CASE INFORMATION
Case ID: DIV-2025-020
Case Name: Robert Williams
Age: 62
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: D92 – Diverticular Disease
COMPETENCY OUTCOMES
Competency Domain | Competency Element |
---|---|
1. Communication and Consultation Skills | 1.1 Takes a structured gastrointestinal history, including dietary habits and symptom impact 1.2 Provides clear explanations about the diagnosis, management, and prevention of complications |
2. Clinical Information Gathering and Interpretation | 2.1 Conducts a thorough abdominal examination and evaluates for signs of complications 2.2 Differentiates between uncomplicated diverticulosis and complicated diverticulitis |
3. Diagnosis, Decision-Making and Reasoning | 3.1 Diagnoses diverticular disease based on clinical presentation and history 3.2 Determines when further investigations (e.g., imaging, colonoscopy) or hospital referral is required |
4. Clinical Management and Therapeutic Reasoning | 4.1 Develops an appropriate treatment plan, including dietary and pharmacological management 4.2 Provides safety-netting and follow-up for potential complications |
5. Preventive and Population Health | 5.1 Educates on lifestyle modifications to reduce the risk of diverticulitis flares and complications |
6. Professionalism | 6.1 Provides empathetic care and acknowledges patient concerns about long-term bowel health |
7. General Practice Systems and Regulatory Requirements | 7.1 Ensures appropriate documentation, prescribing, and follow-up |
9. Managing Uncertainty | 9.1 Recognises when hospital referral or specialist review is required |
10. Identifying and Managing the Patient with Significant Illness | 10.1 Identifies and manages complications such as diverticulitis, abscess, perforation, or fistula formation |
CASE FEATURES
- Older male presenting with intermittent lower abdominal pain and altered bowel habits, requiring differentiation between diverticulosis, diverticulitis, and other gastrointestinal conditions.
- Recognition of red flags, such as fever, peritonism, rectal bleeding, or signs of perforation.
- Management plan incorporating dietary modifications, symptom control, and escalation criteria.
- Addressing patient concerns about disease progression and long-term bowel health.
INSTRUCTIONS
Review the following patient record summary and scenario.
Your examiner will ask you a series of questions based on this information.
You have 15 minutes to complete this case.
The time for each question will be managed by the examiner.
The time allocation for each question is roughly as follows:
- Question 1 – 3 minutes
- Question 2 – 3 minutes
- Question 3 – 3 minutes
- Question 4 – 3 minutes
- Question 5 – 3 minutes
PATIENT RECORD SUMMARY
Patient Details
Name: Robert Williams
Age: 62
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous
Allergies and Adverse Reactions
- Nil known
Medications
- Perindopril 5mg daily (for hypertension)
- Atorvastatin 40mg daily (for dyslipidaemia)
- Occasional paracetamol for musculoskeletal pain
Past History
- Hypertension
- Dyslipidaemia
- Colonoscopy 5 years ago – mild diverticulosis noted
Social History
- Retired truck driver, sedentary lifestyle
- BMI 31 (overweight)
- Smokes 15 cigarettes/day
- Drinks 8–10 standard drinks per week
- Low-fibre diet with frequent processed foods
Family History
- Father had bowel cancer at age 70
Smoking
- Current smoker (15 cigarettes/day)
Alcohol
- Above recommended limits (8–10 drinks/week)
Vaccination and Preventative Activities
- Up to date with bowel cancer screening
SCENARIO
Robert Williams, a 62-year-old retired truck driver, presents with intermittent lower left abdominal pain and changes in bowel habits over the past 6 months.
He reports periods of constipation alternating with loose stools but no rectal bleeding or weight loss. The pain is crampy, relieved with bowel movements, and worse after eating processed foods.
He was diagnosed with diverticulosis on colonoscopy 5 years ago but has never had an episode of diverticulitis.
He is concerned about whether his symptoms indicate worsening disease or risk of bowel cancer.
