CCE-CE-062

CASE INFORMATION

Case ID:2025-01A
Case Name: Rebecca Johnson
Age: 48
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: B80 – Anaemia

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to gather relevant information about symptoms and concerns
1.2 Provides clear and empathetic explanations regarding the diagnosis and management plan
2. Clinical Information Gathering and Interpretation2.1 Takes a comprehensive history, including dietary intake, menstrual history, and gastrointestinal symptoms
2.2 Orders and interprets appropriate investigations to determine the cause of anaemia
3. Diagnosis, Decision-Making and Reasoning3.1 Identifies clinical features of anaemia and differentiates between types (iron deficiency, B12 deficiency, chronic disease)
3.2 Recognises red flags requiring urgent referral (e.g., malignancy, significant blood loss)
4. Clinical Management and Therapeutic Reasoning4.1 Develops an evidence-based management plan, including supplementation, dietary advice, and treating the underlying cause
4.2 Identifies when referral to a specialist (e.g., gastroenterologist, haematologist) is required
5. Preventive and Population Health5.1 Provides advice on optimising iron intake and preventing recurrence
6. Professionalism6.1 Demonstrates patient-centred care and addresses patient concerns, particularly regarding fatigue and lifestyle impact
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate follow-up and monitoring of treatment response
8. Procedural Skills8.1 Interprets full blood count (FBC), iron studies, and other relevant tests appropriately
9. Managing Uncertainty9.1 Recognises when anaemia may have an undiagnosed underlying cause requiring further workup
10. Identifying and Managing the Patient with Significant Illness10.1 Identifies cases requiring urgent intervention (e.g., severe symptomatic anaemia, malignancy-related anaemia)

CASE FEATURES

  • Needs education on iron supplementation, dietary changes, and follow-up blood tests.
  • Middle-aged woman presenting with fatigue, dizziness, and shortness of breath on exertion.
  • History of heavy menstrual periods (suggestive of iron deficiency anaemia).
  • Diet low in iron-rich foods, raising concern about inadequate intake.
  • Mild pallor on examination, no overt signs of significant blood loss.
  • Requires assessment of iron levels, FBC, and consideration of secondary causes.

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:

  1. Take an appropriate history.
  2. Outline the differential diagnosis and key investigations required.
  3. Address the patient’s concerns.
  4. Develop a safe and patient-centred management plan.

SCENARIO

Rebecca Johnson, a 48-year-old high school teacher, presents with progressive fatigue over the past three months. She describes feeling more tired than usual, struggling to keep up with work, and experiencing occasional dizziness when standing up quickly. She has also noticed shortness of breath on exertion when climbing stairs, which was not an issue before.

She has a history of heavy menstrual periods, which have worsened over the past year. She describes passing clots and sometimes needing to change pads every 2–3 hours on heavy days. She does not take iron supplements and rarely eats red meat, preferring a mostly vegetarian diet.

PATIENT RECORD SUMMARY

Patient Details

Name: Rebecca Johnson
Age: 48
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Nil regular medications

Past History

  • Heavy menstrual bleeding (menorrhagia)
  • No history of anaemia or iron supplementation

Social History

  • Works full-time as a high school teacher

Family History

  • No known history of blood disorders or malignancy

Smoking

  • Non-smoker

Alcohol

  • Drinks 1-2 glasses of wine per week

Vaccination and Preventative Activities

Last Pap smear and mammogram were normal

Up to date with routine 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 SCRIPT

Opening Line

“Doctor, I’ve been feeling so tired lately, and I get dizzy sometimes when I stand up. Could it be something serious?”

General Information

You are Rebecca Johnson, a 48-year-old high school teacher who has been feeling progressively fatigued over the past three months. At first, you thought it was just work stress, but lately, the fatigue has become worse. You feel exhausted by the afternoon, and it’s getting harder to focus at work.

You also feel lightheaded and dizzy when standing up quickly, and you’ve noticed shortness of breath when climbing stairs—something that never used to be a problem.

Specific Information

(Reveal only when asked)

Background Information

You have had heavy periods for years, but they seem to have gotten worse in the last year. On heavy days, you need to change pads every 2-3 hours, and you sometimes pass clots. You’ve never thought much about it because you assumed it was normal for your age.

