CCE-CE-054.1 - GP Exams

CASE INFORMATION

Case ID: CCE-GI-014
Case Name: David Reynolds
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: D01 – Abdominal pain

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport and engages the patient 1.2 Explores the patient’s concerns, ideas, and expectations 1.3 Provides clear and structured explanations about diagnosis, prognosis, and management
2. Clinical Information Gathering and Interpretation	2.1 Takes a structured history, including onset, duration, location, radiation, severity, and aggravating/relieving factors 2.2 Identifies red flags and risk factors for serious conditions (e.g., perforation, obstruction, malignancy)
3. Diagnosis, Decision-Making and Reasoning	3.1 Develops an appropriate differential diagnosis based on clinical findings 3.2 Identifies when further investigations or specialist referral is required
4. Clinical Management and Therapeutic Reasoning	4.1 Provides evidence-based initial management 4.2 Discusses lifestyle modifications, symptom control, and follow-up planning
5. Preventive and Population Health	5.1 Identifies risk factors for gastrointestinal diseases and provides preventive advice 5.2 Encourages appropriate cancer screening where indicated
6. Professionalism	6.1 Demonstrates empathy and a patient-centred approach to managing abdominal pain
7. General Practice Systems and Regulatory Requirements	7.1 Identifies when referral for specialist assessment or emergency care is required
8. Procedural Skills	8.1 Orders and interprets relevant investigations (e.g., FBC, LFTs, abdominal ultrasound)
9. Managing Uncertainty	9.1 Recognises when symptoms may indicate a functional disorder versus an organic condition
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and appropriately manages conditions such as peptic ulcer disease, gallbladder pathology, or bowel obstruction

CASE FEATURES

Lifestyle factors (diet, alcohol, stress) influencing symptoms
Gradual-onset epigastric pain with bloating and nausea
Concerns about possible serious causes (e.g., ulcer, reflux, gallstones)
Need for appropriate initial investigation and management

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face to face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

Take an appropriate history, including onset, location, severity, associated symptoms, and lifestyle factors.
Develop a differential diagnosis and identify any red flags requiring urgent assessment.
Provide a diagnosis and discuss an initial management plan.
Educate the patient on lifestyle modifications, symptom monitoring, and follow-up care.

SCENARIO

David Reynolds, a 45-year-old sales manager, presents with gradual-onset epigastric pain over the past two months. He describes it as a burning sensation that worsens after meals and sometimes radiates to his back. He has also noticed bloating, occasional nausea, and mild discomfort at night.

He has been taking antacids with some relief but is worried because the pain is becoming more frequent. He drinks 3–4 beers most nights after work and often eats takeaway food due to work stress.

His main concerns are:

“Could this be an ulcer or something serious?”
“Do I need tests to find out what’s wrong?”
“What can I do to stop this pain from coming back?”

PATIENT RECORD SUMMARY

Patient Details

Name: David Reynolds
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

None known

Medications

Over-the-counter antacids as needed

Past History

Mild reflux symptoms in the past, never formally investigated
No history of peptic ulcer disease, gallstones, or gastrointestinal bleeding

Social History

Works long hours as a sales manager, high-stress job
Drinks 3–4 beers per night, often with takeaway food
Smokes 5–10 cigarettes per day
No regular exercise

Family History

Father had stomach ulcers and was treated for H. pylori
No known history of gastrointestinal cancers

Smoking

Smokes 5–10 cigarettes per day

Alcohol

Drinks 3–4 beers per night

Vaccination and Preventative Activities

Has never had a screening colonoscopy
No recent health check-ups

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, I’ve been getting this burning pain in my stomach for a couple of months now, and it’s getting worse. I think I might have an ulcer. Do I need tests?”

General Information

David Reynolds is a 45-year-old sales manager presenting with gradual-onset epigastric pain over the past two months.

Pain description: A burning sensation in the upper abdomen, mainly after eating and at night.
Location: Centre of the abdomen, sometimes radiating to the back.
Other symptoms: Bloating and occasional nausea, but no vomiting.
Pain relief: Improves temporarily with antacids, but returns.
Pain triggers: Worse after spicy, greasy, or large meals.

His main concerns are:

“Could this be an ulcer or something serious?”
“Do I need tests to find out what’s wrong?”
“What can I do to stop this pain from coming back?”

Specific Information (To be revealed only when asked)

Pain and Gastrointestinal Symptoms

Pain started two months ago, gradually worsening.
Burning pain in the upper abdomen, no sharp or stabbing pain.
Worse after eating heavy meals, better with small snacks.
Wakes up at night with discomfort occasionally.
No weight loss or changes in appetite.
No vomiting, blood in stools, or black stools.

Lifestyle Factors

Diet: Eats a lot of fast food and spicy meals due to a busy work schedule.
Alcohol: Drinks 3–4 beers per night, often with takeaway food.
Smoking: Smokes 5–10 cigarettes per day.
Exercise: No regular exercise.
Stress: High stress levels due to work deadlines, often skips meals or eats late.

Medication and Family History

Self-medicating with antacids, which help temporarily.
No history of regular NSAID or aspirin use.
Father had stomach ulcers and was treated for H. pylori.
No known family history of gastrointestinal cancers.

Impact on Daily Life

Struggling with work performance—sometimes skips meals to avoid discomfort.
Avoids social gatherings involving food and alcohol.
Not sleeping well due to occasional nighttime discomfort.

Emotional Cues

David is concerned but not overly anxious.

Worried about long-term effects: “Could this turn into cancer if I ignore it?”
Frustrated with symptoms: “I just want to enjoy a meal without feeling sick.”
Seeking reassurance: “Do I need serious tests, or can this be managed with medication?”

If the candidate provides a clear explanation and structured plan, David will be reassured and open to making lifestyle changes.

If the candidate is vague or dismissive, David may become more anxious and push for unnecessary tests.

Questions for the Candidate

David will ask some of the following questions, especially if the doctor does not address them directly:

“What could be causing this pain?”
“Do I need an endoscopy?”
“Is this something serious like stomach cancer?”
“Should I change my diet?”
“How can I stop this from coming back?”
“Do I need to stop drinking alcohol completely?”
“Could this be caused by stress?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

David will feel reassured and motivated to make lifestyle changes.
He will accept treatment recommendations and follow up as advised.
He may say, “That makes sense. I’ll cut down on alcohol and try the medication.”

If the candidate is vague or dismissive:

David may insist on unnecessary tests due to concern about cancer.
He may say, “I need something stronger. Can you refer me for a scan?”

If the candidate does not provide a management plan:

David may feel frustrated and confused, saying “So what should I actually do?”
He may seek a second opinion if he feels his concerns are not taken seriously.

Key Takeaways for the Candidate

Take a structured abdominal pain history, identifying red flags.
Develop an appropriate differential diagnosis, including reflux, ulcers, gallbladder disease, and functional dyspepsia.
Explain the likely diagnosis and management plan clearly.
Provide lifestyle advice on diet, alcohol, and smoking cessation.
Ensure follow-up for symptom monitoring and further tests if needed.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including onset, location, severity, associated symptoms, and lifestyle factors.

The competent candidate should:

Elicit a detailed history of abdominal pain, including onset, duration, severity, radiation, and aggravating/relieving factors.
Assess associated symptoms, such as nausea, vomiting, bloating, weight loss, dysphagia, change in bowel habits, melaena, or haematemesis.
Explore lifestyle factors, including diet, alcohol consumption, smoking, stress, and medication use (e.g., NSAIDs, aspirin).
Identify red flags, such as unintentional weight loss, persistent vomiting, gastrointestinal bleeding, or anaemia.
Assess relevant medical and family history, particularly peptic ulcer disease, gastroesophageal reflux, gallstones, and malignancy.

Task 2: Develop a differential diagnosis and identify any red flags requiring urgent assessment.

The competent candidate should:

Consider common causes based on history:
- Peptic ulcer disease (PUD) – burning epigastric pain, worsened by food or alcohol, relieved with antacids.
- Gastroesophageal reflux disease (GORD) – heartburn, regurgitation, worse when lying down.
- Functional dyspepsia – bloating, early satiety, post-meal discomfort without structural abnormality.
- Gallbladder disease – episodic postprandial pain, radiation to the back, nausea.
- Gastritis – associated with alcohol, NSAID use, or H. pylori infection.
Recognise red flags requiring urgent referral or further investigations:
- Unexplained weight loss or persistent vomiting.
- Gastrointestinal bleeding (melaena, haematemesis).
- Severe, sudden-onset pain suggesting perforation or obstruction.
- Progressive dysphagia or early satiety (suggesting malignancy).

Task 3: Provide a diagnosis and discuss an initial management plan.

The competent candidate should:

Explain the likely diagnosis, considering PUD or functional dyspepsia based on symptoms.
Discuss investigations, including:
- H. pylori testing (stool antigen or urea breath test).
- Blood tests (FBC, iron studies, liver function tests if gallbladder pathology suspected).
- Referral for endoscopy if red flags are present.
Provide an initial treatment plan:
- Lifestyle modifications: reducing alcohol, smoking, spicy/fatty foods, late-night eating.
- Trial of proton pump inhibitors (PPIs) or H2-receptor antagonists for symptomatic relief.
- H. pylori eradication therapy if tested positive.
- Consider referral for further imaging if atypical symptoms persist.

Task 4: Educate the patient on lifestyle modifications, symptom monitoring, and follow-up care.

The competent candidate should:

Provide dietary advice, including smaller, frequent meals and avoiding trigger foods.
Discuss the impact of smoking and alcohol, recommending reduction or cessation.
Advise on medication adherence, explaining the importance of completing treatment.
Ensure follow-up in 4–6 weeks to assess symptom improvement and review test results.
Discuss when to return for urgent care, including worsening pain, gastrointestinal bleeding, or significant weight loss.

SUMMARY OF A COMPETENT ANSWER

Takes a thorough abdominal pain history, identifying onset, triggers, and associated symptoms.
Considers an appropriate differential diagnosis, distinguishing benign from serious causes.
Identifies red flags requiring urgent referral, such as weight loss, GI bleeding, and dysphagia.
Provides an evidence-based management plan, including PPIs, H. pylori testing, and lifestyle changes.
Educates the patient on symptom control, monitoring, and follow-up care.

PITFALLS

Failing to explore red flags, missing signs of malignancy or serious GI conditions.
Prescribing PPIs without considering H. pylori testing, delaying appropriate treatment.
Overlooking the impact of alcohol, smoking, and diet, reducing the effectiveness of management.
Not explaining follow-up recommendations, risking poor compliance or delayed diagnosis.
Providing vague dietary advice, leading to unclear expectations and limited lifestyle changes.

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

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.
1.3 Provides clear and structured explanations about diagnosis, prognosis, and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured history, including onset, duration, location, radiation, severity, and aggravating/relieving factors.
2.2 Identifies red flags and risk factors for serious conditions (e.g., perforation, obstruction, malignancy).

3. Diagnosis, Decision-Making and Reasoning

3.1 Develops an appropriate differential diagnosis based on clinical findings.
3.2 Identifies when further investigations or specialist referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides evidence-based initial management.
4.2 Discusses lifestyle modifications, symptom control, and follow-up planning.

5. Preventive and Population Health

5.1 Identifies risk factors for gastrointestinal diseases and provides preventive advice.
5.2 Encourages appropriate cancer screening where indicated.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach to managing abdominal pain.

7. General Practice Systems and Regulatory Requirements

7.1 Identifies when referral for specialist assessment or emergency care is required.

8. Procedural Skills

8.1 Orders and interprets relevant investigations (e.g., FBC, LFTs, abdominal ultrasound).

9. Managing Uncertainty

9.1 Recognises when symptoms may indicate a functional disorder versus an organic condition.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and appropriately manages conditions such as peptic ulcer disease, gallbladder pathology, or bowel obstruction.

Competency at Fellowship Level

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