CASE INFORMATION
Case ID: CCE-2025-005
Case Name: Michael Dawson
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: D11 (Diarrhoea)
COMPETENCY OUTCOMES
Competency Domain | Competency Element |
---|---|
1. Communication and Consultation Skills | 1.1 Establishes rapport and engages empathetically 1.2 Uses appropriate questioning techniques to explore symptoms and concerns 1.5 Provides clear explanations about diagnosis and management |
2. Clinical Information Gathering and Interpretation | 2.1 Takes a comprehensive gastrointestinal history 2.2 Identifies red flags requiring urgent intervention |
3. Diagnosis, Decision-Making and Reasoning | 3.1 Forms an appropriate differential diagnosis 3.3 Recognises the need for further investigations |
4. Clinical Management and Therapeutic Reasoning | 4.2 Develops a safe and patient-centred management plan 4.4 Balances conservative, pharmacological, and referral strategies |
5. Preventive and Population Health | 5.3 Provides education on food hygiene, infection prevention, and lifestyle modifications |
6. Professionalism | 6.2 Manages uncertainty and ensures patient-centred care |
7. General Practice Systems and Regulatory Requirements | 7.1 Ensures appropriate documentation and referral pathways |
9. Managing Uncertainty | 9.2 Recognises when specialist referral is required |
10. Identifying and Managing the Patient with Significant Illness | 10.1 Identifies features of serious gastrointestinal disease requiring urgent management |
CASE FEATURES
- Middle-aged man presenting with a three-week history of diarrhoea.
- Concerned about weight loss, fatigue, and abdominal discomfort.
- Recent overseas travel, raising concerns about infectious causes.
- Possible red flags requiring exclusion of serious conditions (e.g., colorectal cancer, inflammatory bowel disease, coeliac disease).
- Need for appropriate investigations and management plan, balancing conservative and referral options.
CANDIDATE INFORMATION
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 a physical examination.
A patient record summary is provided for your information.
Perform the following tasks:
- Take an appropriate history.
- Outline the differential diagnosis and key investigations required.
- Address the patient’s concerns.
- Develop a safe and patient-centred management plan.
SCENARIO
Michael Dawson, a 45-year-old accountant, presents with a three-week history of persistent diarrhoea.
He reports passing loose stools 4–6 times per day, sometimes urgent, with occasional abdominal cramping. He has lost 3 kg unintentionally and feels more fatigued than usual.
His BP today is 118/76 mmHg, HR 80 bpm, and he appears well but concerned.
PATIENT RECORD SUMMARY
Patient Details
Name: Michael Dawson
Age: 45
Gender: Male
Indigenous Status: Non-Indigenous
Allergies and Adverse Reactions
- Nil known
Medications
- Nil regular medications
Past History
- No significant medical history
Family History
- Father diagnosed with colorectal cancer at age 55
- Mother has coeliac disease
Social History
- Works as an accountant, mostly sedentary lifestyle.
Smoking & Alcohol
- Non-smoker.
- Drinks 2-3 beers per week socially.
Vaccination & Preventative Activities
- Colorectal cancer screening not yet completed (due to start at 50 based on general guidelines, but family history may warrant earlier screening).
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 had diarrhoea for weeks now, and I’m starting to get worried. Could this be something serious?”
General Information
- Your diarrhoea started three weeks ago, shortly after returning from a business trip to Thailand.
- You initially thought it was just traveller’s diarrhoea, but it hasn’t resolved.
- You have loose stools 4–6 times per day, sometimes with urgency.
- Occasionally, you experience mild abdominal cramps, but no severe pain.
Specific Information
(Reveal Only When Asked)
Background Information
- You feel tired and more fatigued than usual, and have noticed you’ve lost about 3 kg without trying.
- Your appetite is mostly normal, but you’ve noticed some discomfort after eating.
- You have no nausea or vomiting.
- You’re worried this could be something serious like bowel cancer since your father was diagnosed at 55.
Bowel Habits & Symptoms
- Your stools are loose but not watery.
- No visible blood or mucus in the stools.
- No fever, night sweats, or chills.
- No recent antibiotic use.
- No significant bloating or excessive gas.
- No joint pain, rashes, or eye problems (no symptoms suggestive of inflammatory bowel disease).
