CCE-CE-187

CASE INFORMATION

Case ID: CCE-2025-006
Case Name: James Reynolds
Age: 49 years
Gender: Male
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: D01 (Dyspepsia/indigestion), D86 (Gastro-oesophageal reflux disease), D87 (Peptic ulcer)

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Engages the patient to understand their ideas, concerns, and expectations.
1.2 Develops a respectful and empathetic doctor-patient relationship.
1.4 Provides appropriate patient-centred explanations.
2. Clinical Information Gathering and Interpretation2.1 Gathers relevant history, including systemic and red flag symptoms.
2.2 Selects and interprets appropriate investigations.
3. Diagnosis, Decision-Making and Reasoning3.1 Develops a differential diagnosis based on clinical findings.
3.5 Identifies red flag symptoms requiring urgent referral.
4. Clinical Management and Therapeutic Reasoning4.1 Formulates a safe and evidence-based management plan.
4.3 Provides appropriate follow-up and monitoring.
5. Preventive and Population Health5.2 Addresses modifiable risk factors for gastrointestinal disease.
6. Professionalism6.1 Maintains patient confidentiality and professional integrity.
7. General Practice Systems and Regulatory Requirements7.1 Orders appropriate tests in accordance with MBS guidelines.
9. Managing Uncertainty9.2 Develops a plan for a patient with an unclear diagnosis.
10. Identifying and Managing the Patient with Significant Illness10.1 Recognises and acts on life-threatening conditions.

CASE FEATURES

  • Middle-aged male presenting with three months of intermittent upper abdominal discomfort and indigestion.
  • Describes symptoms as burning and discomfort after meals, sometimes associated with mild nausea.
  • Reports occasional reflux symptoms, particularly after eating spicy foods or drinking alcohol.
  • No weight loss, difficulty swallowing, or overt red flag symptoms, but is concerned about a serious stomach issue or cancer.
  • Requires clinical reasoning to differentiate between functional dyspepsia, gastro-oesophageal reflux disease (GORD), peptic ulcer disease (PUD), and Helicobacter pylori infection.

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

James Reynolds, a 49-year-old male, presents to your clinic with a three-month history of indigestion and upper abdominal discomfort. He describes the discomfort as a burning sensation in the upper stomach that occurs after meals and is sometimes associated with mild nausea. He has noticed that spicy foods, coffee, and alcohol seem to worsen his symptoms, but he has not made significant dietary changes.

PATIENT RECORD SUMMARY

Patient Details

Name: James Reynolds
Age: 49 years
Gender: Male
Gender Assigned at Birth: Male
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • Ramipril 5 mg daily (Hypertension)
  • Occasional ibuprofen for back pain

Past History

  • Hypertension (diagnosed 5 years ago)
  • No known gastrointestinal diseases

Social History

  • Works as a construction manager, often eats takeaway meals due to busy work hours.
  • Smokes 5 cigarettes per day for the past 20 years.
  • Drinks 3-4 standard drinks per week, mostly beer.

Family History

  • Father: Peptic ulcer disease in his 50s.
  • Mother: Alive, hypertension.
  • No known family history of stomach cancer.

Vaccination and Preventative Activities

  • Up to date with vaccinations.
  • Last health check one year ago.

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 this burning sensation in my stomach after meals for a few months now. It’s not going away, and I’m starting to worry it could be something serious.”

General Information

(Freely Shared if Asked Open-Ended Questions)

  • The symptoms started about three months ago and have been getting more frequent.
  • You feel a burning pain or discomfort in the upper stomach, mostly after eating.
  • The discomfort is worse after spicy foods, coffee, and alcohol.
  • You feel bloated at times but have not had vomiting, black stools, or noticeable weight loss.

Specific Information

(Only Revealed if the Candidate Asks Targeted Questions)

Background Information

  • The symptoms are not severe enough to wake you up at night, but they are bothersome.
  • You sometimes take ibuprofen for back pain, usually a few times a week.
  • You have not tried any medications for the indigestion yet.
  • You feel fine otherwise, apart from the stomach discomfort.

