EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for Rachel’s gastrointestinal symptoms?

• Prompt: How do you differentiate between functional and organic causes?
• Prompt: What red flags would indicate the need for urgent investigation?

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

• Prompt: What dietary, infectious, or inflammatory factors should be considered?
• Prompt: What tests would help confirm or rule out key differential diagnoses?

Q3. How would you explain the diagnosis and next steps to Rachel?

• Prompt: How do you provide reassurance while addressing her concerns about coeliac disease?
• Prompt: What lifestyle modifications or dietary changes would you recommend?

Q4. Outline your management plan for Rachel’s symptoms.

• Prompt: What non-pharmacological and pharmacological treatments are effective?
• Prompt: When would you refer her for specialist review?

Q5. What preventive strategies should Rachel follow to maintain long-term digestive health?

• Prompt: How can she optimise her diet and lifestyle to reduce symptom flares?
• Prompt: What screening or follow-up is necessary for chronic gastrointestinal conditions?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for Rachel’s gastrointestinal symptoms?

A structured approach is required to differentiate between functional vs organic gastrointestinal (GI) conditions.

• Functional GI Disorders (More Likely in This Case):
  • Irritable Bowel Syndrome (IBS) – Alternating diarrhoea/constipation, bloating, relieved by defecation, exacerbated by stress.
  • Functional Dyspepsia – Upper GI discomfort without structural abnormalities.
• Organic Causes (Must Exclude):
  • Coeliac Disease – Family history, worsened symptoms after gluten intake, potential iron deficiency.
  • Inflammatory Bowel Disease (IBD – Crohn’s or Ulcerative Colitis) – Persistent diarrhoea, rectal bleeding, weight loss, nocturnal symptoms.
  • Small Intestinal Bacterial Overgrowth (SIBO) – Bloating, postprandial discomfort, response to antibiotics.
• Serious Causes (Red Flags to Exclude):
  • Colorectal Cancer – Older age, rectal bleeding, weight loss, nocturnal diarrhoea.
  • Endometriosis – Overlap of GI and gynaecological symptoms.

A competent candidate prioritises functional disorders while screening for serious pathology.

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

• Further History:
  • Dietary triggers: Gluten, dairy, high-FODMAP foods.
  • Bowel pattern: Consistency (Bristol Stool Chart), frequency, urgency, nocturnal symptoms.
  • Red flags: Unintentional weight loss, rectal bleeding, persistent vomiting.
  • Gynaecological history: Endometriosis overlap, menstrual-related symptoms.
• Investigations:
  • Coeliac serology – IgA-tTG and total IgA.
  • Faecal calprotectin – Elevated in IBD but normal in IBS.
  • Iron studies, FBC – To check for anaemia (coeliac disease, IBD).
  • Stool culture, ova, and parasites – If infectious cause suspected.

A competent candidate tailors investigations based on red flags and risk factors.

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Q3: How would you explain the diagnosis and next steps to Rachel?

1. Acknowledge concerns:
   • “I understand that these symptoms are distressing, and you’re concerned about coeliac disease.”
2. Explain likely cause:
   • “Your symptoms are suggestive of Irritable Bowel Syndrome (IBS), a functional gut condition influenced by diet, stress, and gut sensitivity.”
3. Address coeliac concerns:
   • “Given your family history, we’ll test for coeliac disease to be thorough.”
4. Discuss symptom management:
   • “Regardless of the cause, dietary adjustments, stress management, and gut-friendly habits will be key.”
5. Plan follow-up:
   • “I’ll review your test results in 2 weeks, and we’ll adjust management based on findings.”

A competent candidate explains the diagnosis clearly while ensuring appropriate investigations and follow-up.

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Q4: Outline your management plan for Rachel’s symptoms.

1. Lifestyle and Dietary Modifications:
   • Trial a low-FODMAP diet – Eliminate then reintroduce to identify triggers.
   • Increase dietary fibre – If constipation predominant.
   • Regular exercise and stress management – Can improve gut function.
2. Pharmacological Management (If Needed for Symptom Control):
   • Antispasmodics (Hyoscine, Peppermint Oil) – For cramping.
   • Loperamide – For diarrhoea-predominant IBS.
   • Probiotics – May reduce bloating and discomfort.
3. Referral Criteria:
   • Gastroenterology referral if:
     • Persistent symptoms despite treatment.
     • Positive coeliac serology or suspected IBD.
4. Follow-Up:
   • Review in 2–4 weeks, reassess symptoms and test results.

A competent candidate provides a stepwise approach, integrating lifestyle changes with pharmacological options as needed.

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Q5: What preventive strategies should Rachel follow to maintain long-term digestive health?

1. Optimise Diet:
   • Maintain a balanced, gut-friendly diet, avoiding known triggers.
   • If coeliac disease is confirmed, strict gluten-free diet is essential.
2. Monitor Symptoms and Adjust Lifestyle:
   • Keep a symptom diary to track flare triggers.
   • Regular stress management (CBT, mindfulness, yoga).
3. Routine Health Monitoring:
   • Regular GP follow-ups if ongoing symptoms.
   • Faecal calprotectin monitoring if IBD diagnosed.
4. When to Seek Medical Attention:
   • If new red flags develop (rectal bleeding, weight loss, nocturnal symptoms).

A competent candidate provides a proactive plan for symptom management and long-term well-being.

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SUMMARY OF A COMPETENT ANSWER

• Distinguishes between IBS and organic GI conditions, ensuring red flags are excluded.
• Takes a structured history, assessing diet, bowel patterns, and family history.
• Orders targeted investigations, prioritising coeliac testing, inflammatory markers, and anaemia screening.
• Explains the condition clearly, addressing patient concerns about coeliac disease.
• Implements an evidence-based management plan, including dietary modifications, pharmacological options, and specialist referral if needed.
• Provides preventive strategies, ensuring long-term digestive health and symptom monitoring.

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PITFALLS

• Failing to consider organic causes, leading to missed coeliac disease or IBD.
• Over-investigating without clinical indication, causing unnecessary anxiety.
• Not addressing psychological factors, missing the role of stress and gut-brain interaction.
• Neglecting dietary modifications, relying solely on medications.
• Not providing follow-up guidance, leading to poor symptom control and patient frustration.

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REFERENCES

• RACGP – RACGP Guidelines for Preventive Activities in General Practice
• GP Exams – Disease digestive system

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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