- No recent travel to rural areas, lakes, or exposure to animals that could indicate parasitic infections.
Dietary Triggers & Lifestyle
- You generally eat a balanced diet but tend to eat out frequently due to work commitments.
- You ate a lot of street food in Thailand and mostly drank bottled water.
- You’ve noticed that dairy makes your symptoms worse, though you’re not sure if it’s the cause.
- No history of coeliac disease, but your mother has it.
Family & Cancer Risk
- Your father had bowel cancer at age 55, which concerns you.
- You haven’t had a colonoscopy before but are aware that screening starts at 50.
- You ask whether you should have early screening due to your family history.
Emotional Cues
Concern About Serious Illness
- You look worried and ask:
- “Could this be cancer? Should I be getting a colonoscopy?”
- If the doctor reassures you too quickly, you push back:
- “But my dad had cancer at my age—how can we be sure?”
Frustration About Symptoms
- You lean forward and sigh, saying:
- “This is really affecting my work—I can’t keep running to the bathroom during meetings.”
- “I feel like I’m constantly tired, and I just want to get back to normal.”
Uncertainty About Dietary Triggers
- You ask:
- “Should I stop eating dairy? Could I be lactose intolerant?”
- “I read online that gluten can cause issues—should I cut that out too?”
Key Questions for the Candidate
(Ask these naturally throughout the consultation, especially if the doctor hasn’t already addressed them.)
- “Do I need a colonoscopy? I don’t want to miss something serious.”
- “Could this be something I caught in Thailand?”
- “Is this diet-related? Should I change what I eat?”
- “When will this go away? I just want to feel normal again.”
- “Is there anything I can take to stop the diarrhoea?”
Possible Patient Reactions Based on the Candidate’s Response
If the Doctor Engages Empathetically & Explains Clearly
- You become more receptive and ask:
- “So you’re saying we should do some tests first before worrying?”
- “Okay, I can try changing my diet, but when will I know if it’s working?”
If the Doctor is Too Dismissive or Reassures Too Quickly
- You respond with frustration:
- “But what if it is cancer? What if we’re missing something?”
- “I’ve never had this before, and now it’s been three weeks—why wouldn’t I be worried?”
If the Doctor Doesn’t Provide a Clear Plan
- You push for more action:
- “So what do we do next? Just wait and see?”
- “I need to get back to work. Can’t we do something to stop the diarrhoea?”
Role-Player’s Objective
- Encourage the candidate to take a structured approach to history-taking.
- Assess whether the candidate recognises red flags, including weight loss and family history.
- Observe if the candidate can provide clear explanations about diagnosis, investigations, and management.
- Determine if the candidate addresses your emotional concerns (fear of cancer, frustration about symptoms, and lifestyle impact).
THE COMPETENT CANDIDATE
The competent candidate should be able to:
Task 1: Take a structured history of the patient’s diarrhoea, including duration, triggers, and associated symptoms.
The competent candidate should:
- Establish rapport and acknowledge the patient’s concerns about bowel cancer.
- Take a structured gastrointestinal history, covering:
- Onset, duration, and frequency of diarrhoea (acute vs chronic).
- Stool characteristics (watery, bloody, fatty, presence of mucus).
- Associated symptoms, including abdominal pain, weight loss, bloating, nausea, vomiting, or fever.
- Presence of red flags (weight loss, family history, rectal bleeding, nocturnal symptoms).
- Dietary triggers (lactose, gluten, high-fat foods).
- Travel history, particularly exposure to street food and unsafe water in Thailand.
- Medication use, including antibiotics, NSAIDs, or proton pump inhibitors.
- Family history of gastrointestinal conditions, including bowel cancer, coeliac disease, or inflammatory bowel disease (IBD).
Task 2: Explain the likely diagnosis and need for further investigations.
The competent candidate should:
- Acknowledge the patient’s concerns while explaining that multiple conditions could cause his symptoms.
- Outline the most likely differential diagnoses, including:
- Infectious diarrhoea (post-travel bacterial or parasitic infection) – e.g., Giardia, E. coli.
- Lactose intolerance – worsened by dairy.
- Coeliac disease – family history present.
- Inflammatory bowel disease (IBD) – less likely due to lack of blood or mucus in stools.
