CCE-CBD-166

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis for John’s rectal bleeding and how would you prioritise them?

• Prompt: Discuss how you consider his age, symptoms, family history, and exam findings.
• Prompt: How would you assess the risk of malignancy?

Q2. What investigations would you order and why?

• Prompt: Discuss initial investigations in rural general practice.
• Prompt: Consider FBE, FOBT, colonoscopy referral, iron studies, and lifestyle assessments.

Q3. How would you manage John’s rectal bleeding in the short and long term?

• Prompt: Include symptomatic relief (haemorrhoid management) and cancer screening.
• Prompt: Discuss referral pathways, including access to colonoscopy.

Q4. How would you counsel John about his colorectal cancer risk and prevention strategies?

• Prompt: Include education on family history, dietary/lifestyle modifications, screening, and red flags.

Q5. How do you address rural health access issues in managing John’s case?

• Prompt: Include strategies to ensure timely referral, follow-up, and safety netting in a rural context.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis for John’s rectal bleeding and how would you prioritise them?

Answer:

In assessing John’s rectal bleeding, I would consider several differentials, prioritising based on risk, symptomatology, and patient history.

Primary Differentials:

• Colorectal cancer (CRC): Given his age (54 years), positive family history (father diagnosed at 72), and iron deficiency anaemia, colorectal cancer must be considered a top differential.
• Haemorrhoids: His past history and the presence of external haemorrhoids on examination make this a likely cause. Bleeding is typically bright red, painless, and seen on toilet paper or in the bowl.
• Anal fissure: Less likely in this case due to the absence of pain during defecation.
• Diverticular disease: Common in this age group but typically presents with copious, painless bleeding, not usually with iron deficiency anaemia.
• Angiodysplasia: Often painless, intermittent bleeding more common in older patients but can be associated with anaemia.
• Inflammatory bowel disease (IBD): Less likely due to the absence of diarrhoea, mucous, abdominal pain, or systemic symptoms.

Risk Factors Elevating CRC Suspicion:

• Family history of CRC
• No prior screening with FOBT or colonoscopy
• Iron deficiency anaemia (Hb 115 g/L, Ferritin 18 µg/L)

Conclusion: Colorectal cancer is the most urgent to rule out, followed by benign anorectal causes like haemorrhoids. A stepwise approach to investigations is warranted, including colonoscopy referral, to ensure timely diagnosis and management.

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Q2: What investigations would you order and why?

Answer:

Initial Investigations (within the scope of general practice):

• Full Blood Examination (FBE): Already done, revealing iron deficiency anaemia (Hb 115 g/L). Repeat post-intervention.
• Iron Studies: Confirm iron deficiency and monitor treatment response.
• Faecal Occult Blood Test (FOBT): Although not diagnostic in symptomatic patients, it can aid screening in asymptomatic populations. Here, priority is colonoscopy.
• Colonoscopy referral: Urgent referral to exclude colorectal cancer is warranted given his risk factors.
• Flexible sigmoidoscopy: Considered if colonoscopy is not immediately available but less comprehensive.

Further Tests Based on Risk and Access:

• Digital Rectal Examination (DRE): Already performed.
• Abdominal Ultrasound: Less useful unless other symptoms indicate alternative pathology.
• CT Colonography: If colonoscopy contraindicated or inaccessible.

Rationale: Given iron deficiency anaemia, rectal bleeding, and family history, an urgent colonoscopy is indicated as per the National Bowel Cancer Screening Program guidelines and RACGP Red Book.

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Q3: How would you manage John’s rectal bleeding in the short and long term?

Answer:

Short-term Management:

• Referral: Urgent colonoscopy referral to a colorectal surgeon or gastroenterologist. Use the Optimal Care Pathway for colorectal cancer to prioritise.
• Symptom Relief: For haemorrhoids, recommend:
  • Increase dietary fibre intake (25-30g/day)
  • Adequate hydration
  • Topical treatments (e.g., hydrocortisone suppositories short-term)
  • Avoid straining during bowel movements

Long-term Management:

• Ongoing Monitoring: Review colonoscopy results. If CRC diagnosed, implement multidisciplinary management.
• Iron Deficiency Anaemia: Start oral iron supplementation; monitor response.
• Lifestyle Changes:
  • Increase physical activity
  • Reduce processed foods
  • Promote colorectal cancer screening awareness among family members.
• Rural Health Considerations:
  • Utilise telehealth for specialist follow-ups.
  • Arrange shared care with local services.

Safety Netting:

• Advise on red flag symptoms: worsening bleeding, weight loss, change in bowel habits, fatigue.

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Q4: How would you counsel John about his colorectal cancer risk and prevention strategies?

Answer:

Counselling Content:

• Explain his increased risk due to:
  • Age >50
  • Family history of CRC
• Discuss screening: While national screening starts at 50 with FOBT, his history requires diagnostic colonoscopy.
• Lifestyle Modifications:
  • High-fibre diet (whole grains, fruits, vegetables)
  • Limit red and processed meats
  • Regular exercise (30 minutes most days)
  • Maintain healthy weight
  • Limit alcohol consumption
  • Avoid smoking
• Educate on symptoms:
  • Rectal bleeding
  • Persistent changes in bowel habits
  • Unexplained weight loss
• Encourage family members to be screened early.

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Q5: How do you address rural health access issues in managing John’s case?

Answer:

Strategies:

• Prioritised referral: Contact specialist services directly and highlight rural urgency.
• Telehealth: Use for pre- and post-colonoscopy consults.
• Local Shared Care: Collaborate with regional centres and nurse practitioners.
• Transport and accommodation: Link John to Patient Assisted Travel Schemes (PATS).
• Community Support Services: Refer to local services (social workers, patient navigators).
• Safety Netting: Provide direct contact for urgent concerns.
• Follow-up: Ensure timely recall systems for results and future screenings.

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SUMMARY OF A COMPETENT ANSWER

• Prioritises differential diagnoses, highlighting colorectal cancer risk.
• Orders appropriate investigations, focusing on urgent colonoscopy.
• Manages haemorrhoid symptoms while addressing cancer risk.
• Counsels on lifestyle modification and cancer prevention.
• Addresses rural health barriers with practical strategies.

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PITFALLS

• Failing to prioritise colorectal cancer despite red flag signs.
• Delaying colonoscopy referral by relying on FOBT or less urgent tests.
• Neglecting to address rural healthcare access issues.
• Inadequate safety netting and follow-up planning.
• Overlooking lifestyle advice and preventative care discussions.

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REFERENCES

• RACGP Red Book (9th ed)
• National Bowel Cancer Screening Program
• Optimal Care Pathway for People with Colorectal Cancer
• Murtagh’s General Practice (8th ed)

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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 findings accurately and comprehensively.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises hypotheses about health problems.
3.2 Rationally selects and interprets relevant investigations.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops and implements management plans collaboratively.
4.2 Provides appropriate emergency care.

5. Preventive and Population Health

5.1 Provides care that addresses prevention and early detection of disease.

6. Professionalism

6.1 Adopts a patient-centred approach to care.

7. General Practice Systems and Regulatory Requirements

7.1 Uses practice systems effectively and safely.

8. Procedural Skills

8.1 Performs procedural skills effectively.

9. Managing Uncertainty

9.1 Manages diagnostic uncertainty effectively.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and manages patients with potentially life-threatening conditions.

12. Rural Health Context (RH)

RH1.1 Demonstrates understanding of rural healthcare challenges.

Competency at Fellowship Level

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