Your diet is mostly vegetarian, and you rarely eat red meat. You have never taken iron supplements because you’ve never been told to. You don’t recall ever being diagnosed with anaemia before.

You’re here today because you’re worried. You want to know if your symptoms mean something serious, like cancer, or if there’s an easy fix. You’re hoping to get your energy back so you can keep up with work and life.

Symptoms

  • You feel worn out by the end of the day and often need to sit down to rest after work.
  • You get dizzy when standing up too quickly, but you have not fainted.
  • You have noticed some shortness of breath when climbing stairs or walking fast.
  • You have no chest pain, no palpitations.
  • You haven’t noticed any unusual bruising or bleeding.
  • You haven’t lost weight unintentionally.

Menstrual History

  • Your periods last about 6-7 days, with 2-3 days of heavy flow.
  • On heavy days, you change pads every 2-3 hours and sometimes pass clots.
  • You have never been on hormonal contraception or used an IUD.
  • You don’t have intermenstrual bleeding or postmenopausal bleeding.

Gastrointestinal Symptoms

  • No black or tarry stools.
  • No blood in stools.
  • No abdominal pain, bloating, or nausea.
  • Normal appetite.

Lifestyle and Diet

  • You don’t eat red meat and only occasionally eat chicken or fish.
  • You don’t take iron supplements or multivitamins.
  • You drink 1-2 glasses of wine per week but don’t drink heavily.
  • You don’t smoke.

Concerns and Expectations

  • You are worried that this could be something serious, like cancer.
  • You want to know if your symptoms are due to your diet or heavy periods.
  • You want a quick solution to feel better soon.
  • You wonder if you need a blood transfusion or if there are other treatment options.
  • You want to know how to prevent this from happening again.

Emotional Cues & Body Language

  • You look tired and slightly anxious, especially when asking if this could be something serious.
  • You frown slightly when discussing how your work performance has been affected.
  • You seem relieved if the doctor explains things clearly and reassures you.
  • You engage more when discussing practical solutions like diet and supplements.
  • If the doctor doesn’t address your concerns, you appear frustrated and push for more details.

Questions for the Candidate (Ask Naturally During the Consultation)

  1. “Why am I feeling so tired? Is this something serious?”
  2. “Could this be related to my diet or my periods?”
  3. “Do I need to take iron supplements? How long will it take to feel better?”
  4. “Will I need a blood transfusion?”
  5. “How do I stop this from happening again?”
  6. “Is this common for women my age?”

Response to Advice Given by the Candidate

  • If the candidate explains anaemia clearly, you feel reassured.
  • If they say this is likely due to iron deficiency, you ask how long it will take to feel better.
  • If they suggest iron tablets, you ask if there are any side effects.
  • If they mention blood tests, you ask if you need any special preparation.
  • If they suggest dietary changes, you ask for specific food recommendations.
  • If they don’t provide a clear plan, you push for more details on how to improve your energy levels.

Final Thought

If the candidate provides a clear explanation, reassures you, and outlines a structured treatment plan, you feel confident about managing your anaemia. If they are vague or dismissive, you remain anxious and dissatisfied with the consultation.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including symptoms, dietary intake, menstrual history, and any signs of gastrointestinal blood loss.

The competent candidate should:

  • Elicit a clear symptom history, including:
    • Onset and progression of fatigue (over 3 months).
    • Associated symptoms: dizziness, shortness of breath, reduced exercise tolerance.
    • Impact on daily life, work performance, and quality of life.
  • Assess menstrual history:
    • Duration and severity of heavy periods (e.g., passing clots, frequent pad changes).
    • History of menorrhagia, perimenopausal symptoms, or gynaecological conditions.
  • Review dietary habits:
    • Low iron intake (vegetarian diet, minimal red meat consumption).
  • Assess for gastrointestinal blood loss:
    • Symptoms of blood in stool, black/tarry stools, abdominal pain.
  • Identify risk factors for other causes of anaemia, such as:
    • Chronic disease, recent infections, malignancy risk factors.

Task 2: Identify key clinical features and order appropriate investigations to determine the cause of anaemia.

The competent candidate should:

  • Recognise clinical signs of anaemia, such as:
    • Pallor, tachycardia, mild shortness of breath on exertion.
  • Consider differential diagnoses:
    • Iron deficiency anaemia (common in premenopausal women with heavy periods).
    • Vitamin B12 or folate deficiency (less likely given dietary history).
    • Anaemia of chronic disease (less likely without systemic symptoms).
    • Malignancy-related anaemia (less likely but should assess for red flags).
  • Order appropriate investigations:
    • Full blood count (FBC): check haemoglobin (Hb), mean corpuscular volume (MCV).
    • Iron studies: serum ferritin, transferrin saturation.
    • B12 and folate levels if macrocytosis is present.
    • Renal and liver function tests (UECs, LFTs).
    • Faecal occult blood test (FOBT) if gastrointestinal blood loss is suspected.

Task 3: Explain the likely diagnosis, underlying cause, and treatment options to the patient.

The competent candidate should:

  • Explain anaemia in simple terms: a condition where red blood cells are low, reducing oxygen delivery to the body.
  • Reassure the patient that based on history, iron deficiency due to heavy periods and low dietary intake is the most likely cause.
  • Discuss treatment options, including:
    • Oral iron supplementation (e.g., ferrous sulfate 325 mg daily).
    • Dietary modifications (increase iron-rich foods: leafy greens, lentils, fortified cereals).
    • Managing menorrhagia (consideration of hormonal therapy, referral to gynaecologist if needed).
  • Explain expected recovery timeline:
    • Symptoms should improve within a few weeks, full iron stores may take several months to replenish.
  • Address concerns about serious illness and explain why further tests are not urgently needed.

Task 4: Develop a safe, evidence-based management plan, including iron supplementation, dietary advice, and follow-up monitoring.

The competent candidate should:

  • Prescribe oral iron supplements, advising:
    • Take with vitamin C (e.g., orange juice) to enhance absorption.
    • Avoid taking with tea, coffee, or dairy, which reduce absorption.
    • Common side effects: constipation, dark stools.
  • Consider additional management for heavy menstrual bleeding, such as:
    • Tranexamic acid or NSAIDs for period control.
    • Referral to a gynaecologist if symptoms persist.
  • Follow-up plan:
    • Repeat FBC and iron studies in 3 months to assess response.
    • Monitor symptoms and adjust management if needed.

SUMMARY OF A COMPETENT ANSWER

  • Takes a thorough history, including symptom duration, menstrual bleeding, and diet.
  • Orders appropriate investigations, focusing on FBC, iron studies, and potential secondary causes.
  • Explains the diagnosis in clear, simple terms, reassuring the patient.
  • Provides a structured management plan, including iron supplementation, dietary advice, and follow-up.
  • Discusses strategies for managing heavy menstrual bleeding and prevention of recurrence.

PITFALLS

  • Failing to ask about heavy menstrual bleeding, missing the primary cause.
  • Not ordering iron studies, leading to incomplete assessment of anaemia.
  • Not considering secondary causes (e.g., gastrointestinal blood loss, malignancy).
  • Prescribing iron supplements without explaining side effects or how to take them.
  • Not discussing management options for menorrhagia, leading to ongoing anaemia risk.
  • Lack of structured follow-up, delaying recognition of treatment failure.

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 sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history, including dietary intake, menstrual history, and gastrointestinal symptoms.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies clinical features of anaemia and differentiates between types.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan, including supplementation and treating the underlying cause.

5. Preventive and Population Health

5.1 Provides advice on optimising iron intake and preventing recurrence.

6. Professionalism

6.1 Demonstrates patient-centred care and addresses patient concerns.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate follow-up and monitoring of treatment response.

8. Procedural Skills

8.1 Interprets full blood count (FBC), iron studies, and other relevant tests appropriately.

9. Managing Uncertainty

9.1 Recognises when anaemia may have an undiagnosed underlying cause requiring further workup.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies cases requiring urgent intervention.

Competency at Fellowship Level

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