CCE-CE-067.1 - GP Exams

CASE INFORMATION

Case ID: CCE-GI-027
Case Name: Sarah Mitchell
Age: 42
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: D12 – Constipation

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 bowel habits, diet, medications, and red flags 2.2 Identifies signs requiring further investigation (e.g., colorectal cancer risk)
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between functional constipation, secondary causes, and serious pathology 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 lifestyle, dietary, and pharmacological interventions 4.2 Educates the patient on managing constipation and preventing recurrence
5. Preventive and Population Health	5.1 Identifies lifestyle and dietary factors contributing to constipation 5.2 Advises on long-term prevention strategies, including colorectal cancer screening
6. Professionalism	6.1 Demonstrates empathy and a patient-centred approach
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and follow-up of persistent constipation
8. Procedural Skills	8.1 Orders and interprets relevant investigations (e.g., blood tests, faecal occult blood test, imaging if indicated)
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 red flags for colorectal cancer and serious gastrointestinal conditions

CASE FEATURES

Need for dietary and lifestyle modifications, and possible pharmacological intervention
Chronic constipation with bloating and discomfort
Recent lifestyle changes contributing to symptoms
Concerns about potential serious underlying 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:

Take an appropriate history, including bowel habits, dietary and lifestyle factors, medication use, and red flags for serious conditions.
Differentiate between functional constipation, medication-induced constipation, and red flags requiring further investigation.
Provide a diagnosis and discuss an initial management plan, including dietary, lifestyle, and pharmacological interventions if needed.
Educate the patient on preventive strategies, warning signs that require follow-up, and when to seek medical attention.

SCENARIO

Sarah Mitchell, a 42-year-old office worker, presents with constipation over the past three months.

Her symptoms include:

Having a bowel movement only twice per week.
Straining with stools, which are often hard and dry.
Feeling bloated and uncomfortable most days.
A sense of incomplete evacuation after defecation.
Occasional abdominal discomfort but no severe pain.

Her main concerns are:

“Why am I suddenly getting constipated?”
“Could this be something serious like bowel cancer?”
“What can I do to fix this?”
“Do I need laxatives?”

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Mitchell
Age: 42
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Iron supplements (started three months ago for low ferritin levels)
Oral contraceptive pill

Past History

Mild iron deficiency anaemia
No prior history of gastrointestinal disorders

Social History

Office worker, spends most of the day sitting
Recently reduced fibre intake due to a low-carb diet
Drinks 2–3 cups of coffee daily but limited water intake
No smoking, occasional alcohol use

Family History

Mother had diverticulitis in her 50s
No family history of colorectal cancer

Vaccination and Preventative Activities

Has not had colorectal cancer screening (not yet due for National Bowel Cancer Screening Program).
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.

SCRIPT FOR ROLE-PLAYER

Opening Line

“Doctor, I’ve been really constipated for the last few months, and it’s getting frustrating. I feel bloated all the time.”

General Information

Sarah Mitchell is a 42-year-old office worker presenting with chronic constipation over the past three months.

Bowel movements reduced to about twice per week.
Straining when passing stools, which are often hard and dry.
A sense of incomplete evacuation after defecation.
Bloating and discomfort after meals but no severe pain.
No blood in stools, no weight loss, no nausea or vomiting.
Symptoms started after she made dietary changes and began iron supplements.

Her main concerns are:

“Why am I suddenly getting constipated?”
“Could this be something serious like bowel cancer?”
“What can I do to fix this?”
“Do I need laxatives?”

Specific Information (To be revealed only when asked)

Bowel Habits and Symptoms

Stools are hard, dry, and pellet-like.
Takes 10–15 minutes to pass a bowel motion, often with straining.
No mucus or visible blood in the stools.
Occasionally experiences mild cramping before bowel movements.
No diarrhoea or alternating bowel habits.
No recent travel or infectious gastroenteritis.

Diet and Lifestyle Factors

Started a low-carb diet three months ago to lose weight.
Reduced intake of bread, pasta, fruit, and whole grains.
Eating more meat, cheese, eggs, and dairy.
Drinks about 1 litre of water per day but knows she should drink more.
Drinks 2–3 cups of coffee daily but no excessive caffeine intake.
No regular exercise, spends most of the day sitting at work.

Medication Use and Risk Factors

Started iron supplements three months ago for low ferritin.
Takes the oral contraceptive pill.
No opioid use or other medications known to cause constipation.

Medical and Family History

Mild iron deficiency anaemia diagnosed three months ago.
No previous gastrointestinal issues or surgeries.
Mother had diverticulitis in her 50s.
No family history of colorectal cancer.

Concerns About Serious Causes

Worried about bowel cancer because she has read online that constipation can be a warning sign.
Asks if she needs a colonoscopy.
Wants to know if laxatives are safe and which one she should use.

Emotional Cues

Sarah is concerned but open to solutions.

Frustrated by symptoms: “I just don’t feel right, and it’s really uncomfortable.”
Anxious about serious illness: “Could this be cancer?”
Seeking reassurance: “How can I fix this naturally?”

