CCE-CE-054

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a relevant and focused history from the patient.

The competent candidate should:

• Use open-ended questions initially, followed by targeted questions to explore red-flag symptoms.
• Elicit a detailed pain history, including onset, location, radiation, character, severity, aggravating and relieving factors.
• Clarify associated symptoms such as nausea, vomiting, anorexia, fever, and changes in bowel or urinary habits.
• Explore past medical history, medications, allergies, and family history to identify risk factors.
• Assess psychosocial context, including stress, academic pressures, and support systems.
• Use active listening and empathy to acknowledge the patient’s distress about his exam and concerns about his condition.
• Summarise key points and check the patient’s understanding.

Task 2: Explain your differential diagnosis clearly to the patient.

The competent candidate should:

• Use layperson-friendly language to explain possible causes of Jack’s symptoms.
• Discuss common and serious differentials, including:
  • Appendicitis (most likely) – classic migration of pain, nausea, fever, worsening with movement.
  • Renal colic – sudden onset, severe colicky pain, possible haematuria.
  • Gastrointestinal issues – gastroenteritis, constipation, or mesenteric adenitis.
  • Other considerations – testicular pathology, inflammatory bowel disease.
• Explain why appendicitis is the leading concern and discuss the need for further investigation.
• Reassure the patient while maintaining a clear safety-netting approach, ensuring he understands potential red flags requiring urgent care.

Task 3: Outline your proposed management plan, addressing any immediate concerns the patient has.

The competent candidate should:

• Explain the need for urgent assessment and likely referral to hospital for imaging and possible surgical review.
• Discuss the role of investigations (e.g., full blood count, inflammatory markers, abdominal ultrasound, or CT if required).
• Provide pain management with appropriate analgesia while avoiding NSAIDs if appendicitis is suspected.
• Address psychosocial concerns:
  • Reassure the patient about his academic concerns and discuss options such as medical certification for deferment.
  • Offer emotional support and encourage involving family or friends if needed.
• Implement a clear safety-netting strategy, advising the patient to seek immediate care if symptoms worsen or new symptoms appear.

SUMMARY OF A COMPETENT ANSWER

• Thorough history-taking, covering pain characteristics, associated symptoms, red flags, and psychosocial impact.
• Clear and structured differential diagnosis, prioritising appendicitis but considering other possibilities.
• Effective communication, using simple explanations, active listening, and reassurance.
• Patient-centred management plan, addressing both medical and psychosocial aspects.
• Safety-netting, ensuring the patient understands red flag symptoms and next steps.

PITFALLS

• Failure to explore key symptoms, such as fever, nausea, vomiting, or urinary issues.
• Not considering serious differentials, especially appendicitis, which requires urgent management.
• Overuse of medical jargon, leading to poor patient understanding and increased anxiety.
• Lack of patient reassurance or emotional support, particularly regarding exam stress and potential hospitalisation.
• Inadequate safety-netting, failing to advise on worsening symptoms or when to seek urgent care.

REFERENCES

• Murtagh’s General Practice – Approach to Abdominal Pain.
• GP Exams – Abdominal pain

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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 relevant history from the patient to support clinical decision-making.

3. Diagnosis, Decision-Making and Reasoning

3.1 Formulates a differential diagnosis from available information.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops safe management plans based on patient information and clinical findings.
4.5 Demonstrates appropriate management of urgent conditions.

5. Preventive and Population Health

5.1 Identifies relevant preventive measures and interventions.

6. Professionalism

6.1 Demonstrates respectful interaction and maintains patient confidentiality.

8. Procedural Skills

8.1 Appropriately selects and interprets investigations.

9. Managing Uncertainty

9.1 Recognises and manages clinical uncertainty appropriately.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies patients who require urgent or emergency care.

Competency at Fellowship Level

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