EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is the most likely explanation for Emily’s abnormal blood test results?

• Prompt: How do the findings of low haemoglobin, low MCV, and low ferritin fit together?
• Prompt: What is the significance of the mild ALT elevation?

Q2. What further history and investigations would be useful in this case?

• Prompt: What dietary, menstrual, or gastrointestinal factors could contribute to these results?
• Prompt: What additional tests would you order to confirm the underlying cause?

Q3. How would you explain the test results and next steps to Emily?

• Prompt: How do you address her concerns while providing clear explanations?
• Prompt: What lifestyle modifications or treatments would you recommend?

Q4. Outline your management plan for Emily’s iron-deficiency anaemia.

• Prompt: What dietary and supplementation advice should she follow?
• Prompt: When should she return for follow-up, and what should be monitored?

Q5. What preventive strategies should be implemented to maintain Emily’s long-term health?

• Prompt: How can she prevent recurrent iron deficiency?
• Prompt: What other health screenings or lifestyle modifications are relevant at her age?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What is the most likely explanation for Emily’s abnormal blood test results?

Emily’s blood test results suggest iron-deficiency anaemia (IDA), given:

• Low haemoglobin (114 g/L) → Indicates anaemia.
• Low MCV (75 fL) → Suggests microcytic anaemia, commonly due to IDA.
• Low ferritin (8 µg/L) → Confirms iron deficiency.

The mildly elevated ALT (42 U/L) could be:

• Benign or transient, possibly due to dietary factors, mild fatty liver, or recent exercise.
• Less likely causes: Alcohol-related liver injury (unlikely given low intake), viral hepatitis (no risk factors).

A competent candidate recognises IDA as the primary abnormality while considering secondary causes for ALT elevation.

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Q2: What further history and investigations would be useful in this case?

• Further History:
  • Dietary intake: Vegetarian diet may predispose to iron deficiency.
  • Menstrual history: Heavy or prolonged periods could contribute to IDA.
  • Gastrointestinal symptoms: Coeliac disease, reflux, NSAID use (occult bleeding).
  • Family history: Haemoglobinopathies, chronic illnesses.
• Investigations:
  • Iron studies: To confirm iron deficiency and exclude other causes.
  • Coeliac serology: If persistent IDA or gastrointestinal symptoms.
  • Liver function tests (LFTs): If ALT remains elevated, check full liver panel.
  • Faecal occult blood test (FOBT): If age-appropriate or unexplained IDA.

A competent candidate takes a focused history and orders relevant tests based on risk factors.

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Q3: How would you explain the test results and next steps to Emily?

1. Acknowledge concerns:
   • “I understand that receiving abnormal test results can be stressful.”
2. Explain key findings:
   • “Your results show iron-deficiency anaemia, which means your iron levels are too low to produce enough healthy red blood cells.”
3. Discuss possible causes:
   • “This is likely due to low dietary iron intake, possibly worsened by menstrual blood loss.”
4. Address ALT elevation:
   • “Your liver enzyme ALT is slightly elevated, but this is not concerning at this stage. We will monitor it.”
5. Plan next steps:
   • “We’ll start iron supplementation and reassess in 6–8 weeks.”
   • “If symptoms develop or the anaemia persists, we may do further tests.”

A competent candidate provides a clear, non-alarming explanation with an action plan.

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Q4: Outline your management plan for Emily’s iron-deficiency anaemia.

1. Iron Supplementation:
   • Ferrous sulfate 325 mg daily (or alternative if not tolerated).
   • Take with vitamin C to enhance absorption.
   • Avoid taking with tea, coffee, or calcium (reduces absorption).
2. Dietary Advice:
   • Increase iron-rich foods (leafy greens, legumes, eggs, fortified cereals).
   • Consider heme iron sources if comfortable (e.g., seafood, poultry).
3. Monitor Response:
   • Repeat FBC and ferritin in 8 weeks.
   • If inadequate improvement, consider alternative causes (malabsorption, chronic disease).
4. Manage ALT Elevation:
   • Repeat ALT in 3 months.
   • If persistent, check full LFTs, hepatitis serology, and ultrasound if indicated.

A competent candidate tailors management with clear instructions and follow-up plans.

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Q5: What preventive strategies should be implemented to maintain Emily’s long-term health?

1. Preventing Recurrent IDA:
   • Optimise dietary iron intake, consider ongoing iron supplementation if needed.
   • Monitor for ongoing blood loss (e.g., heavy periods, GI symptoms).
2. Regular Health Screenings:
   • Annual FBC if risk persists.
   • Routine cervical and breast cancer screening.
3. General Health Advice:
   • Regular exercise, maintaining a balanced diet.
   • Monitor liver function, especially if ALT remains high.

A competent candidate integrates preventive health measures tailored to the patient’s risks.

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SUMMARY OF A COMPETENT ANSWER

• Correctly identifies iron-deficiency anaemia as the likely diagnosis, with dietary and menstrual causes.
• Explains results clearly and non-alarmingly, addressing patient concerns.
• Orders appropriate follow-up tests, considering alternative causes if needed.
• Implements a structured treatment plan, including iron supplements, dietary advice, and monitoring.
• Incorporates preventive strategies, ensuring long-term health optimisation.

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PITFALLS

• Failing to consider alternative causes of IDA, such as malabsorption (coeliac disease) or chronic blood loss.
• Not addressing the mild ALT elevation, missing liver pathology if persistent.
• Over-investigating without clear indications, leading to unnecessary patient anxiety.
• Not providing clear follow-up instructions, resulting in poor adherence to iron therapy.
• Neglecting preventive health measures, missing an opportunity to optimise long-term well-being.

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REFERENCES

• RACGP – RACGP Guidelines on Cardiovascular Disease Risk Assessment
• GP Exams – Blood test NOS

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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