EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for Margaret’s unexplained bruise?

• Prompt: How would you differentiate between a benign vs pathological cause of bruising?
• Prompt: What features in the history and examination guide your diagnosis?

Q2. What further history and investigations would help clarify the cause of bruising?

• Prompt: What targeted questions would you ask regarding falls, medications, and systemic symptoms?
• Prompt: What laboratory tests would be most relevant in this case?

Q3. How would you explain your assessment and possible causes to Margaret in a reassuring but informative way?

• Prompt: How do you address her concerns about serious conditions like leukaemia?
• Prompt: What lifestyle modifications and precautions would you recommend?

Q4. Outline your management plan based on the most likely diagnosis.

• Prompt: What adjustments, if any, should be made to her medication?
• Prompt: When would you refer her to a specialist (e.g., haematologist, geriatrician)?

Q5. What preventive measures can be implemented to reduce the risk of future bruising or falls?

• Prompt: What safety modifications should be considered for an elderly patient living alone?
• Prompt: How do you educate her about medication-related bruising?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for Margaret’s unexplained bruise?

A structured differential diagnosis is essential to differentiate benign vs pathological causes of bruising.

• Benign Causes (most likely):
  • Age-related skin changes (senile purpura): Fragile capillaries in elderly patients, exacerbated by minor trauma.
  • Medication-related bruising: Aspirin use increases the risk of easy bruising due to platelet inhibition.
  • Minor trauma: The patient may have sustained an unnoticed injury.
• Serious Causes (requiring exclusion):
  • Coagulopathy:
    • Primary bleeding disorders (e.g., von Willebrand disease, platelet dysfunction).
    • Acquired (e.g., liver disease, vitamin K deficiency, disseminated intravascular coagulation).
  • Haematological malignancies: Leukaemia or myelodysplastic syndromes (if associated with pallor, fatigue, recurrent infections).
  • Systemic conditions:
    • Liver disease (impaired clotting factor production).
    • Connective tissue disorders (e.g., vasculitis, scurvy).
  • Elder abuse: Consider if bruises appear in unusual locations (e.g., upper arms, face) or are unexplained.

A competent candidate prioritises medication-related bruising while ensuring red flag conditions are ruled out.

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Q2: What further history and investigations would help clarify the cause of bruising?

• Targeted History:
  • Bleeding tendencies: Epistaxis, gum bleeding, haematuria, menorrhagia.
  • Bruising pattern: Localised vs generalised, presence of petechiae or purpura.
  • Medications and supplements: Aspirin, anticoagulants, NSAIDs, fish oil, herbal remedies.
  • Falls history: Unreported trauma, balance issues, dizziness.
  • Systemic symptoms: Fatigue, weight loss, night sweats, joint pain.
  • Social concerns: Risk factors for elder abuse, history of neglect or cognitive impairment.
• Investigations:
  • Full blood count (FBC): To assess platelet count and haemoglobin.
  • Coagulation studies (INR, APTT): To rule out clotting disorders.
  • Liver function tests (LFTs): To assess hepatic synthesis of clotting factors.
  • Renal function and electrolytes: Chronic kidney disease can contribute to platelet dysfunction.
  • Vitamin C levels: If scurvy is suspected.

A competent candidate tailors history-taking and investigations to patient context, ensuring an efficient, hypothesis-driven approach.

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Q3: How would you explain your assessment and possible causes to Margaret in a reassuring but informative way?

1. Acknowledge concerns:
   • “I understand that an unexplained bruise can be worrying, especially when there’s no clear injury.”
2. Explain likely cause:
   • “Given your age, the use of aspirin, and the absence of red flag symptoms, this bruising is most likely related to minor trauma that you may not have noticed.”
3. Address fears about serious conditions:
   • “Leukaemia and serious bleeding disorders usually present with multiple bruises, fatigue, or other symptoms, which you don’t have. However, to be thorough, I’ll check your blood tests.”
4. Reassure about next steps:
   • “We will monitor the bruise, check some blood tests, and review in a week. If you notice more bruises, excessive bleeding, or feel unwell, let me know sooner.”

A competent candidate provides a clear, empathetic explanation while ensuring patient engagement and shared decision-making.

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Q4: Outline your management plan based on the most likely diagnosis.

1. Reassurance and Monitoring:
   • “We expect this bruise to resolve in 2-3 weeks. If new bruises appear, let me know.”
2. Medication Review:
   • Consider reducing aspirin dose if recurrent bruising occurs, in consultation with her stroke prevention specialist.
3. Lifestyle Modifications:
   • Fall prevention: Encourage safe home environment, proper footwear, and regular strength exercises.
4. Follow-up Plan:
   • Review in 1-2 weeks with blood results.
   • If blood tests are normal, reassure and continue monitoring.
   • If abnormal, refer to haematologist for further workup.

A competent candidate ensures a balanced approach, adjusting medications cautiously while focusing on fall prevention strategies.

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Q5: What preventive measures can be implemented to reduce the risk of future bruising or falls?

1. Medication Safety:
   • Minimise use of antiplatelet agents, NSAIDs, or anticoagulants unless essential.
   • Review with her cardiologist or neurologist if bruising worsens.
2. Fall Prevention:
   • Home modifications: Remove tripping hazards, install grab rails, improve lighting.
   • Physiotherapy referral: Strength and balance exercises.
3. Skin Care and Nutrition:
   • Hydration and moisturisers to improve skin integrity.
   • Ensure adequate vitamin C and protein intake for skin and vessel health.

A competent candidate prioritises preventive strategies, considering medication adjustments, lifestyle modifications, and fall risk assessment.

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SUMMARY OF A COMPETENT ANSWER

• Systematically differentiates between benign vs serious causes of bruising.
• Asks relevant history questions, including falls, medications, systemic symptoms, and social risk factors.
• Orders appropriate investigations, focusing on FBC, coagulation studies, and liver function tests.
• Provides clear and empathetic explanations, addressing patient concerns about malignancy.
• Develops an evidence-based management plan, incorporating medication review, monitoring, and fall prevention strategies.
• Implements preventive measures, including lifestyle adjustments and safety interventions.

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PITFALLS

• Failing to rule out red flag conditions (e.g., leukaemia, clotting disorders, elder abuse).
• Over-investigating without clinical justification, leading to unnecessary tests and patient anxiety.
• Inadequate medication review, ignoring aspirin as a likely contributor.
• Not addressing fall prevention, missing an opportunity for proactive intervention.
• Providing insufficient reassurance, leaving the patient anxious about a serious underlying disease.

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REFERENCES

• RACGP – RACGP Bruising and Bleeding Guidelines
• GP Exams – Bruise/contusion

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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 Communicates effectively and appropriately to provide quality care.
1.3 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information effectively.
2.3 Identifies red flags and important diagnostic features.

3. Diagnosis, Decision-Making and Reasoning

3.1 Applies a structured approach to making a diagnosis.
3.3 Identifies and manages urgent and serious conditions.

Competency at Fellowship Level

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