CCE-CBD-139.1

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your diagnosis and differential diagnosis for John’s abnormal blood tests?

Answer:

The primary diagnosis is iron deficiency anaemia (IDA). This is based on the low haemoglobin (Hb 98 g/L), microcytic indices (MCV 75 fL), low ferritin (6 µg/L), low serum iron, and elevated red cell distribution width (RDW 18%). In adult males, iron deficiency anaemia is pathological until proven otherwise.

Differential Diagnoses:

• Iron Deficiency Anaemia (likely due to chronic blood loss—GIT malignancy or other causes)
• Anaemia of Chronic Disease (but ferritin is typically normal or elevated in ACD)
• Thalassaemia trait (unlikely with no family history and the absence of hypochromia/target cells on smear; also, normal RBC count)
• Lead poisoning (unlikely in this age/context)
• Vitamin B12/Folate deficiency (usually macrocytic, but mixed anaemia can be microcytic)

In this context, the leading differential is gastrointestinal blood loss due to a possible colorectal malignancy, especially given his age and positive family history.

Red Flags:

• Male gender with IDA
• Family history of bowel cancer
• Subtle weight loss (as reported by his wife)
• No prior screening (no FOBT or colonoscopy)

Q2: How would you further investigate the cause of John’s iron deficiency anaemia?

Answer:

Step 1: Gastrointestinal Investigations

• Colonoscopy: To rule out colorectal cancer or polyps
• Gastroscopy: To evaluate for upper GI bleeding, including peptic ulcers, gastric cancer, or coeliac disease

Step 2: Additional Blood Tests

• Coeliac serology (tTG-IgA and total IgA) to rule out coeliac disease as a cause of malabsorption
• Faecal occult blood test (FOBT) (although colonoscopy is more definitive)

Step 3: Other Investigations

• Urinalysis (to rule out haematuria)
• Stool examination (if indicated) for parasites (unlikely in this case)

Referrals:

• Gastroenterologist for upper and lower endoscopy
• Dietitian if malabsorption is diagnosed

Q3: What is your initial management plan while awaiting investigations?

Answer:

Immediate Plan:

• Start oral iron replacement (e.g., ferrous sulfate 325 mg daily or alternate days, depending on tolerance)
• Advise on dietary iron intake (red meats, leafy greens, legumes) and vitamin C to enhance absorption
• Counsel on potential side effects (constipation, GI upset)

Monitoring:

• Recheck Hb and ferritin in 2-4 weeks to assess response
• If no improvement or intolerance, consider IV iron

Addressing Concerns:

• Acknowledge his anxiety about cancer; explain the rationale for investigations
• Reassure that finding the cause early improves outcomes
• Emphasise a structured approach—we need to identify the source to treat appropriately

Q4: How would you communicate the need for further investigations, including invasive procedures, to John?

Answer:

• Use empathetic, clear communication; validate his concerns
• Explain the findings: “Your iron levels are low, and this is not normal in men. It can signal internal bleeding, often from the gut.”
• Discuss that a colonoscopy and gastroscopy are the gold standards for finding a cause
• Frame positively: “These tests can help detect and prevent serious disease early.”
• Use shared decision-making: involve him in choices, offer support
• Provide written information, answer all questions
• Offer a support person for his appointments if he wishes

Q5: What preventive health strategies should you discuss with John at this visit?

Answer:

• Colorectal cancer screening: Discuss routine screening starting at age 50, or earlier if high risk (as in his case)
• Cardiovascular risk management: BP well controlled, but assess lipids, blood glucose, BMI, and physical activity
• Vaccination: Ensure he is up to date with influenza, pneumococcal, and COVID-19 vaccines, given his age
• Smoking: Reaffirm cessation (he is an ex-smoker)
• Alcohol: Discuss alcohol intake and ensure it is within NHMRC guidelines
• Diet and Exercise: Promote a Mediterranean diet, regular exercise (150 mins/week)
• Mental health: Offer support or referral if he expresses anxiety related to his health status

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SUMMARY OF A COMPETENT ANSWER

• Identifies iron deficiency anaemia in a male as a red flag requiring urgent investigation
• Prioritises colorectal cancer as a potential cause
• Requests gastroscopy and colonoscopy with appropriate referrals
• Initiates iron replacement therapy while awaiting investigations
• Communicates clearly and empathetically, addressing concerns about cancer
• Incorporates preventive health strategies (screening, vaccinations, lifestyle)

PITFALLS

• Failing to recognise the significance of IDA in men
• Delaying investigation for GI malignancy
• Neglecting to order both upper and lower GI evaluations
• Inadequate communication about invasive investigations
• Overlooking preventive health opportunities (screening, vaccinations)

REFERENCES

• RACGP Red Book (9th Edition)
• Cancer Council Australia on Colorectal Cancer Guidelines
• National Institutes of Health on Anaemia

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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 Communication is appropriate to the person and the sociocultural context
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives
1.4 Communicates effectively in routine and difficult situations

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets information about health needs, including the patient’s life stage and context

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses about health needs
3.2 Demonstrates diagnostic reasoning and clinical judgement

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements patient-centred management plans
4.2 Applies evidence-based medicine and shared decision-making

5. Preventive and Population Health

5.1 Provides health promotion and disease prevention strategies

6. Professionalism

6.1 Adheres to ethical, legal, and professional standards

7. General Practice Systems and Regulatory Requirements

7.1 Practices within the Australian health care system and understands referral pathways

9. Managing Uncertainty

9.1 Manages uncertainty and risk in decision-making

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and responds to potentially life-threatening conditions

Competency at Fellowship Level

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