CCE-CBD-062

Examiner Only Information

Questions

Q1. How would you explain Sarah’s diagnosis and its underlying cause?

• Prompt: How do you explain iron deficiency anaemia in simple terms?
• Prompt: What are the most likely contributing factors?

Q2. What further investigations would you consider to confirm the diagnosis and rule out other causes?

• Prompt: What additional blood tests may be needed?
• Prompt: When would you consider gastrointestinal investigations?

Q3. What are the key components of Sarah’s management plan?

• Prompt: How would you correct her iron deficiency?
• Prompt: How would you manage her heavy periods?

Q4. What dietary and lifestyle advice would you provide to help prevent recurrence?

• Prompt: What iron-rich foods should she include in her diet?
• Prompt: What factors enhance or inhibit iron absorption?

Q5. When would you consider referral to a specialist?

• Prompt: When would a gynaecology referral be warranted?
• Prompt: When is a haematology or gastroenterology referral indicated?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: How would you explain Sarah’s diagnosis and its underlying cause?

The competent candidate should:

• Explain anaemia in simple terms:
  • “Anaemia means your red blood cell levels are lower than normal, reducing your body’s ability to carry oxygen.”
  • “This is why you have been feeling tired and breathless.”
• Discuss the likely cause:
  • “Your heavy periods and low iron intake from your vegetarian diet are contributing to this.”
• Reassure while addressing concerns:
  • “The good news is that iron deficiency anaemia is treatable with dietary changes and iron supplements.”

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Q2: What further investigations would you consider to confirm the diagnosis and rule out other causes?

The competent candidate should:

• Confirm iron deficiency and rule out other types of anaemia:
  • Reticulocyte count (assesses bone marrow response).
  • Peripheral blood smear (to check for abnormal red blood cells).
• Consider gastrointestinal (GI) investigations if needed:
  • If symptoms persist despite iron supplementation or if there are GI symptoms (e.g., weight loss, abdominal pain, rectal bleeding).
  • Faecal occult blood test (FOBT) or colonoscopy if concern for occult blood loss.

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Q3: What are the key components of Sarah’s management plan?

The competent candidate should:

• Iron supplementation:
  • Oral iron (ferrous sulfate 100-200 mg daily), taken with vitamin C to enhance absorption.
  • Monitor response with repeat haemoglobin and ferritin in 3 months.
• Menorrhagia management:
  • Consider tranexamic acid, NSAIDs, or hormonal therapy (oral contraceptives, Mirena IUD) to reduce bleeding.

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Q4: What dietary and lifestyle advice would you provide to help prevent recurrence?

The competent candidate should:

• Iron-rich foods:
  • Legumes, tofu, fortified cereals, spinach, nuts, and seeds.
• Iron absorption factors:
  • Enhancers: Vitamin C (e.g., citrus fruits).
  • Inhibitors: Tea, coffee, calcium supplements.

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Q5: When would you consider referral to a specialist?

The competent candidate should:

• Gynaecology referral if:
  • Medical management of menorrhagia fails.
  • Suspected fibroids or endometrial pathology.
• Gastroenterology referral if:
  • Persistent anaemia despite adequate iron replacement.
  • Unexplained GI symptoms or positive FOBT.
• Haematology referral if:
  • Suspected haemolysis, marrow disorder, or other non-iron deficiency causes.

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SUMMARY OF A COMPETENT ANSWER

• Clearly explains iron deficiency anaemia and contributing factors.
• Orders appropriate tests to confirm diagnosis and exclude other causes.
• Implements a structured management plan including iron therapy and menorrhagia treatment.
• Provides dietary advice for iron-rich foods and optimising absorption.
• Recognises when to refer to gynaecology, gastroenterology, or haematology.

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PITFALLS

• Not considering alternative causes of anaemia beyond iron deficiency.
• Failing to address menorrhagia as an ongoing source of blood loss.
• Inadequate dietary advice or failure to explain factors affecting iron absorption.
• Delaying referral when warranted (e.g., persistent anaemia despite treatment).

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REFERENCES

• RACGP Guidelines on Investigation and Management of Anaemia
• National Blood Authority – Iron Deficiency Anaemia Management
• National Institutes of Health on Iron Deficiency and Menorrhagia

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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 Clearly explains anaemia, symptoms, and management options.

2. Clinical Information Gathering and Interpretation

2.1 Orders appropriate tests and considers underlying causes.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies iron deficiency anaemia and differentiates from other causes.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate treatment plan, including iron replacement and menorrhagia management.

5. Preventive and Population Health

5.2 Provides dietary and lifestyle advice to prevent recurrence.

6. Professionalism

6.3 Addresses patient concerns and expectations regarding treatment.

7. General Practice Systems and Regulatory Requirements

7.2 Ensures appropriate follow-up and specialist referral as needed.

9. Managing Uncertainty

9.1 Recognises when to investigate further for alternative diagnoses.

10. Identifying and Managing the Patient with Significant Illness

10.3 Detects and appropriately manages underlying conditions contributing to anaemia.

Competency at Fellowship Level

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