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 urgent referral or further investigations?

• Prompt: What features would warrant an urgent gastroscopy?
• 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 or referral?

Q4. Daniel is concerned about whether he needs lifelong medication. How would you counsel him?

• Prompt: How would you explain the role of PPIs and their long-term risks?
• Prompt: What strategies can help reduce medication dependency?

Q5. What preventive strategies can Daniel implement to improve his stomach health?

• Prompt: How can he modify his diet, lifestyle, and stress levels to reduce 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 functional dyspepsia, given his chronic postprandial discomfort, bloating, and early satiety without alarming features.

Key Differential Diagnoses:

1. Functional Dyspepsia (Most Likely) – Chronic upper abdominal discomfort, no structural abnormalities, worsened by large meals and stress.
2. Gastritis or Peptic Ulcer Disease – May present with epigastric pain, nausea, and partial response to PPIs.
3. Gastroesophageal Reflux Disease (GORD) – Consider if symptoms include heartburn and regurgitation.
4. Helicobacter pylori Infection – Can cause chronic gastritis or peptic ulceration.
5. Gastroparesis – Early satiety and bloating, often associated with diabetes or medication use.
6. Gastric Malignancy (Unlikely but Important to Exclude) – Consider if weight loss, persistent vomiting, or GI bleeding are present.

Further assessment will help confirm the diagnosis and guide management.

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

Red flags requiring urgent gastroscopy or specialist referral:

• Unintentional weight loss (>5% in 6 months).
• Progressive dysphagia or odynophagia.
• Persistent vomiting or gastrointestinal bleeding (melaena, haematemesis).
• Age >50 with new-onset dyspepsia.
• Family history of upper GI malignancy.

Recommended Investigations:

• H. pylori testing (faecal antigen or urea breath test).
• FBC, iron studies – Assess for anaemia or chronic blood loss.
• LFTs, lipase – Exclude liver or pancreatic pathology.
• Gastroscopy (if red flags present).

As Daniel has no red flags, a H. pylori test-and-treat approach is reasonable.

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Q3: How would you manage Daniel’s condition?

Lifestyle Modifications:

• Reduce alcohol and caffeine intake.
• Smoking cessation – Smoking worsens gastric mucosal damage.
• Eat smaller, more frequent meals, avoid late-night eating.
• Manage stress, as psychological factors contribute to functional dyspepsia.

Pharmacological Therapy:

• H. pylori eradication if positive (PPI + amoxicillin + clarithromycin for 14 days).
• Continue PPI trial (esomeprazole 20mg daily) for 4–8 weeks, then reassess.
• Prokinetics (e.g., domperidone, metoclopramide) for gastroparesis symptoms.

Follow-Up Plan:

• Review in 4–6 weeks to assess symptom improvement.
• Consider gastroscopy if persistent symptoms despite treatment.

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Q4: Daniel is concerned about whether he needs lifelong medication. How would you counsel him?

1. Acknowledge Concerns & Provide Reassurance
   • “Most people do not need lifelong PPIs; they are used to manage symptoms and protect the stomach lining.”
2. Discuss Long-Term Risks of PPIs
   • “Long-term PPI use may increase risk of osteoporosis, vitamin B12 deficiency, and infections.”
3. Strategies to Reduce Dependence
   • Step-down approach: Reduce dose or switch to on-demand use.
   • Lifestyle modifications to manage symptoms without PPIs.
   • H. pylori eradication can lead to long-term symptom relief.
4. Follow-Up & Monitoring
   • Regular medication reviews to assess need for ongoing treatment.
   • If symptoms persist, consider alternative diagnoses or specialist review.

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Q5: What preventive strategies can Daniel implement to improve his stomach health?

1. Dietary Modifications:
   • Avoid spicy, acidic, and fatty foods that trigger symptoms.
   • Increase fibre intake and maintain hydration.
2. Lifestyle Adjustments:
   • Quit smoking, as it worsens gastric inflammation.
   • Limit alcohol and caffeine intake.
   • Reduce stress with relaxation techniques or therapy.
3. Regular Medical Reviews:
   • Monitor for medication side effects or need for deprescribing.
   • Seek review if new symptoms or red flags develop.

Preventing recurrence involves a combination of lifestyle changes, medication review, and stress management.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing functional dyspepsia from gastritis, GORD, and peptic ulcer disease.
• Identification of red flags, ensuring urgent investigations when necessary.
• Structured evidence-based management plan, including H. pylori testing, PPI therapy, and lifestyle modifications.
• Clear patient-centred counselling, addressing long-term medication use and alternative management strategies.
• Preventive strategies, focusing on diet, smoking cessation, and stress reduction.

PITFALLS

• Failing to assess for red flags, leading to missed gastric malignancy or ulcer complications.
• Over-reliance on PPIs, without addressing modifiable lifestyle factors.
• Not testing for H. pylori, missing a treatable cause of dyspepsia.
• Lack of structured follow-up, resulting in poor symptom control.
• Ignoring psychological contributors, such as stress and anxiety-related dyspepsia.

REFERENCES

• RACGP – RACGP Guidelines for Dyspepsia and GORD
• GP Exams – Stomach function disorder

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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 Takes a thorough gastrointestinal history to assess symptoms and impact on daily life.
1.2 Provides clear explanations of diagnosis, investigations, and management.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a structured abdominal examination and identifies red flags.
2.2 Determines when further investigations are warranted.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between common stomach function disorders.
3.2 Identifies when referral to a gastroenterologist is necessary.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an appropriate management plan, including dietary, pharmacological, and lifestyle interventions.
4.2 Ensures treatment is aligned with best-practice guidelines.

5. Preventive and Population Health

5.1 Provides education on lifestyle modifications to prevent and manage symptoms.

6. Professionalism

6.1 Acknowledges patient concerns and maintains a patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate follow-up and safety-netting for gastrointestinal conditions.

9. Managing Uncertainty

9.1 Recognises when further assessment or specialist referral is warranted.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies serious conditions such as peptic ulcer disease, gastric malignancy, or gastroparesis.

Competency at Fellowship Level

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