EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What are your differential diagnoses for Mark’s presentation?

• Prompt: What is the most likely diagnosis and why?
• Prompt: What other conditions should be considered?

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

• Prompt: What features suggest a high risk of colorectal cancer?
• Prompt: What initial investigations would you consider?

Q3. How would you manage Mark’s case?

• Prompt: What investigations are required to rule out malignancy?
• Prompt: When would you refer him for a colonoscopy?

Q4. Mark is worried about having cancer. How would you counsel him?

• Prompt: How do you explain his symptoms and the need for urgent testing?
• Prompt: How can you provide reassurance while ensuring appropriate follow-up?

Q5. What preventive strategies can Mark implement to reduce his risk of colorectal cancer?

• Prompt: What lifestyle modifications should he consider?
• Prompt: What role does bowel cancer screening play in early detection?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What are your differential diagnoses for Mark’s presentation?

Mark’s most likely diagnosis is colorectal cancer (CRC) given his age, rectal bleeding, altered bowel habits, weight loss, and family history of CRC.

Key Differential Diagnoses:

1. Colorectal Cancer (Most Likely) – Persistent rectal bleeding, weight loss, fatigue, and altered bowel habits in a patient >50 years old.
2. Diverticular Disease (Diverticulosis or Diverticulitis) – Consider if LLQ pain, fever (if diverticulitis), or intermittent rectal bleeding.
3. Haemorrhoids or Anal Fissure – If bright red blood with straining, but would not explain weight loss and change in bowel habits.
4. Inflammatory Bowel Disease (IBD – Ulcerative Colitis or Crohn’s Disease) – If chronic diarrhoea, abdominal pain, and extraintestinal symptoms (e.g., joint pain, rashes).
5. Irritable Bowel Syndrome (IBS) – If recurrent abdominal pain, alternating constipation/diarrhoea, but no red flag symptoms (weight loss, anaemia, persistent bleeding).

Further investigations, including colonoscopy and blood tests, are required for diagnosis.

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

Red flags requiring urgent referral:

• Age >50 with new-onset rectal bleeding – Increased CRC risk.
• Unexplained weight loss (>5kg in 3 months) – Concerning for malignancy.
• Persistent change in bowel habits (>6 weeks) – Suggests colonic pathology.
• Iron deficiency anaemia – Common presentation of CRC.
• Palpable abdominal or rectal mass – May indicate advanced malignancy.
• Family history of colorectal cancer (<60 years old) – Higher genetic risk.

Recommended Investigations:

• FBE, Iron Studies, LFTs, CEA (tumour marker) – To assess for anaemia and liver metastases.
• Faecal Occult Blood Test (FOBT) – If CRC is suspected but asymptomatic.
• Colonoscopy (urgent referral) – Gold standard for CRC diagnosis.
• CT Abdomen/Pelvis (staging if cancer is diagnosed).

Mark has multiple red flags, so urgent colonoscopy referral is required.

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Q3: How would you manage Mark’s case?

1. Immediate Investigations:

• Colonoscopy (urgent referral within 4 weeks) – Confirm diagnosis and obtain biopsy.
• Blood Tests (FBE, Iron Studies, LFTs, CEA) – To assess for anaemia and metastases.

2. If Cancer is Confirmed:

• CT Chest/Abdomen/Pelvis (staging workup).
• Multidisciplinary team (MDT) referral (oncology, surgery, gastroenterology).

3. Supportive Care and Symptom Management:

• Address fatigue, anaemia, and nutrition – Consider iron supplementation if deficient.
• Bowel symptom control (fibre modification, stool softeners, pain relief if needed).

4. Patient Counselling and Psychological Support:

• Explain diagnosis and next steps – Ensure realistic but hopeful discussion.
• Provide emotional support and involve family if patient consents.

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Q4: Mark is worried about having cancer. How would you counsel him?

1. Acknowledge Concerns & Provide Reassurance
   • “It’s understandable to feel concerned, but we need to confirm the diagnosis first.”
   • “Most bowel changes are not due to cancer, but given your symptoms, further testing is essential.”
2. Explain the Need for Urgent Testing
   • “A colonoscopy is the best way to check for any abnormalities in your bowel.”
   • “If cancer is found, early detection significantly improves treatment outcomes.”
3. Discuss the Treatment Plan If Cancer is Diagnosed
   • “Bowel cancer is highly treatable, especially when caught early.”
   • “We will involve a team of specialists to ensure the best possible care.”
4. Encourage Open Communication & Support
   • “We will work through this together, and support services are available if needed.”

Providing a structured, compassionate discussion reduces patient anxiety and promotes adherence to investigations.

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Q5: What preventive strategies can Mark implement to reduce his risk of colorectal cancer?

1. Bowel Cancer Screening:
   • Encourage participation in the National Bowel Cancer Screening Program (FOBT every 2 years for ages 50–74).
   • Colonoscopy screening every 5 years if increased risk (e.g., family history).
2. Lifestyle Modifications:
   • Diet: Increase fibre intake (vegetables, whole grains) and reduce processed meats.
   • Exercise: Aim for 150 minutes of moderate exercise per week.
   • Weight Management: Maintain healthy BMI (<25).
3. Smoking & Alcohol Reduction:
   • Smoking cessation – Reduces CRC risk.
   • Limit alcohol (<2 standard drinks/day).
4. Regular GP Reviews:
   • Monitor bowel habits, weight changes, and anaemia.
   • Ensure ongoing engagement with cancer screening programs.

Mark can significantly reduce his future risk through screening and lifestyle changes.

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SUMMARY OF A COMPETENT ANSWER

• Comprehensive differential diagnosis, distinguishing CRC from benign causes like diverticular disease or haemorrhoids.
• Identification of red flags, ensuring urgent colonoscopy referral if needed.
• Structured, evidence-based management plan, including investigations, referral, and symptom management.
• Clear patient-centred counselling, addressing cancer concerns, prognosis, and next steps.
• Preventive strategies, including FOBT screening, diet changes, and smoking cessation.

PITFALLS

• Failing to assess for red flags, missing high-risk CRC features.
• Overlooking colonoscopy referral, delaying early cancer diagnosis.
• Dismissing symptoms as IBS or haemorrhoids, rather than considering malignancy.
• Not discussing screening and lifestyle factors, missing prevention opportunities.
• Lack of follow-up planning, leading to missed diagnoses or late-stage cancer presentation.

REFERENCES

• 
  RACGP Guidelines for Preventive Activities in General Practice (Red Book)
• Cancer Council Australia on Bowel Cancer
• Australian Government National Bowel Cancer Screening Program
• GP Exams – Malignant neoplasm colon/rectum

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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 structured gastrointestinal history, including red flag symptoms.
1.2 Provides clear explanations about the diagnosis, investigations, and management options.

2. Clinical Information Gathering and Interpretation

2.1 Conducts a systematic abdominal and rectal examination.
2.2 Differentiates between benign and malignant causes of altered bowel habits and rectal bleeding.

3. Diagnosis, Decision-Making and Reasoning

3.1 Diagnoses colorectal cancer based on clinical features and investigations.
3.2 Determines when urgent referral (urgent colonoscopy or specialist review) is required.

Competency at Fellowship Level

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