CCE-CBD-155

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis for Ethan’s symptoms?

• Prompt: Explore inflammatory and non-inflammatory causes
• Prompt: How does his presentation guide your thinking?
• Prompt: What would make you concerned about other causes (e.g., malignancy)?

Q2. What is your diagnostic approach to confirm the diagnosis of inflammatory bowel disease in this patient?

• Prompt: Investigations already done, next steps
• Prompt: What would you do in rural general practice?
• Prompt: How would you engage specialists?

Q3. What is your initial management plan for Ethan?

• Prompt: Symptomatic relief and induction of remission
• Prompt: Non-pharmacological advice
• Prompt: Address concerns about medications

Q4. What preventive health and long-term management considerations are relevant for Ethan?

• Prompt: Vaccinations, cancer screening, bone health
• Prompt: Psychosocial impact and support
• Prompt: Monitoring for complications and medications

Q5. How would you address Ethan’s concerns about living with chronic illness and its impact on his lifestyle?

• Prompt: Communication strategies
• Prompt: Self-management support and resources
• Prompt: Addressing rural health barriers

THE COMPETENT CANDIDATE

The competent candidate should be able to:

---

Q1: What is your differential diagnosis for Ethan’s symptoms?

Answer:

Ethan Williams presents with chronic diarrhoea, rectal bleeding, weight loss, and systemic symptoms like fatigue. In a rural general practice setting, it’s critical to develop a broad differential diagnosis while focusing on likely causes.

Primary Differential Diagnoses:

• Ulcerative Colitis (UC): Most likely diagnosis, given the chronicity, presence of bloody diarrhoea, rectal urgency, and elevated inflammatory markers (CRP, ESR). Faecal calprotectin is also markedly elevated, supporting an inflammatory bowel process.
• Crohn’s Disease: Less likely but needs consideration, particularly if there were signs of perianal disease or small bowel involvement (e.g., skip lesions, fistulas).
• Infectious Colitis: Less likely as stool MCS is negative and no travel history or recent antibiotic use; however, pathogens such as Clostridioides difficile should be excluded.
• Irritable Bowel Syndrome (IBS): Unlikely due to the presence of blood in stool, weight loss, and elevated inflammatory markers.
• Colorectal malignancy: Although Ethan is young, family history, rectal bleeding, and weight loss raise concern. Important to consider, though less common at his age.
• Ischaemic colitis: Unlikely in a young, healthy male without vascular risk factors, but differential includes.
• Coeliac Disease: Can cause diarrhoea and weight loss but doesn’t typically result in rectal bleeding or elevated CRP/ESR.

Summary Reasoning: Ethan’s age, symptoms, and rural context prompt prioritising inflammatory causes such as UC or Crohn’s disease. His rectal bleeding with diarrhoea and elevated calprotectin strongly point toward UC. However, it’s essential to remain alert to the risk of colorectal malignancy despite his age.

---

Q2: What is your diagnostic approach to confirm the diagnosis of inflammatory bowel disease in this patient?

Answer:

Initial Investigations (already completed):

• Bloods: Show microcytic anaemia, elevated inflammatory markers, and hypoalbuminaemia.
• Stool MCS: No infectious organisms detected.
• Faecal calprotectin: Elevated, consistent with mucosal inflammation.

Further Diagnostic Steps:

1. Colonoscopy with Biopsy:
   • Gold standard to confirm UC.
   • Aims to assess the extent and severity of disease (continuous mucosal inflammation starting from the rectum).
   • Helps exclude other causes (e.g., malignancy).
2. Histopathology:
   • Confirms chronic mucosal inflammation typical of UC.
3. Imaging:
   • In settings where colonoscopy access is delayed, CT abdomen/pelvis or MR enterography may assess disease burden.
4. Blood Tests:
   • Additional tests to assess nutritional deficiencies (iron, folate, B12).
   • LFTs and renal function prior to starting any systemic therapy.
5. Specialist Referral:
   • Gastroenterologist involvement is critical for definitive diagnosis and treatment.
   • In a rural setting, telehealth services may be necessary.

Rural Practice Considerations:

• Expedite referral to regional centres.
• Consider early coordination with specialist teams via telehealth.
• Provide patient education on the diagnostic process to alleviate anxiety.

---

Q3: What is your initial management plan for Ethan?

Answer:

Goals:

• Induce remission.
• Manage symptoms and improve quality of life.
• Address nutritional deficiencies.

Pharmacological Management:

1. Induction Therapy:
   • Oral 5-aminosalicylic acid (5-ASA), e.g., Mesalazine.
   • Consider rectal 5-ASA (suppositories/enemas) for proctitis or left-sided colitis.
2. Corticosteroids:
   • If 5-ASA ineffective, consider oral prednisolone for moderate-to-severe disease.
3. Iron Supplementation:
   • For microcytic anaemia, oral or IV iron depending on severity and response.

Non-Pharmacological Management:

• Dietary advice:
  • Low-residue diet during flares.
  • Nutritional support for weight loss.
• Hydration and Electrolyte Replacement.

Referral and Follow-up:

• Gastroenterology referral for ongoing management and consideration of immunomodulators or biologics if necessary.
• Regular monitoring of symptoms and blood work.

Patient Concerns:

• Discuss medication side effects, long-term prognosis, and fertility considerations.
• Reassure about maintaining physical activity within tolerance.

---

Q4: What preventive health and long-term management considerations are relevant for Ethan?

Answer:

Preventive Health:

• Vaccination status review: Ensure protection against pneumococcus, influenza, hepatitis B (especially before immunosuppression).
• Bone health: Monitor for osteoporosis risk, especially with corticosteroid use (calcium, vitamin D, DEXA scan).
• Colorectal Cancer Screening: Colonoscopy surveillance from 8-10 years after diagnosis.
• Smoking cessation: Reinforce non-smoking (protective in UC).

Psychosocial Considerations:

• Assess and manage mental health: Increased anxiety/depression risk.
• Discuss support groups, e.g., Crohn’s & Colitis Australia.

Monitoring:

• Regular follow-up for disease activity, drug side effects, nutrition, and quality of life.
• Monitor for complications like primary sclerosing cholangitis or extraintestinal manifestations.

---

Q5: How would you address Ethan’s concerns about living with chronic illness and its impact on his lifestyle?

Answer:

Communication Strategies:

• Use empathetic, patient-centred communication.
• Validate his concerns about chronic illness and medication.

Education and Empowerment:

• Provide information about UC, treatment options, and disease control.
• Clarify that remission is achievable and discuss treatment goals.

Lifestyle and Self-Management:

• Encourage physical activity tailored to energy levels.
• Discuss dietary changes that are manageable and sustainable.
• Provide a flare action plan.

Rural Health Barriers:

• Utilise telehealth for gastroenterology follow-ups.
• Discuss logistics for accessing regional services.
• Explore local community resources and support networks.

---

SUMMARY OF A COMPETENT ANSWER

• Clear differential diagnosis with focus on UC, but considers Crohn’s, malignancy, and infections.
• Diagnostic plan includes colonoscopy with biopsies, histopathology, and appropriate rural strategies.
• Management plan incorporates pharmacological and non-pharmacological treatments tailored to UC severity.
• Preventive health includes immunisation, bone health, cancer screening, and psychosocial support.
• Effective communication addressing chronic disease impact, promoting self-management, and overcoming rural healthcare barriers.

---

PITFALLS

• Failure to consider colorectal malignancy despite young age.
• Omitting referral for colonoscopy, relying solely on blood tests.
• Neglecting preventive health like vaccination before immunosuppression.
• Inadequate addressing of psychosocial concerns, risking poor adherence.
• Overlooking rural healthcare limitations, leading to delays in specialist input.

---

REFERENCES

• RACGP Guidelines for Preventive Activities in General Practice (“Red Book”)
• Therapeutic Guidelines on Gastroenterology
• Crohn’s & Colitis Australia
• Australian IBD Standards (Gastroenterological Society of Australia)
• eTG complete (Therapeutic Guidelines)

---

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 and issues.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses and diagnoses.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans.
4.2 Prescribes and monitors therapies appropriately.

5. Preventive and Population Health

5.1 Provides care that includes health promotion and illness prevention activities.

6. Professionalism

6.1 Adopts a patient-centred approach to care.

7. General Practice Systems and Regulatory Requirements

7.1 Practices in accordance with relevant policies and guidelines.

8. Procedural Skills

8.1 Performs procedural skills safely.

9. Managing Uncertainty

9.1 Manages uncertainty in diagnosis and management.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages the patient with potentially serious illness.

12. Rural Health Context (RH)

RH1.1 Provides comprehensive, evidence-based care appropriate to rural settings.

---

Competency at Fellowship Level

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