, and discuss the next steps.

EXAMINATION FINDINGS

General Appearance: Pale, appears tired but alert
Vital Signs: BP 118/75 mmHg, HR 96 bpm, RR 18 bpm, SpO₂ 98% on room air
Skin: Multiple small ecchymoses on the arms and legs, no active bleeding
Lymphatic System: Palpable, non-tender cervical and axillary lymphadenopathy
Abdominal Examination: Mild splenomegaly, no hepatomegaly
Cardiovascular & Respiratory Examination: Normal heart and lung sounds
Neurological Examination: No focal neurological deficits

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess Daniel’s symptoms and identify potential red flags?

Prompt: What key aspects of history would you explore?
Prompt: What examination findings would raise suspicion of haematological malignancy?

Q2. What investigations would you order, and why?

Prompt: What initial blood tests are necessary for evaluating suspected leukaemia?
Prompt: What imaging or specialist investigations might be required?

Q3. How would you manage Daniel’s condition in a general practice setting?

Prompt: What urgent steps should be taken in response to abnormal findings?
Prompt: When is immediate hospital referral necessary?

Q4. How would you counsel Daniel about the possibility of leukaemia and next steps?

Prompt: How do you balance honesty with reassurance?
Prompt: How do you explain the need for urgent haematology referral?

Q5. What long-term considerations should be discussed if leukaemia is confirmed?

Prompt: What supportive care options should be considered?
Prompt: What role does the GP play in ongoing care and survivorship?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess Daniel’s symptoms and identify potential red flags?

1. Comprehensive History-Taking

Onset and duration: Fatigue, bruising, infections over 3 months.
Constitutional symptoms: Weight loss, fever, night sweats.
Bleeding tendencies: Gum bleeding, nosebleeds, heavy bruising.
Infection history: Recurrent, prolonged, unusual infections.
Family history: Leukaemia, lymphoma, autoimmune disorders.
Occupational exposure: Chemicals, radiation.

2. Physical Examination

Pallor: Suggests anaemia.
Petechiae/bruising: Platelet dysfunction.
Lymphadenopathy: Suggests haematological malignancy.
Hepatosplenomegaly: Infiltration by malignant cells.

Conclusion: Daniel’s fatigue, bruising, lymphadenopathy, and splenomegaly raise concern for haematological malignancy, warranting urgent investigation.

Q2: What investigations would you order, and why?

1. Initial Blood Tests

FBC with differential: Anaemia, leukocytosis/leukopenia, thrombocytopaenia.
Blood film: Blast cells suggest acute leukaemia.
Coagulation studies: DIC risk.
LFTs, U&E, LDH: Tumour burden, renal/hepatic function.

2. Confirmatory and Staging Investigations

Bone marrow biopsy: Definitive diagnosis.
Flow cytometry: Immunophenotyping.
Cytogenetics and molecular studies: Prognostic markers.
Chest X-ray: Mediastinal mass (T-cell ALL).
CT/MRI: Lymphadenopathy, organ involvement.

Conclusion: Urgent haematology referral is required for bone marrow biopsy and definitive diagnosis.

Q3: How would you manage Daniel’s condition in a general practice setting?

1. Urgent Referral

Haematology and oncology team.
Expedited bone marrow biopsy.

2. Supportive Care

Transfusion if severe anaemia.
Infection prevention: Antibiotic prophylaxis if neutropaenic.
Psychosocial support: Address distress, provide reassurance.

3. Red Flags for Hospital Admission

Severe anaemia (Hb <80 g/L).
Neutropaenic sepsis: Fever >38°C, hypotension.
Severe bleeding: Platelets <20 x10⁹/L.

Conclusion: Daniel requires urgent specialist care, with primary care focusing on symptom management and emotional support.

Q4: How would you counsel Daniel about the possibility of leukaemia and next steps?

1. Delivering the News Sensitively

Use empathetic language: “Your symptoms and test results are concerning for a serious blood condition.”
Acknowledge uncertainty: “We need more tests to confirm what’s happening.”

2. Explain the Urgent Referral Process

Haematologist will conduct further tests.
Hospital admission may be required.
Treatment options will depend on final diagnosis.

3. Provide Emotional Support

Validate concerns: “I understand this is overwhelming.”
Encourage support networks: Family, friends.

Conclusion: A clear, supportive approach reassures Daniel while preparing him for specialist review and possible hospitalisation.

Q5: What long-term considerations should be discussed if leukaemia is confirmed?

1. Treatment Pathway

Chemotherapy, targeted therapy, or bone marrow transplant.
Potential side effects (immunosuppression, fatigue, nausea).

2. Infection Prevention

Vaccinations: Avoid live vaccines.
Hand hygiene and avoiding sick contacts.

3. Psychological and Social Support

Counselling services and peer support groups.
Workplace adjustments and financial support.

4. GP’s Role in Ongoing Care

Managing treatment side effects.
Screening for relapse.
Mental health and quality of life discussions.

Conclusion: A multidisciplinary, long-term approach is needed, with GP involvement in survivorship care and health optimisation.

SUMMARY OF A COMPETENT ANSWER

Recognises red flags suggestive of leukaemia and initiates urgent investigation.
Orders targeted blood tests and refers promptly for specialist evaluation.
Provides clear, compassionate counselling about diagnosis and next steps.
Manages supportive care, including infection prevention and transfusion support.
Discusses long-term treatment and GP involvement in survivorship care.

PITFALLS

Delaying referral when leukaemia is suspected.
Failing to perform a full blood count as an initial investigation.
Inadequate communication, causing unnecessary distress.
Not addressing infection prevention in immunocompromised patients.
Overlooking the GP’s role in long-term care and survivorship.

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