CCE-CE-125

CASE INFORMATION

Case ID: SFD-001
Case Name: Michael Dawson
Age: 50
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Code: D87 – Stomach Function Disorder

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to understand their concerns and expectations.
1.2 Demonstrates active listening and empathy.
1.4 Explains diagnosis and management in a patient-centred manner.
2. Clinical Information Gathering and Interpretation2.1 Takes a comprehensive history, including symptom characteristics and red flags.
2.2 Identifies risk factors and underlying causes of stomach dysfunction.
3. Diagnosis, Decision-Making and Reasoning3.1 Establishes a working diagnosis based on history and clinical reasoning.
3.2 Differentiates between functional and organic causes of stomach dysfunction.
4. Clinical Management and Therapeutic Reasoning4.1 Develops an evidence-based management plan.
4.5 Provides pharmacological and non-pharmacological recommendations.
4.7 Uses shared decision-making to address patient concerns.
5. Preventive and Population Health5.1 Identifies and addresses lifestyle factors contributing to symptoms.
5.2 Provides education on dietary and lifestyle modifications.
6. Professionalism6.2 Provides reassurance and addresses patient concerns sensitively.
7. General Practice Systems and Regulatory Requirements7.1 Documents history, examination findings, and management plan appropriately.
9. Managing Uncertainty9.3 Recognises when further investigation or referral is required.
10. Identifying and Managing the Patient with Significant Illness10.1 Recognises red flags suggestive of serious gastrointestinal pathology.

CASE FEATURES

  • Middle-aged male presenting with chronic upper abdominal discomfort, bloating, and occasional nausea.
  • Concerned about the possibility of serious illness such as stomach cancer.
  • Lifestyle factors (diet, stress, alcohol) potentially contributing to symptoms.
  • Requires differentiation between functional dyspepsia, gastro-oesophageal reflux disease (GORD), and organic causes (e.g., H. pylori, peptic ulcer disease).
  • Need for shared decision-making regarding investigations and lifestyle modifications.

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

Michael Dawson, a 50-year-old accountant, presents with intermittent upper abdominal discomfort, bloating, and occasional nausea over the past six months. The symptoms are worse after eating large meals or drinking alcohol and are sometimes accompanied by mild heartburn. He has not experienced vomiting, weight loss, or difficulty swallowing.

His observations today are:

  • BP: 130/85 mmHg
  • HR: 74 bpm, regular
  • Temp: 36.7°C
  • RR: 16 breaths/min
  • Oxygen saturation: 99% on room air

PATIENT RECORD SUMMARY

Patient Details

Name: Michael Dawson
Age: 50
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Nil regular

Past History

  • No known gastrointestinal conditions
  • No history of Helicobacter pylori (H. pylori) testing

Social History

  • Occupation: Accountant – sedentary work
  • Smoking: Never smoked
  • Alcohol: 3-4 drinks on weekends

Family History

  • Father: Hypertension, high cholesterol
  • Mother: Type 2 diabetes

Vaccination and Preventative Activities

  • Influenza vaccine – up to date

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 SCRIPTS

Opening Line

“Doctor, my stomach has been bothering me for months now. It feels bloated and uncomfortable, and sometimes I feel a bit nauseous after eating.”

General Information

  • You are a 50-year-old accountant and generally in good health.
  • For the past six months, you have been experiencing on-and-off upper abdominal discomfort.
  • The discomfort mostly happens after meals, particularly if you eat something greasy or large portions.

Specific Information

(Only Provide If Asked)

Background Information

  • You often feel bloated and full, even when you haven’t eaten that much.
  • You sometimes get mild heartburn but not all the time.
  • You occasionally feel nauseous after eating, but you have never vomited.
  • You feel a bit more tired than usual, but you think it’s due to work stress.

Symptoms & History

  • Your appetite is normal, and you haven’t lost weight.
  • You haven’t noticed any blood in your stools or black, tarry stools.
  • You don’t have difficulty swallowing or food getting stuck.
  • You don’t have severe or sharp pain, just a dull, persistent discomfort.
  • The symptoms don’t wake you up at night.

Lifestyle Factors

  • You work long hours at a desk and often eat late at night.
  • Your diet includes a lot of processed foods and takeaway meals due to your busy schedule.
  • You drink alcohol on weekends (3-4 drinks per sitting).
  • You don’t exercise regularly, but you try to walk occasionally.
  • You have never smoked.
  • You often feel stressed because of deadlines at work.

Concerns & Expectations

  • You are worried that this could be stomach cancer, especially after a close friend was recently diagnosed.
  • You are concerned that you may have an ulcer or something serious.
  • You want to know if you need an endoscopy or any other tests.
  • You haven’t spoken to a doctor about this before because you thought it would go away.
  • You are open to lifestyle changes but also want a quick fix for the symptoms.

Possible Questions for the Candidate

  1. “Could this be stomach cancer?”
  2. “Do I need an endoscopy or any tests?”
  3. “Could this be an ulcer?”
  4. “Would changing my diet help?”
  5. “Are there medications I can take to make this go away?”
  6. “How long will it take for my stomach to feel normal again?”
  7. “Is stress making this worse?”
  8. “Would probiotics or natural remedies help?”

How to Respond to the Candidate’s Explanations

If the Candidate Suggests Functional Dyspepsia or Reflux as the Likely Cause:

  • “So does that mean it’s not something serious?”
  • “What’s the difference between reflux and an ulcer?”

If the Candidate Recommends an H. pylori Test Before an Endoscopy:

  • “What is H. pylori, and how does it cause stomach problems?”
  • “Would I need antibiotics if I have it?”

If the Candidate Discusses Lifestyle Changes:

  • “How much of a difference would diet and exercise really make?”
  • “Would drinking less alcohol help?”

If the Candidate Suggests Medications (e.g., PPIs, Antacids):

  • “How long would I have to take them for?”
  • “Are there any side effects of these medications?”

If the Candidate Says an Endoscopy is Not Immediately Necessary:

  • “How do you know I don’t need one?”
  • “Would an endoscopy rule out anything serious?”

Role-Playing Tips for the Candidate Assessment

  • You are concerned but not panicked. Your main fear is stomach cancer, but you are open to reassurance.
  • You want a clear diagnosis. If the candidate doesn’t explain the possible causes well, ask follow-up questions.
  • You are open to lifestyle changes but want to know if they will actually help.
  • You don’t want unnecessary procedures, but if the candidate says an endoscopy isn’t needed, you want a good reason why.
  • If the candidate dismisses your concerns too quickly, push back. Ask, “How can we be sure without testing?”
  • You are looking for practical solutions. If the candidate only gives vague advice, ask, “So what exactly should I do next?”

Final Line (If the Candidate Handles the Case Well)

“Thanks, Doctor. I feel a bit more reassured now. I’ll try those changes and take the medication as you suggested. If things don’t improve, I’ll come back for follow-up.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take a focused history, including symptom characteristics, triggers, and red flag symptoms.

The competent candidate should:

  • Engage the patient with open-ended questions to explore their symptoms and concerns.
  • Obtain a detailed symptom history, including:
    • Onset, duration, and progression of symptoms.
    • Nature of discomfort (burning, bloating, nausea, early satiety).
    • Triggering and relieving factors (food, alcohol, stress, medications).
    • Associated symptoms (heartburn, regurgitation, changes in bowel habits).
  • Identify red flags requiring further investigation:
    • Unintentional weight loss.
    • Haematemesis or melaena.
    • Dysphagia or odynophagia.
    • Persistent vomiting.
  • Explore psychosocial factors, including stress, work-life balance, and impact on daily function.
  • Address patient concerns, particularly fear of serious illness (e.g., stomach cancer).

Task 2: Discuss your differential diagnosis and outline an initial management plan.

The competent candidate should:

  • Explain that the most likely diagnosis is functional dyspepsia or gastro-oesophageal reflux disease (GORD).
  • Differentiate between possible diagnoses:
    • Functional dyspepsia – recurrent epigastric discomfort without clear structural cause.
    • GORD – acid reflux, often with heartburn or regurgitation.
    • Peptic ulcer disease – worsens with fasting, may be due to H. pylori infection or NSAID use.
    • Gastric malignancy – rare, but requires exclusion if red flags present.
  • Discuss initial management:
    • Lifestyle modifications:
      • Smaller, more frequent meals.
      • Avoid spicy foods, caffeine, alcohol, late-night eating.
      • Reduce stress and improve sleep.
    • Trial of medication:
      • Proton pump inhibitor (PPI) for 4-8 weeks if GORD suspected.
      • H. pylori testing if peptic ulcer suspected.
    • Follow-up in 4-6 weeks to assess response to treatment.
  • Discuss when further investigations (e.g., endoscopy) may be necessary.

Task 3: Address the patient’s concerns about serious illness and discuss appropriate investigations.

The competent candidate should:

  • Acknowledge the patient’s anxiety and provide balanced reassurance.
  • Explain that stomach cancer is unlikely, given:
    • No red flags such as weight loss, persistent vomiting, or gastrointestinal bleeding.
    • Symptoms are intermittent and triggered by diet and stress.
  • Outline a rational approach to investigations:
    • No immediate need for endoscopy unless symptoms persist or worsen.
    • H. pylori test (urea breath test or stool antigen test) if ulcer symptoms present.
    • Blood tests (FBC, iron studies) if concerned about anaemia or malabsorption.
  • Encourage ongoing monitoring and follow-up, ensuring red flags are addressed promptly.

Task 4: Develop a comprehensive management plan, including lifestyle advice, pharmacological options, and follow-up care.

The competent candidate should:

  • Non-pharmacological management:
    • Dietary modifications (avoiding large meals, fatty foods, alcohol, caffeine).
    • Stress management (mindfulness, relaxation techniques).
    • Regular physical activity to support digestion and reduce stress.
  • Pharmacological treatment:
    • PPI (e.g., esomeprazole, omeprazole) for 4-8 weeks.
    • H. pylori eradication therapy if positive.
    • Prokinetic agents if functional dyspepsia is suspected.
  • Investigations if symptoms persist or red flags appear:
    • Endoscopy if ongoing symptoms despite PPI therapy.
    • Abdominal ultrasound if concerned about gallbladder disease.
  • Follow-up in 4-6 weeks to review symptom progression and treatment response.

SUMMARY OF A COMPETENT ANSWER

  • Takes a comprehensive history, identifying symptom patterns, triggers, and red flags.
  • Provides a structured differential diagnosis, distinguishing functional vs. organic causes.
  • Reassures the patient while ensuring appropriate investigations.
  • Develops an evidence-based management plan, including lifestyle advice and medications.
  • Uses shared decision-making, particularly regarding investigations.
  • Provides clear follow-up recommendations to monitor symptom progression.

PITFALLS

  • Failing to assess red flags, such as unexplained weight loss or gastrointestinal bleeding.
  • Over-investigating (ordering an endoscopy prematurely without indication).
  • Neglecting lifestyle modifications, focusing only on medications.
  • Dismissing the patient’s concerns too quickly, leading to persistent anxiety.
  • Not providing clear follow-up, potentially missing progression to a significant condition.

REFERENCES

MARKING

Each competency area is rated 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 Engages the patient to understand their concerns and expectations.
1.2 Demonstrates active listening and empathy.
1.4 Explains diagnosis and management in a patient-centred manner.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history, including symptom characteristics and red flags.
2.2 Identifies risk factors and underlying causes of stomach dysfunction.

3. Diagnosis, Decision-Making and Reasoning

3.1 Establishes a working diagnosis based on history and clinical reasoning.
3.2 Differentiates between functional and organic causes of stomach dysfunction.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based management plan.
4.5 Provides pharmacological and non-pharmacological recommendations.
4.7 Uses shared decision-making to address patient concerns.

5. Preventive and Population Health

5.1 Identifies and addresses lifestyle factors contributing to symptoms.
5.2 Provides education on dietary and lifestyle modifications.

Competency at Fellowship Level

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