EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are the key differential diagnoses for David’s diarrhoea?

• Prompt: How do you differentiate between infectious, inflammatory, and functional 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, travel, or antibiotic history is relevant?
• Prompt: What tests would help confirm or rule out key differential diagnoses?

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

• Prompt: How do you address his concerns about an infection?
• Prompt: What dietary or lifestyle modifications would you recommend?

Q4. Outline your management plan for David’s diarrhoea.

• Prompt: When would you prescribe antibiotics?
• Prompt: What hydration and dietary measures should be taken?

Q5. What preventive strategies should David follow for future travel?

• Prompt: What vaccinations or prophylactic measures are useful?
• Prompt: How can he reduce the risk of traveller’s diarrhoea?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What are the key differential diagnoses for David’s diarrhoea?

A structured approach is required to differentiate between infectious, inflammatory, functional, and other causes of diarrhoea.

• Infectious Causes (Most Likely in This Case):
  • Traveller’s diarrhoea (bacterial, viral, or parasitic) – Recent travel, watery stools, self-limiting.
  • Giardiasis – Persistent diarrhoea, bloating, foul-smelling stools, associated with travel.
• Inflammatory Causes:
  • Inflammatory bowel disease (IBD) – Chronic symptoms, blood in stool, weight loss.
  • Coeliac disease – Chronic diarrhoea, weight loss, associated with gluten intake.
• Functional Causes:
  • Irritable bowel syndrome (IBS) – Alternating bowel habits, triggered by stress/diet, no systemic symptoms.
• Serious or Red Flag Conditions (Must Exclude):
  • Colorectal cancer – Weight loss, nocturnal symptoms, anaemia.

A competent candidate prioritises infectious causes while screening for inflammatory and serious pathology.

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

• Further History:
  • Onset and duration – Acute (<2 weeks) vs chronic (>4 weeks).
  • Stool characteristics – Watery vs bloody, urgency, nocturnal symptoms.
  • Dietary factors – Lactose intake, gluten exposure, recent antibiotics.
  • Systemic symptoms – Fever, weight loss, dehydration, joint pain.
• Investigations:
  • Stool microscopy, culture, and sensitivity (MCS) – To detect bacterial or parasitic infections.
  • Faecal calprotectin – Elevated in IBD but normal in IBS.
  • Coeliac serology – IgA-tTG and total IgA.
  • Full blood count (FBC) – Check for anaemia (suggestive of IBD or malignancy).

A competent candidate tailors investigations to confirm infection while ruling out other serious causes.

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

1. Acknowledge concerns:
   • “I understand that persistent diarrhoea can be concerning, especially after recent travel.”
2. Explain likely diagnosis:
   • “Your symptoms suggest traveller’s diarrhoea, which is often caused by bacteria or parasites.”
3. Discuss next steps:
   • “We will send a stool sample for testing, and in the meantime, focus on hydration and symptom relief.”
4. Address treatment expectations:
   • “Most cases resolve within a few weeks, but if this is due to a parasite like Giardia, we may need antibiotics.”
5. Provide safety-netting advice:
   • “If you develop fever, severe abdominal pain, or blood in your stool, please seek urgent medical attention.”

A competent candidate provides a clear, reassuring explanation while ensuring appropriate follow-up.

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Q4: Outline your management plan for David’s diarrhoea.

1. Supportive Care:
   • Oral rehydration – Ensure adequate fluid intake with electrolyte solutions.
   • Dietary modifications – Avoid dairy, caffeine, fatty foods, alcohol.
2. Medications (If Needed):
   • Loperamide – Only if necessary and no suspicion of invasive infection.
   • Antibiotics – If bacterial cause confirmed (e.g., ciprofloxacin or azithromycin for traveller’s diarrhoea, metronidazole for Giardia).
3. Follow-Up and Referral:
   • Review in 3–5 days if no improvement.
   • Referral to gastroenterology if chronic or red flags present.

A competent candidate ensures supportive care while reserving antibiotics for confirmed infections.

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Q5: What preventive strategies should David follow for future travel?

1. Vaccinations and Prophylaxis:
   • Hepatitis A vaccine – If travelling to high-risk areas.
   • Typhoid vaccine – Consider for long-term travel to endemic regions.
2. Food and Water Safety:
   • Avoid tap water – Use bottled or boiled water.
   • Be cautious with raw foods – Avoid salads, unpeeled fruit, street food.
3. Emergency Preparedness:
   • Carry oral rehydration salts (ORS) – To manage dehydration.
   • Consider standby antibiotics – For high-risk travel.

A competent candidate provides comprehensive prevention strategies tailored to the patient’s travel habits.

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SUMMARY OF A COMPETENT ANSWER

• Recognises traveller’s diarrhoea as the most likely diagnosis, while screening for chronic and serious causes.
• Takes a structured history, assessing stool characteristics, systemic symptoms, and travel exposure.
• Orders appropriate investigations, prioritising stool MCS, faecal calprotectin, and coeliac serology if indicated.
• Explains the condition clearly, addressing patient concerns about infection and self-care measures.
• Implements an evidence-based management plan, including hydration, dietary advice, and antibiotics if required.
• Provides preventive strategies, ensuring safe travel habits and appropriate vaccinations.

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PITFALLS

• Failing to consider red flag symptoms, leading to missed serious pathology (IBD, colorectal cancer).
• Overprescribing antibiotics, increasing antibiotic resistance and unnecessary side effects.
• Not providing hydration and dietary advice, leading to delayed recovery.
• Neglecting preventive health strategies, missing opportunities for future risk reduction.

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REFERENCES

• RACGP – RACGP Guidelines on Gastrointestinal Conditions
• GP Exams – Diarrhoea

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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