CCE-CE-155 - GP Exams

CASE INFORMATION

Case ID: IBD-2024-01
Case Name: Sarah Thompson
Age: 27
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2024
ICPC-2 Codes: D94 (Inflammatory Bowel Disease)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Communicates appropriately to the person and the sociocultural context. 1.2 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations. 1.4 Communicates effectively in routine and complex situations.
2. Clinical Information Gathering and Interpretation	2.1 Obtains a detailed history to assess the severity and impact of symptoms. 2.2 Interprets clinical findings and selects appropriate investigations.
3. Diagnosis, Decision-Making and Reasoning	3.1 Identifies and differentiates inflammatory bowel disease from other gastrointestinal conditions. 3.2 Synthesises information to formulate a diagnosis and justify clinical reasoning.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an evidence-based management plan, including pharmacological and non-pharmacological strategies. 4.2 Coordinates specialist referral and ongoing monitoring.
5. Preventive and Population Health	5.1 Provides patient education regarding lifestyle, dietary modifications, and medication adherence.
6. Professionalism	6.1 Demonstrates patient-centred care, empathy, and sensitivity.
7. General Practice Systems and Regulatory Requirements	7.1 Recognises indications for specialist referral and ensures appropriate follow-up.
9. Managing Uncertainty	9.1 Addresses diagnostic uncertainty while ensuring patient safety.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises red flags and escalates care as needed.

CASE FEATURES

Patient is concerned about long-term complications and medication side effects.
27-year-old female presenting with chronic diarrhoea, abdominal pain, and weight loss.
Recent increase in symptoms, including blood in stools and fatigue.
Strong family history of Crohn’s disease.
Intermittent symptoms for two years, but worsening in the last six months.

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

Sarah Thompson, a 27-year-old woman, presents with a six-month history of worsening diarrhoea, abdominal pain, and weight loss. She describes having four to five loose stools per day, occasionally with blood and mucus. She has lower abdominal cramping, worse after eating, and reports significant fatigue.

Over the last three months, her symptoms have become more severe. She has lost 6 kg unintentionally and is now feeling exhausted at work.

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Thompson
Age: 27
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies.

Medications

None currently.

Past History

No significant medical history.

Social History

Works as a marketing executive.
Non-smoker, drinks socially.

Family History

Mother has Crohn’s disease, diagnosed at 40.
No family history of colorectal cancer.

Smoking

Never smoked.

Alcohol

3-4 standard drinks per week.

Vaccination and Preventative Activities

Pap smear and HPV screening normal (last done one year ago).
Up to date with childhood 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 having stomach problems for months now, and it’s getting worse. I’m worried I might have Crohn’s like my mum.”

General Information

You are Sarah Thompson, a 27-year-old marketing executive living with your partner. For the past six months, you have been experiencing persistent diarrhoea, abdominal pain, and weight loss. You initially thought it was due to stress and diet, but symptoms have worsened. You are concerned about long-term effects, fertility, and whether you have a serious illness like your mother’s Crohn’s disease.

Specific Information

Only reveal if the candidate asks relevant questions.

Background Information

Diarrhoea: Loose stools 4-5 times a day for six months, sometimes with blood and mucus.
Abdominal pain: Cramping and discomfort, mainly in the lower abdomen. Worse after eating, but no severe night-time pain.
Bloating: Feels gassy and bloated, especially in the evenings.
Fatigue: Constantly tired, struggles to keep up with work.
Weight loss: Lost 6 kg in three months unintentionally.
Diet: Generally healthy but avoids dairy because it “seems to make things worse.” Noticed that spicy and greasy foods also trigger discomfort.
Smoking & Alcohol: Never smoked, drinks 3-4 standard drinks per week.
Exercise: Used to go to the gym but has stopped due to fatigue.
Stress: No major life stressors, but work can be busy and demanding.

Emotional Cues

Anxious: You’re worried about having Crohn’s disease and what that means for your future.
Frustrated: You feel like previous doctors didn’t take your concerns seriously.
Hopeful: You want answers and a proper plan to help you feel better.

If the doctor is dismissive, you should express frustration and ask for more investigations.

Questions for the Candidate

You should ask these questions naturally during the consultation:

“Do you think I have Crohn’s disease?”
“What kind of tests do I need? Is a colonoscopy painful?”
“If it’s Crohn’s, will I have to take medication forever?”
“Will this affect my ability to have children?”
“Can stress make this worse?”

Possible Responses to the Candidate’s Explanations

If the candidate mentions a colonoscopy, you can say:
“I’ve heard those can be really painful. Is there another way to diagnose this?”
If they mention dietary changes, you can say:
“I’ve already tried cutting out dairy, but it hasn’t helped much. What else should I do?”
If they recommend medications, you can ask:
“Are there any side effects? I don’t want to be on medication forever.”
If they say stress is a trigger, you can say:
“I don’t feel particularly stressed, so I don’t understand why this is happening.”

Key Points to Portray as the Role-Player

Realistic frustration and concern: You want to be taken seriously.
Hopefulness for a diagnosis: You are ready to take action if the doctor gives you a clear plan.
Mild scepticism about medications and tests: You need reassurance.

