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 initially to explore the patient’s symptoms, then ask targeted questions to clarify the clinical picture.
• Establish onset, duration, and progression of symptoms, including fatigue, joint pain, and rash.
• Identify red flag symptoms, such as weight loss, night sweats, persistent fever, chest pain, shortness of breath, or neurological symptoms (seizures, confusion, numbness).
• Assess for systemic symptoms of SLE, including oral ulcers, hair thinning, Raynaud’s phenomenon, photosensitivity, and history of miscarriages (suggesting antiphospholipid syndrome).
• Explore family history of autoimmune diseases, particularly SLE, rheumatoid arthritis, or thyroid disorders.
• Evaluate triggers and risk factors, such as sun exposure, recent infections, or medication use.
• Address psychosocial concerns, including impact on daily life, fears about long-term disability, and pregnancy concerns.

Task 2: Discuss your differential diagnosis with the patient.

The competent candidate should:

• Explain that autoimmune diseases can present with a range of symptoms, and further testing is needed.
• Discuss most likely differentials:
  • Systemic Lupus Erythematosus (SLE): Joint pain, malar rash, fatigue, photosensitivity, and systemic involvement.
  • Rheumatoid arthritis (RA): Symmetrical joint pain with morning stiffness, less likely with photosensitivity and rash.
  • Dermatomyositis: Rash with muscle weakness, may also present with photosensitivity.
  • Viral arthritis (e.g., Parvovirus B19): Can mimic autoimmune disease but usually resolves spontaneously.
  • Hypothyroidism: Can cause fatigue and hair thinning but lacks joint and skin involvement.
• Address the patient’s concern about lupus, explaining that it is a possibility but needs confirmation with tests.

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

The competent candidate should:

• Justify initial investigations, including:
  • Full blood count (FBC): To assess for anaemia, leukopenia, or thrombocytopenia.
  • Renal function tests (U&E) and urinalysis: To check for lupus nephritis.
  • Liver function tests (LFTs): To assess systemic involvement.
  • Anti-nuclear antibodies (ANA): Screening test for SLE (positive in >95% of cases).
  • Anti-double-stranded DNA (anti-dsDNA) and anti-Smith antibodies: Highly specific for SLE.
  • Complement levels (C3, C4): Often low in active lupus.
  • ESR/CRP: Elevated in inflammation but normal in purely autoimmune conditions.
  • Antiphospholipid antibodies: If concerned about clotting risk.
• Explain that results will help confirm the diagnosis and guide management.
• Provide clear follow-up plans for reviewing test results and next steps.

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

The competent candidate should:

• Develop a management plan based on findings:
  • If SLE is confirmed: Refer to a rheumatologist, start hydroxychloroquine for symptom control, and consider corticosteroids for flares.
  • If alternative cause is found: Tailor treatment accordingly (e.g., NSAIDs for inflammatory arthritis, thyroid replacement for hypothyroidism).
  • If diagnosis remains unclear: Monitor closely and arrange further investigations.
• Provide supportive care, including fatigue management, joint protection strategies, and psychological support.
• Address lifestyle modifications, including avoiding sun exposure, using sunscreen, and maintaining a healthy diet.
• Discuss pregnancy considerations, particularly contraception and risks if antiphospholipid syndrome is present.
• Provide safety-netting advice, advising urgent review for worsening symptoms, fever, or new organ involvement.
• Arrange a follow-up appointment to review test results and discuss further management.

SUMMARY OF A COMPETENT ANSWER

• Takes a structured history, covering autoimmune features, systemic involvement, and red flags.
• Provides a clear differential diagnosis, addressing SLE, RA, viral arthritis, and thyroid disease.
• Orders appropriate investigations, including ANA, dsDNA, renal function, and inflammatory markers.
• Develops a safe, patient-centred management plan, including specialist referral and supportive care.
• Uses empathetic and reassuring communication, addressing concerns about lupus, treatment, and pregnancy.

PITFALLS

• Failure to identify red flag symptoms, missing organ involvement or severe disease manifestations.
• Over-reassurance without appropriate investigations, leading to delayed diagnosis.
• Omitting ANA and specific lupus antibodies, missing the key diagnostic criteria for SLE.
• Not considering other differentials, such as rheumatoid arthritis or viral arthritis.
• Lack of clear safety-netting, leaving the patient uncertain about when to seek urgent care.

REFERENCES

• RACGP Guidelines – Autoimmune Disease Management
• GP Exams – SLE (Systemic Lupus Erythematosus)

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 and supports long-term disease management.

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 progressive or disabling autoimmune conditions.

Competency at Fellowship Level

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