CCE-CBD-216 - GP Exams

CASE INFORMATION

Case ID: MYE-001
Case Name: Peter Robinson
Age: 65 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: B74 (Multiple Myeloma)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes a supportive and empathetic consultation environment 1.2 Uses clear, patient-centred explanations about the condition and necessary investigations 1.3 Engages the patient in shared decision-making regarding next steps
2. Clinical Information Gathering and Interpretation	2.1 Takes a structured history covering systemic symptoms, risk factors, and red flags 2.2 Conducts an appropriate physical examination, including skeletal and haematological assessment 2.3 Recognises abnormal findings requiring urgent investigation
3. Diagnosis, Decision-Making and Reasoning	3.1 Identifies myeloma as a potential cause of unexplained fatigue, bone pain, and recurrent infections 3.2 Uses clinical reasoning to differentiate myeloma from other causes of anaemia, hypercalcaemia, and renal impairment 3.3 Prioritises urgent referral for haematology review and definitive diagnosis
4. Clinical Management and Therapeutic Reasoning	4.1 Initiates urgent diagnostic workup and specialist referral 4.2 Provides supportive care and symptomatic management 4.3 Prepares the patient for potential hospital admission and further investigations
5. Preventive and Population Health	5.1 Provides guidance on bone health, infection prevention, and renal protection 5.2 Encourages ongoing health monitoring and lifestyle modifications
6. Professionalism	6.1 Demonstrates sensitivity when discussing a potential cancer diagnosis
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate and timely referral to haematology and oncology 7.2 Documents discussions, referrals, and safety-netting advice clearly
9. Managing Uncertainty	9.1 Recognises when a non-specific presentation requires urgent escalation
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies red flags suggestive of haematological malignancy and acts appropriately

CASE FEATURES

Older male presenting with fatigue, back pain, and recurrent infections.
Findings suggestive of multiple myeloma requiring urgent assessment.
Discussion about the need for specialist referral and bone marrow biopsy.
Counselling on next steps, prognosis, and support options.

CANDIDATE INFORMATION

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: Peter Robinson
Age: 65 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Paracetamol PRN (for back pain)

Past History

Hypertension, well controlled.
No history of fractures, osteoporosis, or malignancy.

Social History

Works part-time as a retired accountant, enjoys gardening.
Non-smoker, occasional alcohol use.
Lives with his wife, independent in daily activities.

Family History

No known history of haematological malignancy.
Father had prostate cancer.

Vaccination and Preventative Activities

Up to date with routine vaccinations.
No recent cancer screenings.

SCENARIO

Peter, a 65-year-old retired accountant, presents with progressive fatigue, generalised back pain, and recurrent infections over the past 4 months. He describes worsening lower back pain that is not relieved by rest or simple analgesia. He has had three respiratory infections in the past six months, requiring antibiotics.

He denies weight loss or fevers, but has occasional dizziness and increased thirst.

Your role is to assess Peter’s symptoms, recognise red flags, arrange appropriate investigations, and discuss the next steps.

EXAMINATION FINDINGS

General Appearance: Pale, appears mildly unwell but alert
Vital Signs: BP 135/80 mmHg, HR 92 bpm, RR 16 bpm, SpO₂ 98% on room air
Skin: No bruising or petechiae
Skeletal System: Spinal tenderness over the lower thoracic and lumbar spine
Lymphatic System: No significant lymphadenopathy
Cardiovascular & Respiratory Examination: Normal heart and lung sounds
Neurological Examination: No focal neurological deficits, normal power and reflexes

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you assess Peter’s symptoms and identify potential red flags?

Prompt: What key aspects of history would you explore?
Prompt: What examination findings would raise suspicion of multiple myeloma?

Q2. What investigations would you order, and why?

Prompt: What initial blood tests are necessary for evaluating suspected myeloma?
Prompt: What imaging or specialist investigations might be required?

Q3. How would you manage Peter’s condition in a general practice setting?

Prompt: What urgent steps should be taken in response to abnormal findings?
Prompt: When is immediate hospital referral necessary?

Q4. How would you counsel Peter about the possibility of multiple myeloma and next steps?

Prompt: How do you balance honesty with reassurance?
Prompt: How do you explain the need for urgent haematology referral?

Q5. What long-term considerations should be discussed if multiple myeloma is confirmed?

Prompt: What supportive care options should be considered?
Prompt: What role does the GP play in ongoing care and survivorship?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you assess Peter’s symptoms and identify potential red flags?

1. Comprehensive History-Taking

Onset and duration: Progressive fatigue and back pain for 4 months.
Pain characteristics: Persistent, worse at night, not relieved by rest.
Other B symptoms: Unintentional weight loss, fevers, night sweats.
Fracture history: Any unexplained fractures or height loss (suggests vertebral compression).
Infection history: Recurrent respiratory infections, delayed healing.
Neurological symptoms: Weakness, paraesthesia, bowel/bladder dysfunction (spinal cord compression).
Hypercalcaemia symptoms: Thirst, polyuria, constipation, confusion.

2. Physical Examination

General appearance: Pallor, signs of anaemia.
Skeletal system: Spinal tenderness (vertebral involvement).
Neurological exam: Reflexes, sensation, power (spinal cord compression).
Renal signs: Oedema, hypertension (renal impairment).
Lymph nodes & hepatosplenomegaly: Lymphoproliferative disorders.

Conclusion: Peter’s persistent bone pain, recurrent infections, and systemic symptoms suggest multiple myeloma, requiring urgent evaluation.

Q2: What investigations would you order, and why?

1. Initial Blood Tests

FBC: Normocytic anaemia.
ESR/CRP: Markedly elevated.
U&E, creatinine: Renal impairment.
Calcium and albumin: Hypercalcaemia common in myeloma.
LFTs: Check for liver involvement.

2. Specific Myeloma Tests

Serum protein electrophoresis & immunofixation: Detects monoclonal (M) protein.
Serum free light chain assay: Identifies light chain myeloma.
Bence-Jones protein (urine electrophoresis): Light chain excretion.

3. Imaging

Skeletal survey (X-rays): Lytic lesions, vertebral fractures.
MRI spine: Detects cord compression.
CT or PET-CT: Staging.

4. Confirmatory Test

Bone marrow biopsy: >10% plasma cells confirm multiple myeloma.

Conclusion: A stepwise approach with blood tests, imaging, and biopsy confirms myeloma.

Q3: How would you manage Peter’s condition in a general practice setting?

1. Urgent Specialist Referral

Haematology for definitive diagnosis and treatment initiation.

2. Immediate Supportive Care

Hydration for hypercalcaemia.
Analgesia: Paracetamol ± opioids, avoid NSAIDs (renal toxicity).
Bone protection: Start bisphosphonates.

3. When to Consider Emergency Referral

Spinal cord compression: New weakness, incontinence.
Severe hypercalcaemia: Confusion, arrhythmia.
Renal failure: Rapidly rising creatinine, oliguria.

Conclusion: Peter needs urgent haematology referral, symptom management, and hospitalisation if complications arise.

Q4: How would you counsel Peter about the possibility of multiple myeloma and next steps?

1. Acknowledge Concerns and Provide Clarity

Be honest but reassuring: “Your symptoms suggest an issue with your bone marrow.”
Explain the need for further tests: “We need a bone marrow biopsy and imaging to confirm what’s happening.”

2. Explain the Referral Process

Urgent haematology review.
Hospital admission may be needed if complications arise.

3. Address Emotional Impact

Encourage support from family.
Reassure that myeloma is treatable with new therapies.

Conclusion: A calm, structured approach reassures Peter while preparing him for specialist review.

Q5: What long-term considerations should be discussed if multiple myeloma is confirmed?

1. Treatment Options

Chemotherapy (e.g., bortezomib, lenalidomide).
Stem cell transplant (if eligible).
Bisphosphonates for bone protection.

2. Managing Complications

Renal protection: Hydration, avoid nephrotoxic drugs.
Infection prevention: Vaccination (influenza, pneumococcus), prophylactic antibiotics if needed.
Fracture prevention: Avoid high-impact activities.

3. Psychological and Social Support

Counselling and peer support groups.
Workplace adjustments, financial planning.

4. GP’s Role in Ongoing Care

Managing treatment side effects.
Monitoring for recurrence.
Optimising general health (exercise, nutrition, mental health support).

Conclusion: A multidisciplinary approach ensures optimal long-term care.

SUMMARY OF A COMPETENT ANSWER

Recognises red flags for multiple myeloma and initiates urgent investigations.
Orders targeted blood tests and imaging, with priority on bone marrow biopsy.
Refers urgently to haematology while managing symptoms and patient anxiety.
Provides clear, empathetic communication about diagnosis and next steps.
Discusses long-term treatment, complications, and GP’s role in survivorship care.

PITFALLS

Delaying referral when myeloma is suspected.
Misinterpreting back pain as mechanical without further assessment.
Not addressing patient distress and uncertainty.
Prescribing NSAIDs without considering renal function.
Overlooking infection prevention in an immunocompromised patient.

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

Competency at Fellowship Level

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