CASE INFORMATION

Case ID: CCE-AnalFissure-001
Case Name: Daniel Thompson
Age: 38
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: D92 (Anal Fissure), D95 (Perianal Abscess)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Uses appropriate communication for the patient’s sociocultural background. 1.2 Engages the patient to gather information about symptoms, concerns, and healthcare expectations. 1.4 Communicates effectively in routine and sensitive situations.
2. Clinical Information Gathering and Interpretation	2.1 Gathers focused history relevant to perianal pain and bleeding. 2.2 Identifies red flags requiring urgent referral.
3. Diagnosis, Decision-Making, and Reasoning	3.1 Formulates an appropriate differential diagnosis. 3.2 Uses clinical reasoning to differentiate between anal fissure, perianal abscess, haemorrhoids, and other anorectal conditions.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops an appropriate management plan, including conservative and procedural interventions. 4.2 Considers pain management, dietary changes, and surgical referral if needed.
5. Preventive and Population Health	5.1 Provides education on dietary fibre intake and bowel habits to prevent recurrence.
6. Professionalism	6.1 Provides patient-centred care with sensitivity regarding an intimate concern.
7. General Practice Systems and Regulatory Requirements	7.1 Recognises when to refer to a colorectal surgeon for abscess drainage.
8. Procedural Skills	8.1 Describes indications for incision and drainage of a perianal abscess.
9. Managing Uncertainty	9.1 Addresses diagnostic uncertainty and appropriate investigations for persistent or atypical symptoms.
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies features concerning for anorectal cancer or fistula formation.

CASE FEATURES

No history of inflammatory bowel disease or prior anorectal procedures.
38-year-old male presenting with perianal pain and bleeding.
History of constipation and difficulty passing stool.
Pain described as sharp, tearing, worst during defecation, with some lingering discomfort.
Occasional bright red blood on toilet paper but no dark stool or melena.
Reports swelling and tenderness near the anus, worsened in the last 3 days.
No fevers or systemic symptoms.
Mild anxiety due to embarrassment and fear of cancer.

INSTRUCTIONS

You have 15 minutes to complete this consultation.

Treat this as a face-to-face consultation.

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

Daniel Thompson, a 38-year-old male, presents to your clinic with a 3-week history of sharp anal pain that worsens when passing stool. He reports occasional bright red blood on toilet paper, increasing swelling and discomfort near the anus in the last 3 days.

He is visibly uncomfortable, shifting in his seat, and embarrassed about discussing his symptoms. He has no fevers or systemic illness but is worried about cancer due to rectal bleeding.

PATIENT RECORD SUMMARY

Patient Details

Name: Daniel Thompson
Age: 38
Gender: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies.

Medications

No regular medications.

Past History

Occasional constipation.
No history of inflammatory bowel disease or previous anorectal conditions.

Social History

Works as an office manager (sedentary lifestyle).

Family History

No family history of colorectal cancer or inflammatory bowel disease.

Smoking & Alcohol

Smoking: 10 cigarettes/day.
Alcohol: 3-4 standard drinks/week.

Vaccination & Preventative Activities

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:

“Hi Doc, this is a bit embarrassing, but I’ve been having some pain and bleeding down there, and I just want to make sure it’s nothing serious.”

General Information

(Freely Shareable if Asked Open-Ended Questions):

The pain started around three weeks ago and has been getting progressively worse.
It feels like a sharp, tearing pain when passing stool, followed by a throbbing ache that lasts for hours.
There is bright red blood on toilet paper after bowel movements, but not mixed in the stool.
Recently noticed a small swollen lump near the anus, which has become increasingly tender over the last three days.
No fevers, weight loss, or night sweats.
Has not tried any treatments yet, apart from using toilet wipes instead of toilet paper.

Specific Information

(Only if Asked Targeted Questions):

Pain and Symptoms:

The pain is worse when passing stool, sometimes making the patient dread going to the toilet.
Sitting for long periods, especially at work, makes the discomfort worse.
The swollen lump near the anus is now constantly tender, particularly when sitting or walking.
Has not noticed any pus or discharge, but the area around the swelling feels warm.

Bowel Habits and Diet:

Bowel movements are infrequent and hard—sometimes going every three days.
Often strains on the toilet and spends a long time sitting.
Diet is low in fibre—typically eats a lot of takeaway food and processed meals.
Drinks very little water during the day—mostly coffee and soft drinks.
No diarrhoea or mucus in the stool.

Medical and Lifestyle History:

No history of anal trauma, anal sex, or rectal surgeries.
No previous episodes of perianal pain or bleeding.
No family history of bowel cancer or inflammatory bowel disease.
Smokes 10 cigarettes per day.
Drinks alcohol socially (3-4 drinks per week).
Works in an office job, sitting for long hours with minimal physical activity.

Emotional and Behavioural Cues:

Embarrassed about the problem, initially hesitant to go into detail.
Avoids direct eye contact when discussing symptoms.
Anxious about the bleeding, fearing it could be cancer.
Frustrated with the constipation, but unaware of dietary and lifestyle impact.
Visibly uncomfortable, shifting in the chair due to the pain.

Patient’s Concerns (To be Addressed by the Candidate):

Concern #1: “Is this cancer?”

