CCE-CBD-199

EXAMINER ONLY INFORMATION

Questions

1. What is the most likely diagnosis, and what clinical features support this?
   • Prompt: Describe the typical presentation of this condition.
   • Prompt: Are there any other potential diagnoses to consider?
2. What further history would you take from David?
   • Prompt: What specific questions would you ask regarding his sexual history?
   • Prompt: How would you approach the topic of infidelity?
3. What investigations would you perform to confirm the diagnosis?
   • Prompt: What are the key diagnostic tests for suspected STIs?
   • Prompt: How would you counsel David about these tests?
4. What is your initial management plan for David?
   • Prompt: What treatments would you prescribe?
   • Prompt: What is your non-pharmacological management?
   • Prompt: How would you address partner notification and treatment?
5. How would you manage the follow-up for David?
   • Prompt: What are the important aspects of follow-up care?
   • Prompt: How would you discuss preventive measures and safe sex practices?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

1. Most Likely Diagnosis and Clinical Features:

• Identify Gonococcal or Chlamydial Urethritis: Recognize that the most likely diagnosis, given David’s symptoms (penile discharge and dysuria) and recent unprotected sexual encounter, is urethritis, commonly caused by Neisseria gonorrhoeae or Chlamydia trachomatis. This understanding includes knowing that gonococcal infections typically present with more purulent and profuse discharge, whereas chlamydial infections may present similarly but with a clearer discharge.
• Support Diagnosis with Clinical Features: Understand that the yellowish discharge and dysuria are classic symptoms of gonococcal urethritis, while chlamydial urethritis might present similarly but with a clearer discharge. Also, note the absence of systemic symptoms like fever, which supports a localized infection. Additionally, consider other relevant clinical features such as any history of urethral irritation, changes in urinary frequency, and any visible lesions or sores. Recognize the importance of asking about any pain during urination, the presence of blood in the urine, and any accompanying testicular pain that could indicate complications.
• Consider Differential Diagnoses: Include other potential causes, such as non-gonococcal urethritis (e.g., Mycoplasma genitalium), urinary tract infections, and balanitis, while focusing on sexual history to narrow down the most likely cause. Be aware of the possibility of co-infection with other STIs, which can alter the clinical presentation and necessitate broader diagnostic considerations. Discussing recent antibiotic use, which could influence the presence of symptoms, is also essential.

2. Further History:

• Sexual History: Ask detailed questions about the recent sexual encounter, including the timing, nature (vaginal, oral, anal), use of protection, and number of partners. Inquire about any previous history of STIs and treatments. Also, gather information on David’s partner’s health and any symptoms they may have experienced, which could provide additional diagnostic clues. Explore David’s knowledge and understanding of STI prevention and his usual practices concerning sexual health.
• Approach to Infidelity: Address the topic sensitively by ensuring confidentiality, using non-judgmental language, and expressing understanding of the emotional complexity. Encourage honesty for accurate diagnosis and management. Utilize open-ended questions to allow David to share relevant details comfortably. For example, “Can you tell me more about any recent sexual activities that might help us understand your symptoms better?” Offer reassurance about the confidentiality of the consultation to build trust and facilitate open communication.

3. Investigations:

• Diagnostic Tests: Order a urethral swab for Gram stain and culture to detect Neisseria gonorrhoeae and nucleic acid amplification tests (NAATs) for both N. gonorrhoeae and C. trachomatis. A first-void urine sample for NAAT can also be used. These tests are highly sensitive and specific, making them the gold standard for diagnosing these infections. Consider additional tests for other STIs, such as syphilis and HIV, given the risk factors and the need for comprehensive sexual health assessment.
• Counseling on Tests: Explain the purpose of each test, the process, and the importance of accurate diagnosis for effective treatment. Reassure David about the confidentiality of results and discuss the implications for his health and his partner’s health. Emphasize that timely diagnosis and treatment can prevent complications and reduce the risk of transmission. Provide detailed information about what to expect during the testing process, including any potential discomfort or preparation required.

