EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Daniel’s symptoms?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What alternative conditions should be considered?

Q2. What red flags would indicate the need for further investigations?

• Prompt: What symptoms or examination findings would warrant a colonoscopy or further testing?
• Prompt: What initial investigations would be appropriate?

Q3. How would you manage Daniel’s condition?

• Prompt: What lifestyle and dietary modifications would you recommend?
• Prompt: When would you consider pharmacological therapy?

Q4. Daniel is worried about the long-term implications of IBS. How would you reassure him?

• Prompt: How would you explain the nature of IBS and its prognosis?
• Prompt: What support options (e.g., psychology, dietitian referral) might be appropriate?

Q5. What preventive strategies can Daniel implement to minimise symptom flares?

• Prompt: How can he modify his diet, lifestyle, and stress levels to reduce IBS symptoms?
• Prompt: When should he seek further medical review?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Daniel’s symptoms?

Daniel’s most likely diagnosis is Irritable Bowel Syndrome (IBS) based on his chronic intermittent abdominal pain, altered bowel habits, symptom exacerbation with stress, and lack of red flags.

Key Differential Diagnoses:

1. Inflammatory Bowel Disease (IBD) – Crohn’s disease or Ulcerative Colitis
   • Consider if there is bloody diarrhoea, nocturnal symptoms, weight loss, or family history.
2. Coeliac Disease
   • Can mimic IBS; test if there is bloating, fatigue, or malabsorption signs.
3. Lactose or Fructose Intolerance
   • Symptoms triggered by dairy or high-fructose foods.
4. Small Intestinal Bacterial Overgrowth (SIBO)
   • Consider if bloating and diarrhoea worsen after meals.
5. Colorectal Cancer
   • Unlikely in this age group but must be excluded if there is persistent change in bowel habits, weight loss, anaemia, or rectal bleeding.

A targeted history and appropriate investigations will help differentiate IBS from organic pathology.

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Q2: What red flags would indicate the need for further investigations?

Alarm Symptoms Requiring Further Investigation:

• Unintentional weight loss
• Rectal bleeding or melena
• Nocturnal diarrhoea or pain
• Progressive symptoms despite conservative management
• Iron deficiency anaemia
• Family history of colorectal cancer, IBD, or coeliac disease

Recommended Investigations for Red Flags:

• FBC, iron studies, CRP/ESR – Inflammatory or anaemic conditions
• Coeliac serology (tTG-IgA) – Screen for coeliac disease
• Faecal calprotectin/lactoferrin – Helps distinguish IBD from IBS
• Colonoscopy – Indicated if persistent red flags are present

If no red flags, IBS can be diagnosed clinically using Rome IV criteria.

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Q3: How would you manage Daniel’s condition?

Lifestyle and Dietary Modifications:

• Dietary review – Consider low FODMAP diet trial with dietitian support.
• Increase soluble fibre intake (psyllium husk), while avoiding insoluble fibre if diarrhoea is predominant.
• Limit trigger foods – Caffeine, alcohol, high-fat meals.

Pharmacological Therapy (if needed):

• Antispasmodics (e.g., mebeverine, hyoscine) – For cramping.
• Loperamide – For diarrhoea-predominant IBS.
• Osmotic laxatives (e.g., PEG, lactulose) – For constipation.
• Tricyclic antidepressants (e.g., amitriptyline 10-25mg nocte) – If symptoms persist.

Follow-up Plan:

• Review in 4–6 weeks to assess response to interventions.
• Consider psychological interventions (CBT, gut-directed hypnotherapy) if stress is a trigger.

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Q4: Daniel is worried about the long-term implications of IBS. How would you reassure him?

1. Explain IBS as a Functional Condition
   • “IBS is a chronic but non-life-threatening condition related to gut-brain interaction.”
   • “It does not increase the risk of cancer or serious disease.”
2. Discuss Symptom Management and Prognosis
   • “Symptoms fluctuate over time but can be well managed.”
   • “Many people improve with diet, stress reduction, and medication if needed.”
3. Address Work and Quality of Life Concerns
   • Offer strategies for managing symptoms at work.
   • Consider support from a dietitian, psychologist, or gastroenterologist if needed.
4. Provide a Structured Follow-up Plan
   • “Let’s review in a few weeks to assess progress.”
   • “Seek urgent care if new concerning symptoms arise.”

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Q5: What preventive strategies can Daniel implement to minimise symptom flares?

1. Dietary Modifications:
   • Trial a low FODMAP diet under dietitian guidance.
   • Avoid excess caffeine, alcohol, and high-fat meals.
2. Regular Meal Patterns:
   • Maintain consistent meal timing to prevent symptom variability.
3. Stress Management Techniques:
   • Exercise, mindfulness, and cognitive behavioural therapy (CBT).
4. Physical Activity:
   • Regular exercise improves gut motility and stress response.
5. Routine Medical Reviews:
   • Monitor symptoms and adjust treatment as needed.
   • Seek reassessment if new red flags appear.

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SUMMARY OF A COMPETENT ANSWER

• Systematic differential diagnosis, distinguishing IBS from serious pathology.
• Identification of red flags requiring further investigations.
• Clear and evidence-based management, including dietary, pharmacological, and psychological strategies.
• Reassurance about prognosis, addressing patient concerns about long-term health.
• Preventive strategies to reduce IBS symptom flares.

PITFALLS

• Failing to assess red flags, leading to missed serious conditions.
• Overinvestigating mild IBS symptoms, causing unnecessary patient anxiety.
• Lack of individualised management, not tailoring diet and medications.
• Not addressing psychological aspects, ignoring the gut-brain connection.
• Providing vague follow-up, missing chronic symptom progression.

REFERENCES

• RACGP – RACGP Clinical guidelines for IBS in general practice
• GP Exams – Irritable bowel syndrome

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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 about IBS as a functional disorder.
1.2 Provides reassurance and discusses lifestyle modifications.

2. Clinical Information Gathering and Interpretation

2.1 Takes a thorough gastrointestinal history and assesses symptom patterns.
2.2 Identifies red flags requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Applies Rome IV Criteria for IBS diagnosis.
3.2 Differentiates IBS from organic gastrointestinal conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a personalised management plan for IBS symptoms.
4.2 Considers dietary modifications and pharmacological options.

5. Preventive and Population Health

5.1 Provides lifestyle advice for optimising gut health and reducing triggers.

6. Professionalism

6.1 Provides empathetic care and acknowledges the impact of IBS on quality of life.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up for chronic symptom monitoring.

9. Managing Uncertainty

9.1 Recognises when to escalate care for further assessment.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies alarm symptoms that may indicate serious gastrointestinal pathology.

Competency at Fellowship Level

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