CCE-CBD-215 - GP Exams

CASE INFORMATION

Case ID: LYM-001
Case Name: Michael Stevens
Age: 38 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: B72 (Lymphoma)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes a safe and supportive consultation environment 1.2 Uses clear, empathetic explanations about 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 lymphoma as a potential cause of lymphadenopathy and systemic symptoms 3.2 Uses clinical reasoning to differentiate lymphoma from infections, leukaemia, and other malignancies 3.3 Prioritises urgent referral for haematology review and biopsy
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 Provides advice on infection prevention and vaccinations if immunosuppression is anticipated 5.2 Encourages ongoing health monitoring and lifestyle modifications
6. Professionalism	6.1 Demonstrates sensitivity when discussing a potential cancer diagnosis
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 suggestive of haematological malignancy and acts appropriately

CASE FEATURES

Middle-aged male presenting with persistent lymphadenopathy and constitutional symptoms.
Findings suggestive of haematological malignancy requiring urgent assessment.
Discussion about the need for specialist referral and biopsy.
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: Michael Stevens
Age: 38 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 or autoimmune disease.

Social History

Works as a construction site manager, reports high work stress.
Non-smoker, drinks 3-4 alcoholic drinks per week.
No recreational drug use.
Married with two 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

Michael, a 38-year-old construction site manager, presents with a painless lump in his neck that he first noticed two months ago. The lump has gradually increased in size. He also reports fatigue, night sweats, and unexplained weight loss (4 kg in two months).

He has had no recent infections, and no fevers, but has noticed occasional itching and persistent mild cough. He denies shortness of breath or chest pain.

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

EXAMINATION FINDINGS

General Appearance: Pale but well-oriented
Vital Signs: BP 120/75 mmHg, HR 88 bpm, RR 16 bpm, SpO₂ 98% on room air
Skin: No bruising, rashes, or petechiae
Lymphatic System: Palpable, non-tender, rubbery cervical lymphadenopathy (2.5 cm), mobile
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 Michael’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 lymphoma?
Prompt: What imaging or specialist investigations might be required?

Q3. How would you manage Michael’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 Michael about the possibility of lymphoma 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 lymphoma 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 Michael’s symptoms and identify potential red flags?

1. Comprehensive History-Taking

Onset and duration: Painless lump for 2 months, progressive enlargement.
B symptoms (suggestive of lymphoma):
- Fever (>38°C).
- Night sweats.
- Unexplained weight loss (>10% in 6 months).
Lymph node characteristics: Size, tenderness, mobility.
Associated symptoms: Pruritus, fatigue, cough.
Past medical history: Immunosuppression, HIV, EBV exposure.

2. Physical Examination

Lymph node assessment: Firm, rubbery, non-tender lymphadenopathy >1 cm.
Hepatosplenomegaly: Suggests systemic involvement.
Respiratory and cardiovascular exam: Assess for mediastinal mass.

Conclusion: Michael’s painless, progressive lymphadenopathy, weight loss, and night sweats raise suspicion for lymphoma, requiring urgent investigation.

Q2: What investigations would you order, and why?

1. Initial Blood Tests

FBC: Anaemia, leukocytosis, lymphopenia.
ESR/CRP: Inflammatory markers.
LDH: Elevated in aggressive lymphomas.
LFTs and U&E: Liver or renal involvement.
HIV, EBV, Hepatitis B/C serology: Risk factors.

2. Imaging

Chest X-ray: Mediastinal mass (Hodgkin lymphoma).
CT neck, chest, abdomen, pelvis: Extent of lymphadenopathy.

3. Definitive Diagnosis

Excisional lymph node biopsy (preferred over FNA).
Bone marrow biopsy if systemic involvement suspected.

Conclusion: Urgent biopsy and staging investigations are needed for diagnosis and treatment planning.

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

1. Urgent Specialist Referral

Haematologist/Oncologist for biopsy and staging.
Consider hospital admission if symptomatic with systemic involvement.

2. Symptomatic and Supportive Care

Analgesia for discomfort.
Infection prevention if immunosuppressed.
Psychosocial support: Address anxiety about possible malignancy.

3. Red Flags for Immediate Hospital Referral

Airway obstruction or superior vena cava syndrome.
Severe systemic symptoms (high fever, rapid weight loss).

Conclusion: Michael needs urgent haematology referral for definitive diagnosis and management.

Q4: How would you counsel Michael about the possibility of lymphoma and next steps?

1. Communicating Uncertainty and Concern

Be honest but reassuring: “Your symptoms and findings raise concerns about a serious condition, and we need to do more tests.”
Acknowledge emotional impact: “I understand this may be worrying, but we will support you through this.”

2. Explain the Urgent Referral Process

Lymph node biopsy is essential for diagnosis.
CT scans help assess the extent of involvement.
Haematologist will guide further tests and treatment.

3. Address Immediate Concerns

Encourage support from family/friends.
Discuss work adjustments if needed.

Conclusion: A clear, compassionate approach reassures Michael while preparing him for urgent specialist assessment.

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

1. Treatment Pathway

Chemotherapy, radiation, or targeted therapy depending on lymphoma type.
Potential side effects (fatigue, nausea, immunosuppression).

2. Infection Prevention and Vaccination

Avoid live vaccines if immunocompromised.
Routine screening for secondary malignancies.

3. Psychological and Social Support

Counselling and support groups.
Workplace adjustments and financial support.

4. GP’s Role in Ongoing Care

Monitoring for recurrence.
Managing treatment side effects and long-term health maintenance.

Conclusion: A multidisciplinary, long-term approach ensures comprehensive patient support.

SUMMARY OF A COMPETENT ANSWER

Recognises red flags for lymphoma and initiates urgent investigations.
Orders targeted blood tests and imaging, with priority on lymph node biopsy.
Refers urgently to haematology while managing symptoms and patient anxiety.
Provides clear, empathetic communication about diagnosis and next steps.
Discusses long-term treatment, surveillance, and GP involvement in survivorship care.

PITFALLS

Delaying biopsy when lymphoma is suspected.
Misinterpreting lymphadenopathy as infection without further assessment.
Failing to address patient distress and uncertainty.
Not providing appropriate infection prevention measures if immunosuppression occurs.
Overlooking the GP’s role in long-term monitoring 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