Symptoms and Triggers

  • The pain is mostly after eating, especially greasy or spicy foods.
  • No trouble swallowing or food getting stuck.
  • You haven’t noticed your stools changing colour.
  • The discomfort sometimes improves with milk or antacids.
  • Stress doesn’t seem to affect the symptoms, but you have a busy job.
  • No nausea in the mornings and no vomiting after meals.
  • You haven’t been sick recently and haven’t travelled overseas.

Lifestyle & Risk Factors

  • You smoke 5 cigarettes per day and have done so for 20 years.
  • You drink beer 3-4 times a week, usually 1-2 drinks at a time.
  • You eat takeaway food often due to work, mainly fried foods, sandwiches, and fast food.
  • Your father had a stomach ulcer in his 50s but never had cancer.
  • You exercise only occasionally, as your job is quite physical.
  • You are taking ramipril for high blood pressure, which has been well controlled.

Emotional Cues & Concerns

  • You are worried about cancer because you read online that indigestion can be a symptom.
  • You are frustrated because the symptoms are not going away.
  • You want to know what tests are needed and if this will require long-term medication.
  • You are concerned about needing an endoscopy and whether the procedure is safe.

Questions for the Candidate

(Drop these in naturally throughout the consultation)

  1. “What do you think is causing this? Should I be worried?”
  2. “Do I need an endoscopy? Is this cancer?”
  3. “Could this be an ulcer? What causes ulcers?”
  4. “Will I need medication, or can this be managed with diet?”
  5. “Should I stop taking ibuprofen for my back pain?”
  6. “If this is reflux, will I have to take tablets forever?”
  7. “Is there anything I can do to prevent this from getting worse?”

How to Respond Based on the Candidate’s Answers

If the Candidate Provides a Clear Explanation and Plan:

  • You feel relieved but still a little anxious.
  • You may ask for clarification on next steps, such as:
    • “So, you think this is more likely reflux or an ulcer, not something serious?”
    • “And if I follow the treatment plan, I should feel better soon?”
  • You agree to the investigations and follow-up plan.

If the Candidate is Unclear or Dismissive:

  • You become more anxious and insist on further testing.
  • You might push for urgent tests or an immediate referral:
    • “I just don’t want to take any chances. Can we do an endoscopy right away?”
    • “What if this turns out to be something serious and we miss it?”
    • “How do you know this isn’t cancer?”

Ending the Consultation

If the Candidate Has Done Well:

  • You feel somewhat reassured and agree to the plan.
  • You might still confirm:
    • “So, I should come back in a few weeks if I don’t feel better?”
    • “You’ll call me when the test results are in?”
  • You thank the doctor and leave with a clear idea of what to do next.

If the Candidate Has Not Addressed Your Concerns Well:

  • You remain doubtful and uneasy.
  • You may say:
    • “I think I might get a second opinion. I just want to be sure.”
    • “I’m still not sure if this is something serious.”
  • You leave feeling frustrated and uncertain about your next steps.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including red flag symptoms and relevant risk factors.

The competent candidate should:

  • Use open-ended questions to allow the patient to describe symptoms, then follow up with targeted questions.
  • Establish onset, duration, and pattern of dyspepsia, identifying aggravating and relieving factors.
  • Identify red flag symptoms (weight loss, progressive dysphagia, persistent vomiting, haematemesis, melaena, anaemia, new-onset symptoms in patients over 50).
  • Assess for gastro-oesophageal reflux disease (GORD) symptoms, such as heartburn, regurgitation, and postural association.
  • Explore risk factors for peptic ulcer disease (NSAID use, Helicobacter pylori infection, smoking, alcohol use).
  • Evaluate family history, particularly of peptic ulcers and gastrointestinal malignancy.
  • Assess psychosocial impact and patient concerns regarding cancer.

Task 2: Discuss your differential diagnosis with the patient.