4. Initial Management Plan:

• Antibiotic Treatment: Prescribe dual therapy as per guidelines (e.g., ceftriaxone 500 mg IM single dose plus azithromycin 1g orally single dose) to cover both gonorrhea and chlamydia, considering the rising antibiotic resistance. Explain the rationale behind dual therapy, including the prevention of resistance and the high likelihood of co-infection. Discuss the potential side effects of the medications and provide instructions on what to do if side effects occur.
• Non-Pharmacological Management:
  • Prevention
    • Education and Awareness: Informing about transmission, regular screening, and safe sex practices.
    • Risk Reduction Strategies: Identifying and reducing risky behaviours, supporting behaviour change.
    • Safe Sexual Practices: Using condoms, limiting partners, and maintaining monogamous relationships.
    • Regular Screening: Encouraging routine STI checks, especially for high-risk individuals.
  • Symptom Management: Simple analgesia and Ural.
  • Supportive Care: Educating on symptoms, seeking timely medical attention, and maintaining good hygiene.
• Partner Notification and Treatment: Discuss the importance of informing sexual partners to prevent reinfection and further transmission. Provide guidance on how to communicate this to his partner(s) and offer support resources. Emphasize that untreated partners can lead to a cycle of reinfection. Offer patient-delivered partner therapy (where legally permissible) as an option to facilitate the treatment of partners. Provide written information and resources to help David have this conversation with his partner(s) effectively ie Let Them Know.

5. Follow-Up Management:

• Adherence and Side Effects: Ensure that David understands the importance of completing the antibiotic course and discuss potential side effects. Schedule a follow-up appointment to reassess symptoms and review test results. Provide instructions on what to do if symptoms persist or recur after treatment. Encourage David to reach out if he experiences any unexpected side effects or has concerns about his treatment.
• Preventive Measures and Safe Sex Practices: Educate on the use of condoms, the importance of regular STI screenings, and maintaining open communication with sexual partners. Encourage reducing the number of sexual partners and avoiding high-risk sexual behaviours. Provide educational materials and resources on safe sex practices and the availability of STI testing and counselling services. Discuss the availability of pre-exposure prophylaxis (PrEP) for HIV prevention, if appropriate, based on David’s risk factors.

SUMMARY OF A COMPETENT ANSWER:

The candidate demonstrates a comprehensive understanding of the diagnosis and management of urethritis, effectively balances sensitive history-taking with clinical acumen, and ensures thorough follow-up care focusing on prevention and patient education. The candidate addresses the clinical and emotional aspects of the patient’s condition, ensuring a holistic approach to care.

PITFALLS

• Failing to take a comprehensive sexual history
• Not considering other differential diagnoses
• Inadequate counseling on the importance of partner notification and treatment
• Not addressing preventive measures and safe sex practices in follow-up care
• Overlooking the potential for co-infection with other STIs

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

1.5 Communicates effectively in routine and difficult situations

2. Clinical Information Gathering and Interpretation

2.1 A comprehensive biopsychosocial history is taken from the patient

2.4 All available sources of information are appropriately considered when taking a history

3. Diagnosis, Decision-Making and Reasoning

3.1 Integrates and synthesises knowledge to make decisions in complex clinical situations

3.3 Demonstrates diagnostic accuracy; this does not require the correct diagnosis but that the direction of reasoning was appropriate and accurate

4. Clinical Management and Therapeutic Reasoning

4.1 Demonstrates knowledge of common therapeutic agents, uses, dosages, adverse effects, and potential drug interactions, and the ability to prescribe safely

4.7 A patient-centred and comprehensive management plan is developed

5. Preventive and Population Health

5.1 Implements screening and prevention strategies to improve outcomes for individuals at risk of common causes of morbidity and mortality

5.7 Uses appropriate strategies to motivate and assist patients in maintaining health behaviours

6. Professionalism

6.4 Exhibits high standards of moral and ethical behaviour towards patients, families, and colleagues, including an awareness of appropriate doctor-patient boundaries

9. Managing Uncertainty

9.1 Manages the uncertainty of ongoing undifferentiated conditions

9.3 Recognizes when to act and when to defer doing so and uses time as a diagnostic tool

10. Identifying and Managing the Patient with Significant Illness

• 10.1 A patient with significant illness is identified

11. Rural Health Context (RH)

• RH.2 Adapts communication to accommodate situations common in rural and remote areas, and maintains effective communication infrastructure relevant to the practice setting

Examiner’s Overall Rating of the Candidate

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