“I know I shouldn’t Google things, but I did… and I read that rectal bleeding can be a sign of bowel cancer. I’m really worried—do I need a colonoscopy?”

Emotional Cue: Appears nervous and fidgety while waiting for reassurance.

Concern #2: “Do I need surgery?”

“I’ve heard people with anal problems sometimes need surgery… I really don’t want that. Is there any way this can heal on its own?”

Emotional Cue: Looks worried and tense.

Concern #3: “What can I do to stop this from happening again?”

“This has been so painful—I don’t want it to happen again. Is there anything I should be doing differently?”

Emotional Cue: Open to lifestyle and dietary advice but seems unaware of proper bowel habits.

Concern #4: “Will I need antibiotics?”

“Since there’s swelling, does that mean I need antibiotics? Will it go away if I just take some tablets?”

Emotional Cue: Expecting a prescription, but willing to listen to other treatment options.

Additional Questions the Patient May Ask:

“Will this get worse if I don’t do anything about it?”
“Can I use something over-the-counter to help with the pain?”
“Do I need to take time off work?”
“Could this be related to haemorrhoids?”

How the Role-Player Should Respond to Explanations:

If the candidate reassures the patient that cancer is unlikely → The patient should visibly relax but still want clarification about whether further tests are needed.
If the candidate explains that surgery is not needed right now → The patient should appear relieved but ask what will happen if symptoms don’t improve.
If the candidate suggests increasing fibre and water intake → The patient should express mild surprise, as they hadn’t realised diet played such a big role.
If the candidate mentions pain relief options → The patient should nod and appear more comfortable.

Ending the Consultation:

“Thanks, Doc. I feel a lot better knowing this isn’t something serious. I’ll try the diet changes and the treatment you suggested. If things don’t get better, I’ll come back.”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history from the patient regarding their anal pain and bleeding.

The competent candidate should:

Use an empathetic and non-judgmental approach to help the patient feel comfortable discussing a sensitive issue.
Explore the pain characteristics (onset, duration, severity, relation to bowel movements, any aggravating or relieving factors).
Ask about bleeding pattern (colour of blood, frequency, whether it is mixed in stool or only on wiping).
Inquire about associated symptoms (swelling, discharge, itchiness, fever, weight loss, night sweats).
Assess bowel habits and lifestyle factors (dietary fibre intake, hydration, stool consistency, straining, time spent on the toilet).
Screen for red flag symptoms (unexplained weight loss, family history of bowel cancer, changes in stool calibre).

Task 2: Explain the likely diagnosis and differentials to the patient in a clear and reassuring manner.

The competent candidate should:

Explain that the symptoms are most consistent with an anal fissure or a perianal abscess.
Differentiate fissure vs haemorrhoids vs abscess vs colorectal pathology.
Provide reassurance that bowel cancer is unlikely, given the bright red blood, pain with defecation, and absence of systemic symptoms.
Use clear and simple language, avoiding jargon while ensuring patient understanding.

Task 3: Develop a patient-centred management plan, including lifestyle modifications, pharmacological treatment, and follow-up recommendations.

The competent candidate should:

Encourage dietary modifications: Increase fibre intake (fruits, vegetables, whole grains), hydration, and avoid constipation.
Discuss toilet habits: Avoid straining, limit time on the toilet, and use proper wiping techniques.
Prescribe first-line treatments: Topical GTN or diltiazem for fissures, analgesia (paracetamol/NSAIDs), stool softeners (Movicol, Coloxyl).
Educate about red flag symptoms requiring urgent follow-up (worsening pain, fever, purulent discharge, systemic symptoms).
Plan follow-up: If symptoms persist beyond 6 weeks or worsen, consider referral for further assessment (e.g., colorectal surgeon).

SUMMARY OF A COMPETENT ANSWER

Elicits a thorough history, including red flag symptoms and contributing lifestyle factors.
Explains the likely diagnosis clearly, ruling out serious conditions while addressing patient concerns.
Provides evidence-based management, including dietary advice, medications, and self-care strategies.
Ensures a patient-centred approach, addressing embarrassment, concerns, and the impact on quality of life.

PITFALLS

Failing to ask about red flag symptoms (e.g., weight loss, systemic signs, changes in bowel habits).
Dismissing the patient’s concerns about cancer without appropriate explanation and reassurance.
Over-prescribing antibiotics when an abscess is not confirmed.
Not providing preventive advice (fibre intake, hydration, stool softeners) to prevent recurrence.
Ignoring emotional cues and not addressing the patient’s embarrassment or distress.

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 Obtains an appropriate history in a sensitive manner, considering the patient’s discomfort.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies anal fissure or perianal abscess as the most likely diagnosis based on history.
3.2 Considers appropriate differential diagnoses and rules out serious conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an effective and evidence-based management plan.
4.2 Provides practical lifestyle modifications to prevent recurrence.

5. Preventive and Population Health

5.1 Advises on lifestyle modifications to reduce the risk of constipation and recurrence.

6. Professionalism

6.1 Displays professionalism and sensitivity when discussing an embarrassing condition.

9. Managing Uncertainty

9.1 Reassures patient while ensuring red flag symptoms are appropriately investigated.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises when referral or further investigations are warranted.

Competency at Fellowship Level

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