If the candidate provides a structured explanation and management plan, Sarah will be reassured and motivated to make changes.

If the candidate is vague or dismissive, Sarah may insist on immediate testing or strong laxatives.

Questions for the Candidate

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

“Why am I getting constipated all of a sudden?”
“Is this something serious like bowel cancer?”
“What can I do to get back to normal?”
“Should I take a laxative? Which one is best?”
“Do I need any tests like a colonoscopy?”
“How long will it take to improve?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

Sarah will feel reassured and willing to follow dietary and lifestyle advice.
She will understand that her symptoms are likely functional and related to diet and medication.
She may say, “I’ll try increasing my fibre and water intake first.”

If the candidate is vague or dismissive:

Sarah may push for unnecessary testing or medications.
She may say, “So, you don’t think I need any tests?”

Key Takeaways for the Candidate

Take a detailed history, considering diet, medications, and red flags.
Differentiate functional constipation from secondary causes.
Provide an evidence-based management plan, including diet, hydration, and possible laxatives.
Address concerns about serious conditions and provide clear safety-netting advice.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including bowel habits, dietary and lifestyle factors, medication use, and red flags for serious conditions.

The competent candidate should:

Elicit a structured history, including:
- Onset and duration (three months of constipation).
- Bowel pattern changes (reduced to twice weekly, hard stools, straining).
- Dietary and fluid intake (low-fibre diet, reduced carbohydrates, inadequate water).
- Medication history (iron supplements known to cause constipation).
- Lifestyle factors (sedentary job, no regular exercise).
Assess for red flags:
- Unintentional weight loss.
- Rectal bleeding or melena.
- Persistent abdominal pain, anaemia, or family history of bowel cancer.

Task 2: Differentiate between functional constipation, medication-induced constipation, and red flags requiring further investigation.

The competent candidate should:

Consider differential diagnoses:
- Functional constipation (dietary, lifestyle, stress-related).
- Medication-induced constipation (iron supplements).
- Irritable bowel syndrome (IBS-C) (abdominal discomfort with constipation).
- Colorectal malignancy (unlikely but must assess red flags).
Identify indications for further testing:
- Faecal occult blood test (FOBT) if red flags present.
- Iron studies if anaemia persists despite supplementation.
- Colonoscopy if unexplained persistent symptoms or positive FOBT.

Task 3: Provide a diagnosis and discuss an initial management plan, including dietary, lifestyle, and pharmacological interventions if needed.

The competent candidate should:

Explain the likely diagnosis:
- Functional constipation related to dietary changes and iron supplementation.
- Reassure patient that serious conditions are unlikely.
Provide a stepwise management approach:
- Dietary modifications: Increase fibre (whole grains, fruits, vegetables), ensure adequate hydration.
- Lifestyle changes: Encourage physical activity to improve bowel motility.
- Adjust iron supplement regimen: Consider changing to a formulation with less constipation effect.
- Trial of laxatives if needed: Osmotic laxatives (e.g., Movicol) preferred over stimulant laxatives.

Task 4: Educate the patient on preventive strategies, warning signs that require follow-up, and when to seek medical attention.

The competent candidate should:

Provide reassurance and guidance:
- Most constipation resolves with dietary and lifestyle changes.
- Symptoms should improve within weeks of changes.
Discuss warning signs requiring urgent review:
- New-onset rectal bleeding, persistent change in bowel habits, weight loss.
Plan for follow-up:
- Review in 4–6 weeks to assess symptom improvement.
- Further investigations if symptoms persist despite management.

SUMMARY OF A COMPETENT ANSWER

Takes a structured history, identifying dietary, lifestyle, and medication-related contributors.
Differentiates between functional and secondary constipation, recognising red flags.
Provides a structured management plan, including dietary changes, fluid intake, and laxative options if needed.
Educates on prevention, safety-netting for red flags, and appropriate follow-up.

PITFALLS

Failing to assess red flags, leading to missed serious conditions like colorectal cancer.
Over-reliance on laxatives without addressing underlying lifestyle and dietary factors.
Dismissing patient concerns about bowel cancer without providing clear safety-netting and reassurance.
Not considering medication side effects, leading to ongoing symptoms despite treatment changes.
Lack of a follow-up plan, increasing the risk of undiagnosed persistent constipation or progressive disease.

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 bowel habits, diet, medications, and red flags.
2.2 Identifies signs requiring further investigation (e.g., colorectal cancer risk).

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between functional constipation, medication-induced constipation, and serious pathology.
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 lifestyle, dietary, and pharmacological interventions.
4.2 Educates the patient on managing constipation and preventing recurrence.

5. Preventive and Population Health

5.1 Identifies lifestyle and dietary factors contributing to constipation.
5.2 Advises on long-term prevention strategies, including colorectal cancer screening.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up of persistent constipation.

8. Procedural Skills

8.1 Orders and interprets relevant investigations (e.g., blood tests, faecal occult blood test, imaging if indicated).

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 red flags for colorectal cancer and serious gastrointestinal conditions.

Competency at Fellowship Level

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