The competent candidate should:

  • Explain that dyspepsia has multiple possible causes, most of which are benign and treatable.
  • Discuss most likely differentials:
    • Gastro-oesophageal reflux disease (GORD): Burning retrosternal discomfort, worse after meals, improved with antacids.
    • Functional dyspepsia: Chronic indigestion without an identifiable cause, linked to stress or diet.
    • Peptic ulcer disease (PUD): Associated with NSAID use, H. pylori infection, and potential for complications.
    • Medication-related dyspepsia: Ibuprofen and ramipril can irritate the gastric mucosa.
    • Gastric malignancy (less likely but must be excluded in high-risk patients).
  • Address the patient’s concern about cancer, explaining the likelihood based on his presentation.

Task 3: Explain the investigations you will request and why.

The competent candidate should:

  • Justify initial investigations, including:
    • Helicobacter pylori testing (urea breath test, stool antigen test) if ulcer disease is suspected.
    • Full blood count (FBC): To check for anaemia suggesting occult bleeding.
    • Liver function tests (LFTs): To rule out biliary causes.
    • Iron studies and faecal occult blood test (FOBT): If concerned about GI bleeding or malignancy.
    • Gastroscopy (endoscopy): If red flag symptoms are present or symptoms persist despite treatment.
  • Explain that most cases of dyspepsia do not require immediate endoscopy, but it is warranted if red flags are present.
  • Provide clear follow-up plans based on test results.

Task 4: Provide an initial management plan and follow-up advice.

The competent candidate should:

  • Develop a management plan tailored to the likely diagnosis:
    • If GORD is suspected: Lifestyle modifications (avoiding trigger foods, weight management, avoiding late meals), trial of proton pump inhibitors (PPIs) for 4-8 weeks.
    • If H. pylori positive: Eradication therapy (PPI + amoxicillin + clarithromycin/metronidazole for 7-14 days).
    • If NSAID-related: Stop NSAIDs if possible, consider PPI therapy for mucosal protection.
    • If functional dyspepsia: Dietary modifications, reassurance, and consideration of prokinetic therapy if needed.
  • Address smoking cessation and alcohol reduction, particularly given their impact on gastric mucosa and reflux symptoms.
  • Explain when to return for review and provide safety-netting advice for worsening symptoms.

SUMMARY OF A COMPETENT ANSWER

  • Takes a structured history, covering red flag symptoms, dietary triggers, and medication use.
  • Provides a clear, logical differential diagnosis, including common and serious causes.
  • Orders appropriate investigations, ensuring a stepwise diagnostic approach.
  • Develops a safe, patient-centred management plan, including lifestyle modifications and medication trials.
  • Uses empathetic and reassuring communication, addressing the patient’s concerns about cancer.

PITFALLS

  • Failure to identify red flags, potentially delaying the diagnosis of serious conditions.
  • Over-reassurance without considering appropriate investigations, missing conditions such as peptic ulcer disease or malignancy.
  • Omitting H. pylori testing, leading to undiagnosed treatable causes of dyspepsia.
  • Not reviewing medication use, particularly NSAID and antihypertensive-related dyspepsia.
  • Lack of clear safety-netting, leaving the patient unsure when to seek urgent care.

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 relevant history, including red flags.
2.2 Selects and justifies appropriate investigations.

3. Diagnosis, Decision-Making and Reasoning

3.1 Forms a logical differential diagnosis based on history and findings.
3.5 Identifies red flag symptoms requiring urgent referral.

4. Clinical Management and Therapeutic Reasoning

4.1 Develops an evidence-based, patient-centred management plan.
4.3 Provides structured follow-up and safety-netting.

5. Preventive and Population Health

5.2 Addresses modifiable risk factors for gastrointestinal disease.

6. Professionalism

6.1 Maintains confidentiality and professional integrity.

7. General Practice Systems and Regulatory Requirements

7.1 Orders appropriate tests in line with MBS guidelines.

9. Managing Uncertainty

9.2 Develops a structured approach to a patient with an unclear diagnosis.

10. Identifying and Managing the Patient with Significant Illness

10.1 Recognises and acts on potentially serious conditions.

Competency at Fellowship Level

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