Ending the Consultation

Once the candidate has explained the diagnosis, tests, and management plan, you can say:

“Okay, I feel a little better knowing we have a plan. I just want to feel normal again. Thank you for taking the time to explain everything.”

Summary of the Role-Player’s Character

27-year-old female with worsening diarrhoea, weight loss, and abdominal pain.
Concerned about Crohn’s disease due to family history.
Tired, frustrated, and seeking a proper diagnosis and treatment.
Asks reasonable but emotionally charged questions.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient, focusing on gastrointestinal symptoms, impact on quality of life, and relevant risk factors.

The competent candidate should:

Establish the onset, duration, and severity of symptoms, including diarrhoea, abdominal pain, weight loss, bloating, and fatigue.
Explore triggers and relieving factors, including dietary modifications and stress levels.
Clarify the presence of red flags, such as bloody stools, nocturnal symptoms, fever, or anaemia symptoms.
Take a family history, particularly regarding Crohn’s disease or ulcerative colitis.
Assess the psychosocial impact, including effects on work, social life, and emotional wellbeing.

Task 2: Outline the key differential diagnoses and discuss the most likely diagnosis with the patient.

The competent candidate should:

Recognise Inflammatory Bowel Disease (IBD) (likely Crohn’s disease) as a leading diagnosis based on chronic diarrhoea, weight loss, family history, and blood in stools.
Differentiate from other conditions, such as:
- Irritable Bowel Syndrome (IBS) – lacks red flags but can cause similar symptoms.
- Coeliac Disease – requires exclusion, given symptom overlap.
- Infectious Gastroenteritis or Parasitic Infection – particularly with travel history.
- Colorectal Malignancy – consider given weight loss and bleeding but less likely in a 27-year-old.
Explain the chronic nature of IBD, its potential complications, and need for further investigations.

Task 3: Explain the investigations required to confirm the diagnosis.

The competent candidate should:

Justify initial blood tests, including:
- Full blood count (FBC) – assess for anaemia, infection, or inflammation.
- C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) – markers of inflammation.
- Iron studies and vitamin B12 – check for deficiencies due to malabsorption.
- Liver function tests (LFTs) and albumin – assess nutritional status and liver involvement.
Explain the need for a faecal calprotectin test, which is highly suggestive of IBD if elevated.
Discuss stool cultures to rule out infections and parasites.
Justify the need for colonoscopy with biopsy to confirm Crohn’s disease or ulcerative colitis.
Address patient concerns about colonoscopy discomfort and necessity.

Task 4: Develop a management plan, addressing lifestyle, medical therapy, and patient concerns.

The competent candidate should:

Provide reassurance and education about the chronic but manageable nature of IBD.
Discuss initial symptom management:
- Dietary advice: Consider a low-fibre or low-residue diet during flares.
- Lifestyle modifications: Stress management and regular follow-ups.
Introduce medical therapy options:
- 5-ASA drugs (e.g., mesalazine) for mild disease.
- Corticosteroids (e.g., prednisolone) for acute flares.
- Immunomodulators (e.g., azathioprine, methotrexate) if required.
- Biologic therapies for severe cases.
Discuss fertility concerns, explaining that IBD does not prevent pregnancy, but active disease should be well-controlled.
Arrange referral to a gastroenterologist for ongoing care and treatment.
Discuss the importance of long-term monitoring for complications, including osteoporosis, strictures, and malignancy risks.

SUMMARY OF A COMPETENT ANSWER

Comprehensive history covering gastrointestinal symptoms, family history, and psychosocial impact.
Clear differential diagnosis, with emphasis on Crohn’s disease while ruling out IBS, coeliac disease, and infections.
Appropriate investigations, including blood tests, faecal calprotectin, stool studies, and colonoscopy.
Patient-centred management plan, addressing diet, medication, fertility concerns, and specialist referral.
Empathetic communication, acknowledging patient concerns and uncertainties.

PITFALLS

Failing to recognise red flags (e.g., weight loss, bloody stools, persistent diarrhoea).
Not considering differential diagnoses beyond IBD.
Overlooking the psychosocial impact, including work, mental health, and fertility concerns.
Not explaining the need for colonoscopy clearly, leading to patient resistance or anxiety.
Omitting referral to a specialist when necessary.

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.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Gathers and interprets clinical information appropriately to develop a differential diagnosis and a patient-centred management plan.

3. Diagnosis, Decision-Making and Reasoning

3.2 Formulates a differential diagnosis based on history and available clinical findings.

4. Clinical Management and Therapeutic Reasoning

4.3 Develops a safe and patient-centred management plan, considering both medical and lifestyle interventions.

5. Preventive and Population Health

5.1 Advises on long-term health risks and preventive strategies, such as dietary modifications and monitoring for complications.

6. Professionalism

6.2 Recognises the limits of their expertise and refers appropriately when specialist input is required.

7. General Practice Systems and Regulatory Requirements

7.1 Demonstrates appropriate use of diagnostic pathways and referral systems.

9. Managing Uncertainty

9.1 Recognises when a definitive diagnosis is not immediately possible and explains a structured approach to investigations and follow-up.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and appropriately manages patients with chronic, complex, or progressive conditions.

Competency at Fellowship Level

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