- Colorectal cancer – unlikely but requires risk assessment due to family history.
- Recommend appropriate investigations, including:
- Stool microscopy, culture, and PCR – to detect bacterial or parasitic infections.
- Faecal calprotectin – to screen for IBD.
- Serology for coeliac disease (anti-tTG, total IgA).
- Blood tests – full blood count, iron studies (for anaemia), electrolytes, and liver function tests.
- Colonoscopy – may be indicated due to family history and persistent symptoms.
- Reassure the patient that most causes are treatable, but further testing is required to confirm a diagnosis.
Task 3: Outline your management plan, including symptomatic relief and when to refer.
The competent candidate should:
- Address immediate symptom relief, including:
- Oral rehydration solutions to prevent dehydration.
- Loperamide (with caution) for non-infectious diarrhoea affecting daily function.
- Dietary modifications, such as avoiding dairy and high-fat foods.
- Empiric treatment for likely infectious diarrhoea, considering metronidazole for Giardia if suspected.
- Review test results within 1–2 weeks, ensuring follow-up for unresolved symptoms.
- Referral to a gastroenterologist if:
- Symptoms persist despite initial treatment.
- There is faecal calprotectin elevation (suggesting IBD).
- There are alarm symptoms requiring a colonoscopy (family history, weight loss).
- Provide education on food hygiene and travel precautions for future trips.
Task 4: Address the patient’s concerns, including prognosis, dietary changes, and lifestyle modifications.
The competent candidate should:
- Reassure the patient that his symptoms are concerning but not necessarily cancerous.
- Explain the rationale for investigations, particularly regarding his family history of bowel cancer.
- Discuss dietary modifications, including:
- Trialling a lactose-free diet to assess for lactose intolerance.
- Considering a gluten-free diet trial if coeliac disease is suspected.
- Address concerns about work, advising that symptom control is possible with appropriate management.
- Discuss lifestyle measures, including stress reduction, hydration, and fibre intake.
- Provide written resources on bowel cancer screening, coeliac disease, and post-travel gastrointestinal illness.
SUMMARY OF A COMPETENT ANSWER
- Takes a detailed history, covering onset, stool characteristics, red flags, and dietary triggers.
- Explains the likely causes clearly, balancing reassurance with appropriate investigation planning.
- Recognises red flags, particularly family history and weight loss, and recommends appropriate tests.
- Develops a structured management plan, including symptomatic treatment, diet changes, and follow-up testing.
- Addresses the patient’s concerns empathetically, explaining why further investigations are necessary.
PITFALLS
- Failing to assess red flags properly – ignoring family history, weight loss, or persistent symptoms.
- Over-reassuring without investigation – dismissing concerns about bowel cancer without explaining risk assessment.
- Not considering coeliac disease – given family history and dairy-related symptoms.
- Prescribing loperamide without caution – potential risks if infectious diarrhoea is present.
- Delaying specialist referral unnecessarily – failing to refer if symptoms persist despite initial management.
- Not addressing the emotional impact – failing to acknowledge the patient’s anxiety about serious illness.
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
Competency Areas Assessed
1. Communication and Consultation Skills
1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Uses appropriate questioning techniques to explore symptoms and concerns.
1.5 Provides clear explanations about diagnosis and management.
2. Clinical Information Gathering and Interpretation
2.1 Takes a comprehensive gastrointestinal history.
2.2 Identifies red flags requiring urgent intervention.
3. Diagnosis, Decision-Making and Reasoning
3.1 Forms an appropriate differential diagnosis.
3.3 Recognises the need for further investigations.
4. Clinical Management and Therapeutic Reasoning
4.2 Develops a safe and patient-centred management plan.
4.4 Balances conservative, pharmacological, and referral strategies.
5. Preventive and Population Health
5.3 Provides education on food hygiene, infection prevention, and lifestyle modifications.
6. Professionalism
6.2 Manages uncertainty and ensures patient-centred care.
7. General Practice Systems and Regulatory Requirements
7.1 Ensures appropriate documentation and referral pathways.
9. Managing Uncertainty
9.2 Recognises when specialist referral is required.
10. Identifying and Managing the Patient with Significant Illness
10.1 Identifies features of serious gastrointestinal disease requiring urgent management.
Competency at Fellowship Level
☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD