CCE-CE-139

CASE INFORMATION

Case ID: BLOOD-013
Case Name: Daniel Carter
Age: 45 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: B34 – Blood test abnormal, B99 – Other diseases of blood/lymph

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to understand concerns, ideas, and expectations
1.2 Provides clear explanations tailored to the patient’s level of health literacy
1.4 Uses effective consultation techniques, including active listening and empathy
2. Clinical Information Gathering and Interpretation2.1 Reviews abnormal blood test results in the clinical context
2.2 Identifies red flags requiring urgent referral or further investigation
3. Diagnosis, Decision-Making and Reasoning3.1 Develops a differential diagnosis based on abnormal blood/lymph findings
3.2 Determines the need for additional tests and referrals
4. Clinical Management and Therapeutic Reasoning4.1 Develops an evidence-based management plan
4.2 Provides appropriate follow-up and safety-netting
5. Preventive and Population Health5.1 Discusses relevant screening and lifestyle modifications
6. Professionalism6.1 Maintains patient confidentiality and demonstrates ethical practice
7. General Practice Systems and Regulatory Requirements7.1 Ensures appropriate follow-up, documentation, and specialist referrals
9. Managing Uncertainty9.1 Provides reassurance while addressing the possibility of serious underlying conditions
10. Identifying and Managing the Patient with Significant Illness10.1 Recognises abnormal haematological findings that may indicate serious disease

CASE FEATURES

  • Middle-aged male presenting for review of abnormal blood test results.
  • Mild anaemia and abnormal white cell count detected incidentally on routine blood tests.
  • Exploring possible causes, including nutritional deficiencies, chronic disease, bone marrow disorders, or haematological malignancies.
  • Balancing reassurance with the need for further investigation, ensuring appropriate referrals and follow-up.
  • Addressing patient concerns about the possibility of cancer.

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

Daniel Carter, a 45-year-old accountant, attended for a routine health check as part of a workplace screening program. He was feeling well with no significant symptoms, but his blood tests showed mild anaemia (low haemoglobin) and a slightly elevated white cell count.

Daniel is now concerned about what these results mean and whether he has a serious condition, such as leukaemia or another blood disorder.

PATIENT RECORD SUMMARY

Patient Details

Name: Daniel Carter
Age: 45
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • No known drug allergies

Medications

  • No regular medications

Past History

  • Mild hypertension, diet-controlled
  • No history of chronic illnesses or bleeding disorders

Social History

  • Works as an accountant, mostly sedentary lifestyle.
  • Low alcohol intake, occasional drink on weekends.

Family History

  • Father had bowel cancer at age 60.
  • No family history of blood disorders or leukaemia.

Smoking

  • Non-smoker

Alcohol

  • Drinks socially, 2-3 times per week

Vaccination and Preventative Activities

  • Last health check 3 years ago, no major concerns.

Recent Blood Test Results

  • Haemoglobin (Hb): 116 g/L (low, mild anaemia).
  • MCV: 76 fL (microcytosis).
  • Ferritin: 10 ng/mL (low).
  • White cell count: 12.5 ×10⁹/L (mildly elevated).
  • Neutrophils: 9.0 ×10⁹/L (upper normal limit).
  • Platelets: Normal.

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 got my blood test results back, and they said something was abnormal. Does this mean I have cancer?”

General Information

  • Your name is Daniel Carter, and you are 45 years old.
  • You work as an accountant, and your job is sedentary and high-stress.
  • You had a routine health check through work, where blood tests were done as part of screening.
  • You feel well overall and had no specific symptoms that led to these tests.

Specific Information

(Reveal only when asked directly)

Background Information

  • You don’t take any regular medications.
  • Your diet is not the best—you eat a lot of processed foods, not many vegetables, and very little red meat.
  • You are married with two children and live an active family life, though you rarely exercise.
  • You were told that your haemoglobin is low (mild anaemia) and your white cell count is slightly high.
  • You feel a little tired in the afternoons, but you assumed it was due to work stress.
  • You have not noticed any bruising, bleeding, infections, or other signs of illness.
  • You were not expecting any issues in your blood test, and now you are worried about a serious condition like leukaemia or cancer.

Symptoms

  • No fever, chills, or night sweats.
  • No unintentional weight loss.
  • No persistent infections or recurrent colds.
  • No unusual bruising or prolonged bleeding.
  • No changes in appetite or digestion.

Fatigue and Energy Levels

  • You feel mild tiredness in the afternoon, but it is not extreme.
  • You don’t feel dizzy or short of breath.
  • You sometimes feel a bit light-headed if you skip a meal.

Lifestyle and Diet

  • Your diet consists mainly of processed foods, takeaway, and minimal vegetables.
  • You don’t eat much red meat, and your iron intake is probably low.
  • You do not take iron or vitamin supplements.
  • You drink alcohol 2-3 times per week, usually socially.
  • You are not very physically active, apart from walking occasionally.

Family History

  • Your father was diagnosed with bowel cancer at age 60.
  • No family history of leukaemia or blood disorders.

Concerns and Expectations

  • You are worried this could mean leukaemia, cancer, or something serious.
  • You want to know what is causing the abnormal results.
  • You wonder if this could be fixed with diet or if you will need medication.
  • You are concerned that this might mean you need long-term treatment.
  • You want to know if further tests are necessary.
  • You are open to lifestyle changes if they will improve your health.
  • You are nervous about undergoing invasive procedures like a bone marrow biopsy.

Red Flag Symptoms (Reveal only when asked directly)

  • No severe or persistent fatigue.
  • No enlarged lymph nodes or lumps.
  • No recurrent infections or slow-healing wounds.
  • No bone pain or joint pain.
  • No blood in stools or unusual bleeding.

Emotional Cues & Body Language

  • You appear concerned but not panicked.
  • If the doctor is vague or avoids answering directly, you will ask:
    • “But could this be something serious like leukaemia?”
  • If the doctor suggests waiting before more tests, you may ask:
    • “Wouldn’t it be better to find out sooner rather than later?”
  • If the doctor mentions diet or lifestyle, you may seem skeptical at first but will be open to change if explained well.
  • If the doctor reassures you with clear explanations and a structured plan, you will feel relieved and ready to follow their advice.

Questions for the Candidate

(Ask these naturally throughout the consultation.)

  1. “Do I have leukaemia? Is this serious?”
  2. “Why is my white cell count high? Could this mean an infection?”
  3. “What’s causing my anaemia? Could it be cancer?”
  4. “Do I need any more tests? Will I need a bone marrow biopsy?”
  5. “Can I fix this with diet, or do I need medication?”
  6. “How will I know if this gets worse? What symptoms should I look for?”
  7. “Does my family history of bowel cancer mean I need more tests?”
  8. “What should I do next to improve my health?”

Key Behaviours & Approach

  • You are worried but logical, wanting a clear explanation and structured next steps.
  • If the doctor only mentions diet and lifestyle, you may press for more immediate answers or further testing.
  • If the doctor focuses too much on ruling out leukaemia, you may ask:
    • “But if it’s not leukaemia, what else could it be?”
  • If the doctor doesn’t suggest follow-up, you may ask:
    • “So when should I come back to check on this?”
  • If the doctor provides a clear explanation and plan, you will feel reassured and motivated to improve your health.

Additional Context for the Role-Player

  • You are not expecting a serious diagnosis, but the abnormal test results have made you anxious.
  • You trust medical advice but want a clear understanding of what is happening.
  • You are open to lifestyle changes, but you need practical advice rather than vague suggestions.
  • You are not in a hurry to take medication or undergo procedures unless absolutely necessary.

Role-Player Summary

This case assesses the candidate’s ability to:

  • Interpret abnormal blood test results and provide a structured explanation.
  • Formulate a differential diagnosis, considering nutritional deficiency, chronic disease, and haematological conditions.
  • Offer appropriate next steps, including iron studies, further blood tests, and possible colon cancer screening.
  • Address patient concerns empathetically, particularly regarding cancer fears.
  • Ensure safety-netting and follow-up, providing clear guidance on when to return if symptoms develop.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Explain the abnormal blood test results to the patient in clear, non-alarming language.

The competent candidate should:

  • Acknowledge the patient’s concerns and explain that the findings are mild abnormalities that require further clarification but are not immediately concerning.
  • Explain the findings in simple terms:
    • “Your haemoglobin is slightly low, which means mild anaemia. This could be due to low iron levels, diet, or another cause.”
    • “Your white cell count is a little high, which can be from minor infections, inflammation, or other factors.”
  • Clarify that these results do not confirm a serious disease but that further tests are needed to understand the cause.
  • Use visual aids or analogies (if appropriate) to explain what haemoglobin and white blood cells do in the body.
  • Encourage patient participation, asking:
    • “Have you ever had anaemia before?”
    • “Do you recall feeling unusually tired or weak?”
  • Set expectations for the next steps, avoiding unnecessary alarm while ensuring appropriate follow-up.

Task 2: Formulate a differential diagnosis and explain the next steps in investigation.

The competent candidate should:

  • Discuss possible causes of mild anaemia and white cell elevation, categorising them into:
    • Nutritional deficiencies (low iron intake, low vitamin B12 or folate).
    • Chronic disease anaemia (e.g., kidney disease, chronic inflammation).
    • Blood loss causes (possible undiagnosed gastrointestinal bleeding, given family history of bowel cancer).
    • Bone marrow disorders or haematological malignancy (unlikely but important to consider).
  • Explain that further tests will clarify the cause, including:
    • Iron studies, ferritin, and transferrin saturation to assess iron stores.
    • FBC repeat in 4-6 weeks to track trends.
    • CRP/ESR if inflammation is suspected.
    • FOBT (faecal occult blood test) or referral for colonoscopy, given family history of bowel cancer.
  • Provide reassurance while balancing the need for appropriate investigation:
    • “In most cases, this is not serious, but we need to be thorough to rule out all possible causes.”

Task 3: Address the patient’s concerns, including fear of serious illness and the need for follow-up tests.

The competent candidate should:

  • Acknowledge the patient’s anxiety about cancer or leukaemia, and provide logical reassurance based on findings:
    • “Leukaemia usually presents with very different findings, such as very high or low white cell counts, bleeding, or recurrent infections, none of which you have.”
  • Explain why further tests are needed, focusing on finding the correct cause rather than assuming the worst.
  • Discuss lifestyle modifications that may help improve blood results, such as increasing iron-rich foods.
  • Address any misconceptions about the need for invasive tests:
    • “A bone marrow biopsy is not necessary at this stage, and we will only consider it if further tests raise concerns.”
  • Provide a clear follow-up plan, ensuring the patient understands when and why they need to return.

Task 4: Develop an initial management plan, including further investigations, lifestyle modifications, and follow-up.

The competent candidate should:

  • Order follow-up investigations, including:
    • Iron studies, ferritin, transferrin saturation.
    • Repeat full blood count (FBC) in 4-6 weeks.
    • FOBT screening, considering family history of bowel cancer.
    • Additional tests if clinically indicated (e.g., B12, folate, renal function).
  • Discuss dietary modifications, encouraging iron-rich foods (red meat, green leafy vegetables, legumes).
  • Encourage lifestyle changes, including regular exercise and reducing processed foods.
  • Arrange follow-up in 2-4 weeks for results, with a clear plan if results indicate further concerns.
  • Provide safety-netting, advising the patient to return sooner if they develop fatigue, breathlessness, weight loss, or easy bruising.

SUMMARY OF A COMPETENT ANSWER

  • Explains the abnormal blood test results clearly, without unnecessary alarm.
  • Provides a structured differential diagnosis, categorising nutritional, inflammatory, and haematological causes.
  • Reassures the patient appropriately, balancing concern with the need for further investigation.
  • Develops an evidence-based management plan, including further investigations, lifestyle advice, and follow-up.
  • Ensures appropriate safety-netting, advising when to return for review.

PITFALLS

  • Over-reassuring the patient without investigating further, potentially missing an underlying serious cause.
  • Failing to explore red flags, such as undiagnosed gastrointestinal bleeding or malignancy risk.
  • Not addressing lifestyle factors, missing an opportunity for dietary and behavioural improvements.
  • Ordering unnecessary tests, increasing patient anxiety and healthcare costs.
  • Not providing clear follow-up instructions, leaving the patient unsure of next steps.

REFERENCES

MARKING

Each competency area is assessed 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 patient’s concerns and sociocultural context.
1.2 Engages the patient to gather information about symptoms, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Elicits a comprehensive history, including dietary habits, risk factors, and red flags.
2.2 Orders appropriate investigations, balancing clinical suspicion and patient anxiety.

3. Diagnosis, Decision-Making and Reasoning

3.1 Develops a structured differential diagnosis, prioritising common and serious causes.
3.2 Identifies indications for further assessment or referral, ensuring red flags are addressed.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops a structured, evidence-based treatment plan, incorporating investigations, dietary changes, and screening.
4.2 Ensures appropriate pharmacological and non-pharmacological management, promoting preventive health.

5. Preventive and Population Health

5.1 Discusses screening and preventive measures, including diet, iron intake, and bowel cancer screening.

6. Professionalism

6.1 Maintains confidentiality and ethical decision-making.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures accurate documentation and appropriate follow-up.

9. Managing Uncertainty

9.1 Provides reassurance and safety-netting, ensuring the patient understands when to seek further medical care.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises features suggestive of serious disease requiring escalation.

Competency at Fellowship Level

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