CASE INFORMATION

Case ID: CCE-HAEM-022
Case Name: Michael Thompson
Age: 65
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: B80 – Anaemia

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 of symptoms, risk factors, and relevant medical history 2.2 Identifies red flags for serious underlying causes of anaemia
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between different types of anaemia (iron deficiency, chronic disease, B12/folate deficiency, haemolysis) 3.2 Identifies when further investigations or specialist referral is required
4. Clinical Management and Therapeutic Reasoning	4.1 Provides an evidence-based management plan, including iron supplementation, dietary advice, and further investigation 4.2 Monitors response to treatment and adjusts management as needed
5. Preventive and Population Health	5.1 Identifies risk factors for anaemia and advises on prevention strategies 5.2 Encourages lifestyle modifications to optimise long-term health
6. Professionalism	6.1 Demonstrates empathy and a patient-centred approach
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate follow-up, documentation, and possible referral for endoscopic evaluation
8. Procedural Skills	8.1 Orders and interprets relevant investigations (FBE, iron studies, B12/folate, renal function, haemolysis screen)
9. Managing Uncertainty	9.1 Recognises when symptoms require urgent intervention versus ongoing monitoring
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and appropriately manages anaemia due to significant underlying pathology (e.g., gastrointestinal bleeding, malignancy)

CASE FEATURES

Need for investigation of iron deficiency anaemia and possible gastrointestinal blood loss
Progressive fatigue, dizziness, and shortness of breath on exertion
Concern about possible underlying cause
History of NSAID use for osteoarthritis

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 of symptoms, dietary factors, medication use, and potential causes of blood loss.
Differentiate between common causes of anaemia and identify any red flags for serious pathology.
Provide a diagnosis and discuss an initial management plan, including investigations.
Educate the patient on anaemia, possible causes, treatment options, and the need for follow-up.

SCENARIO

Michael Thompson, a 65-year-old retired carpenter, presents with increasing fatigue, dizziness, and breathlessness over the past two months. He struggles to complete his usual walks without stopping and feels light-headed when standing up quickly.

He has been taking ibuprofen most days for knee osteoarthritis and notices that his stools have been darker than usual. He has not had any overt bleeding but has lost some weight unintentionally (around 4kg in the last three months).

His main concerns are:

“Why am I feeling so tired all the time?”
“Could this be something serious?”
“Do I need iron tablets, or is there another cause?”
“What tests do I need?”

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Thompson
Age: 65
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Ibuprofen 400mg twice daily (for osteoarthritis)
Atorvastatin 40mg daily (for hyperlipidaemia)
Paracetamol as needed

Past History

Hypertension (well controlled)
Hyperlipidaemia
Knee osteoarthritis

Social History

Lives with his wife, independent in daily activities
Former smoker, quit 10 years ago after 20 pack-years
Drinks 1–2 beers most nights
Diet low in red meat, mostly poultry and vegetables

Family History

Father had bowel cancer at age 72
Mother had iron deficiency anaemia but no known malignancy

Vaccination and Preventative Activities

Last colonoscopy 8 years ago (normal)
Up to date with vaccinations

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.

ROLE-PLAYER INSTRUCTIONS

SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, I’ve been feeling so tired lately, and I get breathless really easily. I want to know what’s going on.”

General Information

Michael Thompson is a 65-year-old retired carpenter presenting with progressive fatigue, dizziness, and shortness of breath on exertion for two months.

Initially thought it was just getting older, but now struggles with daily activities.
Walking short distances leaves him breathless, and he needs to sit down more frequently.
Feels light-headed when standing up too quickly but has not fainted.
No recent infections, fever, or night sweats.
Noticed his stools have been darker than usual but no obvious blood.
No changes in appetite, but has unintentionally lost around 4kg in three months.

His main concerns are:

“Why am I feeling so tired all the time?”
“Could this be something serious?”
“Do I just need iron tablets, or is there another cause?”
“What tests do I need?”

Specific Information (To be revealed only when asked)

Fatigue and Exertional Symptoms

Feels exhausted by midday and needs to sit down often.
Short of breath after light physical activity, such as walking uphill or climbing stairs.
Occasional mild headaches but no dizziness while sitting.
No chest pain, palpitations, or leg swelling.

Gastrointestinal Symptoms

Stools appear darker over the past month, but no bright red blood.
Occasional mild indigestion, worse after meals but no severe abdominal pain.
No nausea or vomiting.
No constipation or diarrhoea.

Diet and Lifestyle

Eats mostly poultry and vegetables, with minimal red meat in his diet.
Drinks 1–2 beers most nights.
Former smoker (quit 10 years ago, 20 pack-year history).
No recent travel, no changes in living conditions.

Medication Use and Concerns

Takes ibuprofen 400mg twice daily for knee osteoarthritis.
Didn’t realise ibuprofen could cause stomach problems.
Reluctant to stop ibuprofen as it helps his pain.
Worried this could be something serious like cancer.

Emotional Cues

Michael is worried but trying to stay calm.

Concerned about cancer: “My dad had bowel cancer, and I know anaemia can be a sign of that.”
Frustrated by his symptoms: “I used to be active, but now I can barely do a simple walk.”
Seeking reassurance: “Is this something I should be really worried about?”

If the candidate provides a structured explanation and treatment plan, Michael will be reassured and willing to proceed with investigations.

If the candidate is vague or dismissive, Michael may become more anxious and push for immediate answers.

Questions for the Candidate

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

“Why am I feeling so tired?”
“Could this be something serious like cancer?”
“Do I just need iron tablets, or do I need more tests?”
“Is my ibuprofen causing this?”
“What happens if my tests come back abnormal?”
“What can I do to stop this from happening again?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

Michael will feel reassured and willing to undergo investigations.
He will understand the possible link between ibuprofen and gastrointestinal bleeding.
He may say, “I understand now, and I’ll do the tests you recommend.”

If the candidate is vague or dismissive:

Michael may insist on unnecessary immediate treatment (e.g., iron supplements without investigation).
He may say, “So, you’re saying we just wait and see?”

Key Takeaways for the Candidate

Take a detailed anaemia history, identifying risk factors and potential causes.
Differentiate iron deficiency from other types of anaemia.
Recommend appropriate investigations (FBE, iron studies, occult blood testing, possible endoscopy/colonoscopy).
Ensure patient is informed about potential serious causes and the importance of follow-up.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including onset of symptoms, dietary factors, medication use, and potential causes of blood loss.

The competent candidate should:

Elicit a structured history of symptoms, including:
- Onset and progression (fatigue, dizziness, and breathlessness over two months).
- Exertional limitations (struggling with walking, needing frequent rests).
- Presence of systemic symptoms (weight loss, night sweats, fever, palpitations).
- Signs of gastrointestinal bleeding (dark stools, no obvious red blood, mild indigestion).
Identify risk factors for anaemia, including:
- Dietary history (low red meat intake).
- NSAID use (ibuprofen for osteoarthritis, risk of gastrointestinal bleeding).
- Personal and family history of malignancy (father had bowel cancer).

Task 2: Differentiate between common causes of anaemia and identify any red flags for serious pathology.

The competent candidate should:

Consider differential diagnoses:
- Iron deficiency anaemia (most likely due to gastrointestinal blood loss).
- Anaemia of chronic disease (if inflammation from osteoarthritis is significant).
- B12/folate deficiency (less likely given dietary intake).
- Haemolysis or bone marrow disorders (if red flags present).
Recognise red flags that require urgent investigation:
- Persistent weight loss and fatigue.
- Gastrointestinal symptoms (dark stools, indigestion).
- Personal or family history of bowel cancer.

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

The competent candidate should:

Explain the likely diagnosis:
- Iron deficiency anaemia, likely secondary to chronic gastrointestinal blood loss.
- Other potential causes will need exclusion.
Order appropriate investigations:
- Full blood count (FBE) and iron studies to confirm iron deficiency.
- Faecal occult blood test (FOBT) or faecal immunochemical test (FIT) for gastrointestinal bleeding.
- Renal and liver function tests to rule out systemic causes.
- Endoscopic evaluation (gastroscopy and colonoscopy) if concern for malignancy or ongoing bleeding.
Initiate symptom management:
- Oral iron supplementation if iron deficiency is confirmed.
- Address NSAID use, consider alternatives for pain management (e.g., paracetamol, physiotherapy).

Task 4: Educate the patient on anaemia, possible causes, treatment options, and the need for follow-up.

The competent candidate should:

Explain the role of iron and how deficiency leads to symptoms.
Discuss treatment options:
- Oral iron supplements (side effects and importance of adherence).
- Dietary modifications to improve iron intake (red meat, leafy greens, vitamin C for absorption).
Address risk of serious conditions:
- The importance of investigating gastrointestinal blood loss.
- Reassure that early detection improves outcomes.
Ensure follow-up:
- Review iron levels in 4-6 weeks.
- Coordinate further investigations if necessary (e.g., endoscopy, specialist referral).

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, identifying risk factors, potential causes of blood loss, and systemic symptoms.
Differentiates between iron deficiency anaemia, chronic disease anaemia, and other causes.
Recognises red flags requiring urgent investigation, including possible gastrointestinal malignancy.
Provides an evidence-based management plan, including investigations, iron supplementation, and NSAID review.
Educates the patient on anaemia, treatment options, and the importance of follow-up.

PITFALLS

Failing to investigate the underlying cause of anaemia, leading to delayed diagnosis of significant pathology.
Misinterpreting iron deficiency as dietary-related only, without considering gastrointestinal blood loss.
Not recognising NSAID use as a potential cause of chronic gastrointestinal bleeding.
Prescribing iron supplements without confirming iron deficiency, leading to inappropriate treatment.
Neglecting to address red flags, such as weight loss and family history of bowel cancer.
Lack of follow-up planning, increasing the risk of missed serious diagnoses.

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 of symptoms, risk factors, and relevant medical history.
2.2 Identifies red flags for serious underlying causes of anaemia.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between different types of anaemia (iron deficiency, chronic disease, B12/folate deficiency, haemolysis).
3.2 Identifies when further investigations or specialist referral is required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides an evidence-based management plan, including iron supplementation, dietary advice, and further investigation.
4.2 Monitors response to treatment and adjusts management as needed.

5. Preventive and Population Health

5.1 Identifies risk factors for anaemia and advises on prevention strategies.
5.2 Encourages lifestyle modifications to optimise long-term health.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate follow-up, documentation, and possible referral for endoscopic evaluation.

8. Procedural Skills

8.1 Orders and interprets relevant investigations (FBE, iron studies, B12/folate, renal function, haemolysis screen).

9. Managing Uncertainty

9.1 Recognises when symptoms require urgent intervention versus ongoing monitoring.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and appropriately manages anaemia due to significant underlying pathology (e.g., gastrointestinal bleeding, malignancy).

Competency at Fellowship Level

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