EXAMINATION FINDINGS
General Appearance: Well, no systemic symptoms
Vital Signs: HR 78 bpm, BP 135/85 mmHg, Temp 36.8°C
Abdominal Examination:
- Mild tenderness in the left lower quadrant
- No guarding, rigidity, or rebound tenderness
- Normal bowel sounds
- No palpable masses
Digital Rectal Examination:
- No rectal bleeding or masses
EXAMINER ONLY INFORMATION
QUESTIONS
Q1. What are your differential diagnoses for Robert’s symptoms?
- Prompt: What is the most likely diagnosis and why?
- Prompt: What other gastrointestinal conditions should be considered?
Q2. What red flags would indicate the need for urgent referral or further investigations?
- Prompt: What features suggest complicated diverticular disease or alternative pathology?
- Prompt: What initial investigations would you consider?
Q3. How would you manage Robert’s condition?
- Prompt: What dietary and pharmacological interventions would you recommend?
- Prompt: When would you consider referral to gastroenterology?
Q4. Robert is concerned about his risk of bowel cancer. How would you counsel him?
- Prompt: How does diverticulosis relate to bowel cancer risk?
- Prompt: What role does bowel cancer screening play in his case?
Q5. What preventive strategies can Robert implement to reduce diverticulitis risk and improve bowel health?
- Prompt: How can he modify his diet and lifestyle?
- Prompt: What role do fibre intake, smoking cessation, and weight management play?
THE COMPETENT CANDIDATE
The competent candidate should be able to:
Q1: What are your differential diagnoses for Robert’s symptoms?
Robert’s most likely diagnosis is diverticular disease, given his history of diverticulosis, intermittent left lower quadrant pain, and altered bowel habits.
Key Differential Diagnoses:
- Diverticular Disease (Most Likely) – Chronic lower left abdominal pain, bloating, and constipation or diarrhoea.
- Irritable Bowel Syndrome (IBS) – Alternating bowel habits, bloating, relieved by defecation, but no structural abnormality.
- Colorectal Cancer – Consider in older patients with new-onset symptoms, weight loss, rectal bleeding, or change in stool calibre.
- Inflammatory Bowel Disease (IBD, e.g., Ulcerative Colitis, Crohn’s) – Chronic diarrhoea, blood/mucus in stools, systemic symptoms.
- Chronic Constipation with Faecal Impaction – History of low fibre intake, sedentary lifestyle, hard stools.
Further assessment, including bowel cancer screening history, dietary habits, and red flag symptoms, will refine the diagnosis.
Q2: What red flags would indicate the need for urgent referral or further investigations?
Red flags requiring urgent referral:
- Severe, persistent abdominal pain with fever – Concern for acute diverticulitis or abscess.
- Rebound tenderness, guarding, or rigidity – Suggests perforation.
- Unintentional weight loss or anorexia – Consider malignancy.
- Haematochezia or melena – Evaluate for diverticular bleeding or malignancy.
- Family history of colorectal cancer (<60 years) – Consider urgent colonoscopy.
Recommended Investigations (if red flags present):
- FBC, CRP – Assess for infection or inflammation.
- Faecal occult blood test (FOBT) – If bowel cancer screening overdue.
- CT abdomen (if suspected diverticulitis) – Identifies inflammation, abscess, or perforation.
- Colonoscopy (if no recent screening or suspicion of malignancy).
Robert has no immediate red flags, but needs regular screening given his family history.
Q3: How would you manage Robert’s condition?
1. Conservative Management (If Uncomplicated Diverticular Disease):
- Increase dietary fibre (25–30g/day) – Whole grains, fruits, vegetables.
- Adequate hydration (1.5–2L/day).
- Regular exercise to promote bowel motility.
- Smoking cessation and reducing alcohol intake.
2. Symptom Management:
- Paracetamol for pain relief (Avoid NSAIDs due to bleeding risk).
- Bulk-forming laxatives (e.g., psyllium) for constipation.
3. Management of Acute Diverticulitis (If Present):
- Oral antibiotics (Amoxicillin-Clavulanate or Metronidazole + Ciprofloxacin) for 7–10 days if mild infection.
- Hospital admission if severe symptoms, peritonitis, or unable to tolerate oral intake.
4. Follow-Up and Specialist Referral:
- Colonoscopy if not done in the past 5 years, especially with a family history of bowel cancer.
- Review in 4–6 weeks to assess response to dietary changes.
- Gastroenterology referral if recurrent symptoms or complications.
Q4: Robert is concerned about his risk of bowel cancer. How would you counsel him?
- Acknowledge Concerns & Provide Reassurance
- “Diverticulosis itself does not increase bowel cancer risk, but it can mimic symptoms.”
- “Your family history does increase risk, so regular screening is essential.”
- Discuss Bowel Cancer Screening:
- “The National Bowel Cancer Screening Program recommends an FOBT every 2 years for people 50–74 years old.”
- “A colonoscopy is recommended every 5 years if diverticulosis is present.”
- Risk Reduction Strategies:
- High-fibre diet, regular exercise, and smoking cessation reduce colorectal cancer risk.
- Limit alcohol to ≤4 standard drinks per week.
- Safety-Netting:
- “If you experience rectal bleeding, weight loss, or worsening symptoms, see me immediately.”
- “We will arrange a colonoscopy if needed to rule out any serious conditions.”
Providing clear guidance on screening and prevention empowers the patient.
Q5: What preventive strategies can Robert implement to reduce diverticulitis risk and improve bowel health?
- Dietary Modifications:
- Increase dietary fibre (25–30g/day) – Gradual introduction to prevent bloating.
- Avoid highly processed foods.
- Maintain adequate hydration (1.5–2L/day).
- Lifestyle Changes:
- Regular physical activity (150 min/week) improves bowel motility.
- Smoking cessation reduces inflammation and complications.
- Limit alcohol intake (≤4 standard drinks per week).
- Bowel Health Monitoring:
- Avoid straining during defecation (use stool softeners if needed).
- Regular GP reviews for symptom monitoring and bowel cancer screening.
Long-term prevention focuses on fibre intake, lifestyle modifications, and regular screening.
SUMMARY OF A COMPETENT ANSWER
- Comprehensive differential diagnosis, distinguishing diverticular disease from IBS, IBD, colorectal cancer, and chronic constipation.
- Identification of red flags, ensuring timely specialist referral if needed.
- Structured, evidence-based management plan, including dietary fibre, hydration, and symptom control.
- Clear patient-centred counselling, addressing concerns about bowel cancer and long-term gut health.
- Preventive strategies, including smoking cessation, fibre intake, and regular bowel screening.
PITFALLS
- Failing to assess for red flags, missing serious pathology such as colorectal cancer.
- Overprescribing antibiotics unnecessarily, when conservative management suffices.
- Not addressing lifestyle factors, such as smoking, diet, and exercise.
- Delaying colonoscopy in high-risk patients, leading to missed malignancy.
- Lack of structured follow-up, missing recurrent symptoms or progression to complicated disease.
REFERENCES
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 structured gastrointestinal history, including dietary habits and symptom impact.
1.2 Provides clear explanations about the diagnosis, management, and prevention of complications.
2. Clinical Information Gathering and Interpretation
2.1 Conducts a thorough abdominal examination and evaluates for signs of complications.
2.2 Differentiates between uncomplicated diverticulosis and complicated diverticulitis.
3. Diagnosis, Decision-Making and Reasoning
3.1 Diagnoses diverticular disease based on clinical presentation and history.
3.2 Determines when further investigations (e.g., imaging, colonoscopy) or hospital referral is required.
4. Clinical Management and Therapeutic Reasoning
4.1 Develops an appropriate treatment plan, including dietary and pharmacological management.
4.2 Provides safety-netting and follow-up for potential complications.
Competency at Fellowship Level
☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD